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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 34  |  Issue : 2  |  Page : 96-100

Serum lipase amylase ratio in predicting the etiology of acute pancreatitis


1 Department of Surgery, Regional Institute of Medical Sciences, Imphal, Manipur, India
2 Manipur Health Services Department, Govt. of Manipur, Imphal, Manipur, India

Date of Submission03-Dec-2020
Date of Decision05-Dec-2020
Date of Acceptance09-Dec-2020
Date of Web Publication09-Dec-2020

Correspondence Address:
Laishram Jaleshwar Singh
Department of Surgery, Regional Institute of Medical Sciences, Imphal West - 795 004, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jms.jms_121_20

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  Abstract 


Background: Acute pancreatitis remains a major cause of significant morbidity and mortality. Alcoholism and biliary tract stone disease are the main causes in up to 80% of cases. The diagnosis of acute pancreatitis is based on the correlation of clinical, biochemical, and radiological criteria. Serum lipase and amylase have been used to diagnose acute pancreatitis with values greater than three times the upper limit of normal being diagnostic.
Objective: The aim is to study the value of serum lipase: amylase ratio in predicting the etiology of acute pancreatitis.
Materials and Methods: This prospective study was conducted in a tertiary care hospital in North-East India during a 2-year period. The serum lipase/amylase ratio has been evaluated in 52 patients (31 acute alcoholic pancreatitis, 19 acute gallstone pancreatitis, 2 idiopathic).
Results: Analysis of data showed that patients with acute alcoholic pancreatitis had higher serum lipase levels (2722.5 ± 285.7, mean ± standard deviation) compared to acute gallstone pancreatitis (1565.21 ± 198.2). On the other hand, acute gallstone pancreatitis patients had higher serum amylase (862.3 ± 105.5) compared to acute alcoholic pancreatitis patients (683.03 ± 618.31). Determination of lipase: amylase ratio showed that out of 31 patients of acute alcoholic pancreatitis 22 patients (71%) had lipase: amylase ratio ≥3. Out of 19 patients of acute gallstone pancreatitis, 17 patients (89.5%) had lipase: amylase ratio <3, which was found to be statistically significant.
Conclusion: Serum lipase: amylase ratio fixed at 3.0 can assist in differentiating acute biliary pancreatitis from acute alcoholic pancreatitis. The lipase: amylase ratio ≥3 is observed in alcoholic acute pancreatitis while biliary pancreatitis has ratio <3.

Keywords: Alcoholic pancreatitis, biliary pancreatitis, serum amylase, serum lipase


How to cite this article:
Singh HB, Singh LJ, Shougrakpam P. Serum lipase amylase ratio in predicting the etiology of acute pancreatitis. J Med Soc 2020;34:96-100

How to cite this URL:
Singh HB, Singh LJ, Shougrakpam P. Serum lipase amylase ratio in predicting the etiology of acute pancreatitis. J Med Soc [serial online] 2020 [cited 2021 Feb 25];34:96-100. Available from: https://www.jmedsoc.org/text.asp?2020/34/2/96/307888




  Introduction Top


Acute pancreatitis has been recognized since antiquity,[1],[2] but the importance of pancreas and the severity of its inflammatory disorders were realized only in the middle of 19th century.[3]

In 1925, Moynihan described acute pancreatitis as “The most terrible of all calamities that occur in connection with the abdominal viscera. The suddenness of its onset, the agony which accompanies it and the mortality attendant upon it render it the most formidable of all catastrophes.”[4]

Acute pancreatitis remains a major cause of significant morbidity and mortality even today, with increasing incidence in recent years.[5],[6] The reason behind the increase has been speculated due to increase in alcohol abuse and an improved ability to diagnose the disease.

Acute pancreatitis is related to alcohol or biliary tract stone disease in 80% of cases. The remaining 10% is related to metabolic factors, drugs and other conditions and 10% are idiopathic.[3],[6]

Earlier classifications of acute pancreatitis were based on morphology, which was possible only after surgery or during the biopsy. The Atlanta symposium in 1992 established a universally accepted clinically based classification system very much needed at the outset of the disease for a working diagnosis.[7]

A revised Atlanta classification 2012 has subsequently been established based on a better understanding of the pathophysiology of organ failure and necrotizing pancreatitis and their outcomes, as well as improved diagnostic imaging.[8]

An early and accurate diagnosis of acute pancreatitis is essential to facilitate timely and appropriate monitoring assessment of severity and treatment. Serum lipase and amylase measurements are often used to diagnose acute pancreatitis.[9],[10],[11]

In acute pancreatitis, serum amylase activity increased within 2–12 h of the onset of disease with maximal levels in 12–72 h and the levels return to normal by the 3rd–4th days.[12] Pancreatic tumors, pancreatic abscess, and traumatic lesions to the pancreas may elevate serum amylase activity. Any lesion to the salivary gland due to infection (mumps), surgical trauma or any other type of trauma, calculus, and tumors may lead to high amylase activity. Other causes of hyperamylasaemia include renal insufficiency, tumor of thee lung and ovary, cholecystitis, ruptured ectopic pregnancy, cerebral trauma, diabetic ketoacidosis.[12]

