LABORATORY DIAGNOSIS OF

PANCREATIC DISEASES

By
Dr. Marwa Abd Al Haq Abd El Azeem
Assistant Professor of Pathology Department
 Over view

• Pancreas is a glandular organ has digestive and endocrine function.

• It produces several important hormones, as well as secretes pancreatic juice
containing digestive enzymes.
• These enzymes assist the absorption of nutrients and the digestion in the small
intestine.
• Pancreatic enzymes are natural chemicals that help break down fats, proteins, and
carbohydrates.
• The three major groups of pancreatic enzymes which are important to efficient
digestion are: proteases, lipase, and amylase.
• Other pancreatic enzymes in addition to the proteases, lipase and amylase are
ribonuclease, deoxyribonuclease, gelatinase and elastase.
 Acute pancreatitis

• Pancreatitis occurs as a consequence of premature, intra-pancreatic activation

of pancreatic proenzymes. The proenzymes are synthesized by the acinar cells
and stored in vesicles known as zymogens.
• Causes of acute pancreatitis:
1. Gall stones
2. Alcohol
3. Spasm of sphincter of Oddi
4. Drugs: Azathioprine
5. Trauma
6. Infectious causes
• Acute pancreatitis is a potentially lethal disorder
associated with intracellular activation of digestive
enzymes in the pancreas. This results in autodigestion of
the pancreatic tissue by the powerful enzymes normally
secreted into the gastrointestinal tract to degrade ingested
foods.
 Amylase

• Serum amylase is secreted in specific isoforms by the salivary glands

(s-amylase) and pancreas (p-isoamylase).
• Almost all laboratories currently measure total serum amylase so the
result includes both isoenzymes.
• Reference range is 20–300 U/L.
• In acute pancreatitis, amylase rises rapidly within 3–6 hours of the
onset of symptoms, and may remain elevated for up to 5 days.
However, it has a short half-life of 12 hours so the concentration can
normalize within 24 hours. This significantly reduces its value as a
diagnostic test early in the clinical course.
• A urine amylase determination may be helpful in diagnosing
pancreatic disorders, especially when the serum amylase level is
normal or slightly elevated.
• As a general rule, urine amylase rises within 24 hours after an
increase in serum amylase, and remains high for 7 to 10 days
after the serum level returns to normal.
• Renal excretion of amylase depends on the glomerular filtration
rate, thus the urine amylase correlates with the creatinine
clearance (CC).
• In acute pancreatitis, the clearance of amylase into the urine may
be increased compared with creatinine, resulting in an increased
(amylase/creatinine clearance [A/CC]) ratio.
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• Determination of the A/CC ratio involves simultaneous collection of

serum and urine specimens but does not require a complete 24-hour
urine collection.
• In acute pancreatitis, the clearance of amylase into the urine is
increased compared with creatinine, resulting in an increased
(amylase/creatinine clearance [A/CC]) ratio.
• Reference Range for amylase/creatinine clearance: 1-5%.
• In pancreatitis, values range from 5% to greater than 20%.
• Increases in the ratio of amylase to creatinine clearance are found in
several non-pancreatic disorders, such as burns, myeloma, duodenal
perforations, and following extraperitoneal surgical procedures
 Macroamylasemia
• Macroamylasemia is an established cause for an elevated serum
amylase value.
• Macroamylase is a complex of amylase and other molecules,
which may be proteins or carbohydrates.
• Because of its large molecular size, macroamylase is not filtered
by the glomerulus in the kidney.
• Consequently, it accumulates in the serum, causing elevated serum
amylase level.
• Because macroamylase does not enter the urine, the urine
amylase level is normal or low.
• Unlike the situation in acute and chronic pancreatitis in which the
urine amylase level is usually elevated along with the serum
elevation.
• Thus, patients with macroamylasemia have a combination of
elevated serum amylase levels and normal or low urine amylase
levels.
• In macroamylasemia, amylase/creatinine clearance ratio is usually
less than 1%.
• Amylase level is elevated in ascites fluid also.
Lipase

• Lipase has now replaced amylase as the biochemical test of choice in

acute pancreatitis.
• Serum lipase increases 3–6 hours after the onset of acute pancreatitis and
usually peaks at 24 hours. Unlike amylase, there is significant reabsorption
of lipase in the renal tubules so the serum concentrations remain elevated
for 8–14 days.
• This means it is far more useful than amylase when the clinical
presentation or testing has been delayed by more than 24 hours.
• Serum lipase also has a greater sensitivity than amylase in patients with
alcoholic pancreatitis.
• The magnitude of the elevation of amylase and lipase does not predict
disease severity in adults.
• Increased if acute pancreatitis if >5x upper limit of reference range.
• Lipase is the pancreatic enzyme that, along with bile from the
liver, digests fats.
• the reference range is typically 0–160 U/L.
• Conditions associated with non-pancreatitis in which both amylase
and lipase are increased:
1. Biliary disease
2. Intestinal obstruction
3. Pancreatic pseudocyst
4. Renal impairment.
• Clinical conditions associated with elevations in amylase without a
corresponding increase in lipase include:
1. Macroamylasemia
2. Ruptured ectopic pregnancy
3. Salivary gland disease
4. Abdominal and thoracic malignancies.
 Causes of elevated serum amylase and lipase
Causes Amylase
Abdominal conditions Acute pancreatitis, pancreatic
carcinoma, chronic pancreatitis,
intestinal infarction and obstruction,
peritonitis, acute cholecystitis,
perforated peptic ulcer, hepatitis,
ruptured ectopic pregnancy, fallopian
and ovarian cysts
Extra-abdominal conditions Salivary disease, renal failure,
ketoacidosis
Others Macroamylasaemia
Lipase
Acute pancreatitis, pancreatic
carcinoma, chronic pancreatitis,
intestinal obstruction, peritonitis,
acute cholecystitis, malignancy
(especially esophagus, stomach,
duodenum, pancreas)
Renal failure, ketoacidosis, fat
embolism, fat trauma
Hyperlipoproteinaemia
Disorder Test Expected result
Acute pancreatitis Serum amylase Increased
Serum lipase Increased

Amylase/creatinine Increased
clearance

Chronic pancreatitis Serum amylase Increased, normal, or

decreased

Serum lipase Increased, normal, or

decreased

Amylase/creatinine Increased, normal, or

clearance decreased
 Other Laborator y Investigations in Acute
Pancreatitis
• Serum calcium
Pancreatitis cause hypocalcemia , this due to
1. The pancrease release glucagon and gastrin which in turn stimulates
calcitonin release from thyroid , lead calciuria.
2. Also , when calcium binds with fatty acids released from hydrolyzed fat in
abdomen leading to formation of calcium soaps.
• Increased serum triglycerides
• Increased serum glucose level
• Incresaed serum bilirubin
• Increased methemalbumin.
Chronic pancreatitis

• In chronic pancreatitis, the cells that synthesize the digestive enzymes are
destroyed and replaced with fibrous tissue.
• In about one half of the patients with chronic pancreatitis, the serum
amylase and lipase levels remain within the normal range. In other
patients, the values may be borderline or only slightly elevated.
THE END