amylase v.s. lipase?

Started by 12R34Y
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12R34Y

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Just curious.........Are you guys still ordering both amylase/lipase when you suspect pancreatitis?

I was doing a shift with my preceptor in the ED the other night and we had a chronic ETOH, drug abuser, overdose guy come in and after we woke him with Narcan he complained of epigastric pain and in his chart he had a history of pancreatitis.

The doc told me to only order a lipase as it is more specific. I've also seen this several times from senior medical students along with the same reasoning.

just curious.

later
 
I typically will only order a Lipase, AST, and ALK Phos (My residency director has pointed out that if these are elevated you can go from there and order the others. He says that to find one of the others elevated when one of these three are not is kind of atypicaly).

With that being said, there are of course exceptions to the rule. For instance, with traumas, we order only the amylase.
 
Is the reason you order amylase in trauma due to the fact that you get a sharp rise in amylase quickly if an acute pancreatic injury occurs?

Please correct me if i'm wrong.

later
 
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For discussion of serum amylase in trauma see the following.

1: Adamson WT, Hebra A, Thomas PB, Wagstaff P, Tagge EP, Othersen HB.
Serum amylase and lipase alone are not cost-effective screening methods for
pediatric pancreatic trauma.
J Pediatr Surg. 2003 Mar;38(3):354-7; discussion 354-7.
PMID: 12632348 [PubMed - indexed for MEDLINE]

2: Cirillo RL Jr, Koniaris LG.
Detecting blunt pancreatic injuries.
J Gastrointest Surg. 2002 Jul-Aug;6(4):587-98. Review.
PMID: 12127126 [PubMed - indexed for MEDLINE]

3: Boulanger BR, Milzman DP, Rosati C, Rodriguez A.
The clinical significance of acute hyperamylasemia after blunt trauma.
Can J Surg. 1993 Feb;36(1):63-9.
PMID: 7680273 [PubMed - indexed for MEDLINE]


Many trauma centers no longer routinely order amylase on trauma patients for the above reasons.

For discussions of amylase versus lipase in pancreatitis see the following. Bottom line lipase is generally more sensitive and specific

4: Pezzilli R, Billi P, Barakat B, Miglio F.
Lipase-amylase ratio does not determine the etiology of acute pancreatitis.
Another myth bites the dust.
J Clin Gastroenterol. 1998 Jan;26(1):34-8.
PMID: 9492861 [PubMed - indexed for MEDLINE]

5: Keim V, Teich N, Fiedler F, Hartig W, Thiele G, Mossner J.
A comparison of lipase and amylase in the diagnosis of acute pancreatitis in
patients with abdominal pain.
Pancreas. 1998 Jan;16(1):45-9.
PMID: 9436862 [PubMed - indexed for MEDLINE]

6: Chase CW, Barker DE, Russell WL, Burns RP.
Serum amylase and lipase in the evaluation of acute abdominal pain.
Am Surg. 1996 Dec;62(12):1028-33.
PMID: 8955242 [PubMed - indexed for MEDLINE]

7: Orebaugh SL.
Normal amylase levels in the presentation of acute pancreatitis.
Am J Emerg Med. 1994 Jan;12(1):21-4.
PMID: 7506911 [PubMed - indexed for MEDLINE]

8: Gumaste V, Dave P, Sereny G.
Serum lipase: a better test to diagnose acute alcoholic pancreatitis.
Am J Med. 1992 Mar;92(3):239-42.
PMID: 1372152 [PubMed - indexed for MEDLINE]
 
In the private world we get stuck doing a lot of things the old way because the admitting docs want it that way. 90% of the guys I admit to want amylase and lipase. These are the same guys that demand an ABG on every asthmatic and COPDer. I tried to fight it initially. "What's the ABG?" "Who cares, clinically he's sick and need to come in." "How am I going to take care of him without an ABG?" and so it goes. I've given up and just order what they want.

In the same vein I've been called to the ICU more than once to intubate someone who looks ok clinically but just has a bad gas. (I do fight them on that.)
 
If you look @ enough trauma panels with blunt patients you'll notice that its more common then not to get elevated amylase & lipase levels. As pointed out in some of those references, there is some difference in opinion about how cost effective these are as screening tools. What they do, if nothing else, is give something to compare to later for a serial assessment which is sometimes the only way you'll detect some early pancreatic injuries. You'll pick up several a year @ busy centers this way. It's completely defensive medicine, but one malpractice verdict on something like that wipes out the cost savings on 100's of patients (if not more then 1000) that you'd be able to safely screen clinically.There are a lot of the routine tests with trauma that some advocate should be ditched based on cost-analysis & clinical utility. Ones I've see recommend some barebones chem-4 (Na,Cr,K, & I think Cl) & question the routine use of trauma xrays of the pelvis & c-spine
 
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