Case Study 023

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Question 1

Kate is a 33-year-old female who is presented to the emergency department with severe abdominal pain and vomiting. Her symptoms started two days ago. Since then, the pain has just gotten worse, and only relieved a little by bending forward. She was not able to eat or drink anything for more than 24 hours. She has no history of any medical problems. She smokes about 1 package of cigarettes daily and occasionally drinks with friends. The day before her symptoms started she celebrated her friend’s birthday and drank more alcohol than usual. In her family history, her father had hyperlipidemia and still under daily treatment. On examination:

Height: 170 cm, Weight: 69.3 Kg, BMI: 24
BP: 130/85 mmHg, Heart rate: 114/min, Respiratory rate: 30/min, Temperature: 37.2°C, O₂ SAT: 98%
Tender epigastric region on palpation.

What laboratory tests can aid best in the differential diagnosis of severe epigastric pain? (Select all that apply)

A	Hemoglobin, hematocrit
B	White blood cell count and differential
C	AST, ALT, GGT, ALP
D	Cholesterol, triglycerides
E	Creatinine clearance and urea nitrogen
F	Serum glucose
G	Serum amylase and lipase

Question 1 Explanation:

Although all the above laboratory tests are frequently ordered for the examination of abdominal pain, three of them can help differentiate the causes of upper abdominal pain. Low hemoglobin and hematocrit can indicate gastrointestinal hemorrhage due to peptic ulcer. Elevated liver enzymes (AST, ALT, GGT, and ALP) would be found in hepatitis or cholestasis. Finally, the elevated amylase and lipase will determine pancreatitis.

Question 2

Kate’s laboratory examination showed:

Blood analysis:
- CBC:
  - RBCs: 4.5 x 10¹²/ L, Hemoglobin: 146 g/L, Hematocrit: 0.40,
  - MCV: 92 fL, MCH: 31 pg, RDW: 12.2%, Reticulocytes: 1.2%, ESR: 20 mm/hour,
  - WBC: 13.6 x 10⁹/l, (Neutrophils: 8.3 x 10⁹/L, Lymphocytes: 4.4 x 10⁹/L, Basophils: 0.09. x 10⁹/L, Eosinophils: 0.43 x 10⁹/L, Monocytes: 0.8 x 10⁹/L),
  - Platelet counts: 334 x 10⁹/L
- Na: 134 mmol/L, K: 5.1 mmol/L, Ca (total): 1.99 mmol/L, (ionized): 0.9 mmol/L
- Glucose: 7.5 mmol/L, Creatinine: 82.2 umol/L, Uric Acid: 223 mmol/L
- Triglycerides: 9.4 mmol/L, Cholesterol: 9.9 mmol/L, LDL: 6.4 mmol/L, HDL: 0.4 mmol/L
- Total bilirubin: 12 umol/L,
- AST: 72 U/L, ALT: 44 U/L, ALP: 100 IU/L, GGT: 22 IU/L, 5'-NT: 12 IU/L, Albumin: 42.6 g/L, LDH: 228 U/L
- Amylase: 1126 U/L, Lipase: 1327 U/L
- CRP: 64 mg/L
- INR: 1.0, Prothrombin time: 12 sec
- Viral serology: HBsAg, HCV Ab, HAV IgG: negative
Urine analysis: color: yellow, pH: 6.6, specific gravity: 1019, osmolarity: 634 mmol/kg; glucose: negative, ketones: +, bilirubin, urobilinogen: negative, bile salts: negative, WBCs and RBCs: 0 and 0/HPF, squamous epithelial cells: 1-2/HPF, casts, bacteria: negative, yeast: +.

What does the amylase and lipase levels indicate?

A	Alcoholic hepatitis
B	Acute pancreatitis
C	Cholecystitis
D	Peptic ulcer
E	Peritonitis

Question 2 Explanation:

High amylase and lipase levels indicate the diagnosis of acute pancreatitis. In Kate’s case, the amylase and lipase levels are about 10 times higher than the normal values.

Question 3

What are the two main underlying pathological mechanisms of elevated amylase levels in pancreatitis?

A	Damage to the pancreatic acinar cells
B	Damage to the pancreatic beta cells
C	Obstruction of the pancreatic duct system
D	Autoimmune antibodies bind to the pancreatic acinar cell membrane
E	Drug toxicity

Question 3 Explanation:

As an exocrine gland, the pancreas normally secretes amylase among other digestive enzymes into the pancreatic duct. The enzymes reach the duodenum through the common bile duct. In acute pancreatitis, cellular damage can occur due to the toxic effect of alcohol, inflammation or due to the obstruction of the smaller pancreatic ducts. As a result of the cellular damage, amylase leaks from the cells to the surrounding tissue.

Question 4

When would you expect the serum amylase level to return to normal if there is no complication of the pancreatitis?

A	In 2-3 days
B	In 5-6 days
C	In 7-8 days
D	Amylase stays elevated for about 2 months after acute pancreatitis.

Question 4 Explanation:

Serum amylase become abnormally elevated in 12 hours and expected to return to normal in 48-72 hours if complication has not occurred. Note: in chronic kidney failure amylase is not excreted well, therefore remains elevated longer.

Question 5

Which one is a true characteristic of amylase and lipase?

A	Serum lipase levels peak later and remain elevated longer than serum amylase in acute pancreatitis.
B	Serum amylase levels peak later and remain elevated longer than serum lipase in acute pancreatitis.
C	Lipase becomes elevated earlier than amylase but quickly removed from the blood by the kidneys, so it is more useful for the early diagnosis of pancreatitis.
D	Serum amylase is more specific to pancreatitis than lipase.

Question 5 Explanation:

Serum lipase level becomes elevated in 48 hours and return back to normal in 5 to 7 days. Lipase is considered to be more specific to pancreatic diseases, however kidney failure, bowel obstruction or necrosis can also cause higher serum lipase.

Question 6

Which one of the following conditions can cause elevated serum amylase?

A	Brain tumor
B	Pneumonia
C	Parotitis
D	Acute myocardial infarction

Question 6 Explanation:

Salivary glands also secrete amylase, which is sometimes referred as salivary amylase. Inflammation of the parotid glands (Parotitis) can cause elevated serum amylase. Other conditions that are associated with elevated serum amylase include duodenal perforation, penetrating gastric ulcer, ectopic pregnancy, or diabetic ketoacidosis.

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