In acute pancreatitis, increased lipase activity in blood is seen after 4–8 h of an attack, peaks at about 24h, and comes back to the normal level by 8–14 days.[12] Serum lipase measurement is a highly specific marker of pancreatic disease than amylase, its activity remains increased for longer than that of serum amylase, and there are no other sources of lipase to reach the blood.[13],[14] Other conditions in which high serum lipase activity is seen are obstruction of the pancreatic duct by calculus or by carcinoma of the pancreas, acute, and chronic renal diseases.[12] Some investigators recommend simultaneous measurement of serum amylase and lipase to improve diagnostic accuracy.[15]

It has long been established that abnormalities in blood concentrations of alanine transaminases or aspartate transaminases on admission with acute pancreatitis may be applied to indicate a biliary etiology.[16] The serum lipase amylase (L/A) ratio was significantly higher in alcoholic acute pancreatitis than in the nonalcoholic form of the disease, which is mainly biliary.[17],[18]

Although the clinical picture is similar irrespective of etiology, patients with severe episodes of acute pancreatitis require specific therapeutic maneuvers when biliary induced, while in the case of alcoholic origin, they only need supportive measures.[19]

Since serum amylase and lipase are highly specific markers for acute pancreatitis and the ratio of serum lipase to amylase was found to be significantly higher in alcoholic acute pancreatitis than nonalcoholic acute pancreatitis (as reported by many studies), this study was undertaken to study the efficacy of lipase amylase ratio in arriving at the clinical diagnosis of acute pancreatitis and also to differentiate the alcoholic from the nonalcoholic form of acute pancreatitis.


  Materials and Methods Top


This prospective study was conducted in the Department of General Surgery of a tertiary care hospital in North-East India during a 2-year period. Ethical approval was taken from the Institutional Ethics Committee.

A total of 52 consecutive patients diagnosed with acute pancreatitis during the study period and willing to give valid consent were included in the study. Patients with ultrasonography/computed tomography/magnetic resonance imaging scan reports of acute pancreatitis with coexisting conditions such as perforated peptic ulceration, intestinal gangrene, intracranial bleed, ectopic pregnancy and carcinoma head of the pancreas and renal failure were excluded. Patients who were found to be suffering from cardiovascular, respiratory, and systemic failure previously were also excluded.

Statistical analysis was performed using appropriate statistical tools. Study variables were analyzed using Chi-square test for significance.


  Results Top


In our study of a total of 52 patients, 33 were males with a male:female ratio of 1.7:1 [Table 1]. The mean age of the patients in the study was 41.52 years. Higher incidence was seen in urban areas than in rural areas.
Table 1: Age distribution of respondent stratified by sex

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Mean lipase value was 222.1 ± 156.8 IU/L with majority of patients having >600 IU/L (80.8%) [Table 2]. Mean amylase value was 732.9 ± 796.3 IU/L with maximum values between 101 and 300 IU/L and 301–600 IU/L (30.8% each) [Table 3].
Table 2: Distribution of respondents by lipase values

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Table 3: Distribution of respondents by amylase values

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Mean values of serum lipase in alcoholic pancreatitis patients was 2722.5 ± 285.7 IU/L, which was higher than gallstone pancreatitis patients 1565.21 ± 198.2 IU/L and miscellaneous group was 672.0 ± 380.4 IU/L [Table 4]. On the other hand, mean values of serum amylase were higher in gallstone pancreatitis patients 862.3 ± 105.5 IU/L compared to alcoholic pancreatitis patients (683.03 ± 618.3 IU/L) and miscellaneous group patients (278.5 ± 125.2 IU/L) [Table 4].
Table 4: Mean values of serum lipase and serum amylase

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Mean lipase: amylase ratio was 3.56 ± 2.66 [Table 5]. Among the 52 patients, 31 were diagnosed with acute alcoholic pancreatitis, 19 with acute gallstone pancreatitis and remaining 2 were idiopathic. Alcoholic pancreatitis had more patients with lipase: amylase ratio ≥3 than other types of pancreatitis and the finding is found to be significant (P < 0.05) [Table 6]. Of the 31 patients of alcoholic pancreatitis, 22 patients (71%) had a lipase: amylase ratio ≥3. Of the 19 patients of gallstone pancreatitis, 17 patients (89.5%) had a lipase: amylase ratio <3. The ratio was <3 in the miscellaneous group [Table 6].
Table 5: Distribution of respondents by lipase: amylase ratio

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Table 6: Lipase: amylase ratio according to etiology

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The calculated sensitivity and specificity of lipase: amylase radio ≥3 for predicting alcoholic pancreatitis are 70.9% and 90.5%, with positive predictive value of 91.7% and negative predictive evaluate of 67.4%, respectively. The sensitivity and specificity of lipase : amylase ratio <3 for predicting gallstone pancreatitis is 89.5% and 66.7%, with positive predictive value of 60.7% and negative predictive value of 91.7%, respectively.

The serum lipase: amylase ratio can therefore be used as an useful index for predicting the alcoholic and biliary etiology in acute episodes of acute pancreatitis.


