Pancreatic Enzymes Elevation and Emergency Setting: Pancreatitis or Not Pancreatitis? That is the Question

Abstract

Dear Editor, Notwithstanding often no clinically evident acute pancreatitis findings are found, a serum pancreatic enzyme elevation is found in up to 80% of critically ill patients.[1] In an emergency setting, in fact, the diagnosis of acute pancreatitis can be misleading due to various reasons, hence concomitant patients’ clinical conditions (e.g. hemodynamic instability, mechanical ventilation) and the establishment of rapidly evolving physiopathological mechanisms. Does an enzyme increase justify the diagnosis of pancreatitis? Actually no. Although a three-time greater titer than upper limits represents one of the recognized diagnostic criteria, findings of hyperamylasemia and/or hyperlipasemia could lead to several interpretations, such as the evolution of severe acute pancreatitis, as defined by the Atlanta criteria, pancreatic complications in patients admitted for other pathologies or a mere biochemical increase in the absence of clinical-radiological signs attributable to pancreatic inflammation. Furthermore, the enzymatic titer does not represent a prognostic factor or an index of progression to a necrotic or haemorrhagic state. Although, a diagnosis of acute pancreatitis at onset can established on the basis of an enzymatic increase supported by suggestive clinical findings, the enzymatic dosage cannot be considered predictive of progression, as in case of the C-reactive protein. Furthermore, in the early stages of the disease, the extensive use of diagnostic radiologic investigations (<96 hours) has no role.[2] As reported by Weaver et al.,[3] in a retrospective analysis including 192 emergency patients, 36.45% had hyperamylasemia but none met clinical or radiological criteria for acute pancreatitis. Furthermore, only 9.4% in this cohort was attributable to an increase in the pancreatic serum isoform. The authors therefore concluded by recommending caution in the dosage and interpretation of the titers of serum amylase in critically ill patients. If on the one hand these evidences represent an explicit recommendation for a prompt and exhaustive nosological classification of hyperamylasemia that could mislead to an erroneous diagnosis, on the other they suggest the need for a critical review of the diagnostic criteria of acute pancreatitis where laboratory findings as far as clinical and radiological findings could lead to a reduced diagnostic power in critically ill patients. Mirko Barone,1 Massimo Ippoliti,1 Felice Mucilli1,2