  Discussion Top


In our study, the mean age for patients of acute pancreatitis was 41.52 years, with a standard deviation of 1.34 years. The mean age of alcoholic pancreatitis patients was slightly younger (42.4 years) compared to gallstone pancreatitis patients (42.7 years). Other studies also reported that patients with alcoholic acute pancreatitis were relatively younger than the biliary acute pancreatitis.[20] The reason for the younger age group of alcoholic pancreatitis was attributed to initiation of alcohol consumption and its dependence at a very early age.

Alcoholic pancreatitis, in our study, was exclusively seen in the male population (100%), whereas 89.5% of gallstone pancreatitis were females. The male predominance of alcoholic pancreatitis and female preponderance in biliary pancreatitis reported in various studies.[21],[22] The scenario is explained by the lower percentage of alcoholism reported in females when compared to males in the Indian population. Moreover, the reported cases of acute pancreatitis in females for other causes of pancreatitis such as biliary is much higher than the alcoholic variety.[23]

The number of alcoholic pancreatitis patients (59.6%) was marginally higher than the nonalcoholic patients, gallstone pancreatitis (36.5%), miscellaneous (3.8%). Similarly, Devanath et al.[23] in their retrospective study, alcoholic pancreatitis patients comprised 50.9% of the study population, gallstone pancreatitis 30.1%, and miscellaneous group comprised 19% of the patients. This reflects a higher incidence of alcoholic pancreatitis compared to gallstone pancreatitis among Indians.

Our study found that there was a significant difference in serum lipase and amylase values when alcoholic pancreatitis was compared with biliary pancreatitis. The mean levels of serum lipase were found to be comparatively higher in the alcoholic pancreatitis patients with a mean value of 2722.5 ± 285.7 IU/L than the biliary pancreatitis patients with a mean value of 1565.21 ± 198.2 IU/L or the idiopathic patients with the mean value of 672 ± 380.4 IU/L. The amylase values were lower in alcoholic acute pancreatitis with mean value of 683.03 ± 618.31 IU/L compared to biliary acute pancreatitis patients 862.5 ± 105.5 IU/L. Idiopathic patients' mean amylase value was 278.5 ± 125.2 IU/L. Pacheco et al.[20] in their study found that the mean levels of serum lipase were higher in acute alcoholic pancreatitis compared to acute gallstone pancreatitis whereas King et al.[22] and Chang et al.[24] found that the median amylase was significantly higher in biliary acute pancreatitis in comparison to alcoholic acute pancreatitis.


  Conclusion Top


We would like to conclude that serum lipase: amylase ratio fixed at 3.0 can assist in differentiating acute biliary pancreatitis from acute alcoholic pancreatitis. The lipase: amylase ratio ≥3 is observed in alcoholic acute pancreatitis while biliary pancreatitis has ratio <3. Hence, the lipase: amylase ratio can be utilized in predicting the etiology of acute pancreatitis in a patient presenting with clinical features of acute pancreatitis and raised serum levels of amylase and lipase and aid in better management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Treacy J, Williams A, Bais R, Willson K, Worthley C, Reece J, et al. Evaluation of amylase and lipase in the diagnosis of acute pancreatitis. ANZ J Surg 2001;71:577-82.  Back to cited text no. 15
    
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McMahon MJ, Pickford IR. Biochemical prediction of gallstones early in an attack of acute pancreatitis. Lancet 1979;2:541-3.  Back to cited text no. 16
    
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Tenner SM, Steinberg W. The admission serum lipase: Amylase ratio differentiates alcoholic from nonalcoholic acute pancreatitis. Am J Gastroenterol 1992;87:1755-8.  Back to cited text no. 17
    
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Maes B, Hastier P, Buckley MJ, Peten EP, Paolini O, Staccini P, et al. Extensive aetiological investigations in acute pancreatitis: Results of a 1-year prospective study. Eur J Gastroenterol Hepatol 1999;11:891-6.  Back to cited text no. 18
    
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Pacheco RC, Oliveira LC. Lipase/amylase ratio in biliary acute pancreatitis and alcoholic acute/acutized chronic pancreatitis. Arq Gastroenterol 2007;44:35-8.  Back to cited text no. 20
    
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Fan ST, Choi TK, Lai CS, Wong J. Influence of age on the mortality from acute pancreatitis. Br J Surg 1988;75:463-66.  Back to cited text no. 21
    
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King LG, Seeling CB, Ranney JE. The Lipase to amylase ratio in acute pancreatitis. Am J Gastroenterol 1995;90:67-9.  Back to cited text no. 22
    
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Devanath A, Kumari J, Joe J, Peter S, Rajan S, Sabu L, et al. Usefulness of lipase/amylase ratio in acute pancreatitis in Suoth Indian population. Indian J Clin Biochem 2009;24:361-5.  Back to cited text no. 23
    
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Chang KC, Changchien CS, Kuo CM, Chiu YC, Chuah SK, Chiu KW, et al. Clinical analysis of the efficacy in lipase/amylase ratio for acute pancreatitis. J Intern Med Taiwan 2005;16:113-20.  Back to cited text no. 24
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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