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DIFFERENTIAL DIAGNOSIS out Immediately the Blood Samples Had Been Taken 602 Ocr. 3, 1959 ACRYLIC INVESTMENT OF INTRACRANIAL ANEURYSMS Bwrrm colleagues at the South-western Regional Neurosurgical TABLE I.-Serum Amylase Estimations in 454 Cases Unit, Mr. Douglas Phillips and Mr. Allan Hulme, who encouraged me to make use of the method in their cases Serum Amylase (Units/100 ml.) Total Diagnosis No. and for allowing me access to their notes, and to specially <200 200-355 400-640 800+ Cases thank Mr. G. F. Rowbotham, of the Regional Centre of Neurological Surgery, Newcastle upon Tyne, who also Acute appendicitis .. 85 5 Nil Nil 90 Exacerbation of peptic ulcer 81 6 9 .. 87 referred three cases to me. I am especially grateful to Perforated viscus .. .. 20 12 2 1 35 Intestinal obstruction .. 29 5 Nil Nil 34 Dr. R. M. Norman and Dr. R. Sandry, of the Neuro- Coronary thrombosis .. 30 Nil 30 pathological Laboratory, Frenchay Hospital, Bristol, for the Acute cholecystitis .. 55 5 1 61 Miscellaneous .. .. 67 4 1 72 histological studies. I also wish to acknowledge the grant Acute pancreatitis .. .. Nil 2 12 27 41 made by the University of Bristol Department of Surgery Clhronic pancreatitis .. 2 1 1 Nil 4 and to Professor Masservy and staff of the Veterinary College, Langford, for facilities for the preliminary experimental work. (1946). This measures the rate of hydrolysis of a REFERENCES standard starch solution (75 mg. /100 ml.) by the af Bjorkesten, G., and Troupp, H. (1958). Acta chir. Scand., 115, amylase at 370 C. to erythrodextrin, achrodextrin, 153. Coy, H. D., Bear, D. M., and Kreshover, S. J. (1952). J. Amer. maltose, and glucose. Sampling was carried out at 30 dent. Ass., 44, 251. seconds and one minute, then at two-minute intervals, Dutton J. E. M. (1956). Brit. med. J., 2, 585. reverting to intervals of 30 seconds when the end-point Hook, 6., and Norlen, G. (1958). Acta chir. Scand., Suppi., 235, 1. van Huysen, G., and Boyd, D. A. (1953). J. prosth. Dent., 3, 818. (a final disappearance of any blue colour) was neared. Kramer, I. R. H. (1955). J. dent. Res., 34, 782. A normal range of 60 to 200 units/ 100 ml. was (1956). Proc. roy. Soc. Med., 49, 376. and McLean, J. W. (1952). Brit. dent. J., 92, 255, 281, 311. established. Lefkowitz, W., Seelig, A., and Zachinsky, L. (1949). N.Y. St. dent. J., 15, 376. Precautions Logue, V. (1956). Brit. med. J., 1, 473. (a) Blood for serum amylase estimation was taken in Massler, M., and Silberkweit, M. (1954). J. dent. Res., 33, 712. Muller, 0., and Maeglin, B. (1953). Int. dent. J., 4, 167. all cases prior to operation or administration of Norldn, G., and Olivecrona, H. (1953). J. Neurosurg., 10, 404. morphine derivatives. Nygaard-Ostby, B. (1955). J. Amer. dent. Ass., 50, 7. Robinson, R. G., and Macalister, A. D. (1954). Brit. J. Surg., 42, (b) McGeachin (1953) stated that no deterioration in 312. serum amylase activity occurred in serum stored at Zander, H. A. (1951). Oral Surg., 4, 1563. 40 C. for periods up to 72 hours. Six out of 30 consecutive serum amylases of the early cases, redetermined after refrigeration at 40 C. for periods SERUM AMYLASE ESTIMATIONS IN varying from 12 to 24 hours, showed some diminution in activity. In consequence, all estimations were carried DIFFERENTIAL DIAGNOSIS out immediately the blood samples had been taken. BY (c) Salivary contamination of the starch substrate was ROGER CHAPMAN, M.B., Ch.B. prevented by incorporating cotton-wool filters in all Registrar in Pathology, Sefton General Hospital, Liverpool pipettes. (d) Amylase-producing organisms may be introduced "The diastase content of each individual is very into the substrate and cause deterioration. The constant, so that deviations from this normal value are commonest significant natural contaminants, shown by significant " (Somogyi, 1938, 1941). The simplest daily cultures of the substrate, were starch-splitting laboratory investigation used in differentiating acute organisms of the Bacillus subtilis group. Estimations pancreatitis from other " acute abdomens " is the serum using starch solution grossly contaminated with these amylase estimation. Occasional rises encountered in cultures were compared with the results using other abdominal emergencies (Burnet and Ness, 1955), uncontaminated starch and after seven days with a after the administration of opiates (Wapshaw, 1953), in freshly prepared substrate. No deterioration occurred mumps (Wolman et al., 1947), after alcohol (Carter, over this period provided the solution was refrigerated 1945), in renal failure and other miscellaneous when not in use. In consequence starch substrate conditions (Polowe, 1946), have thrown doubt on its was prepared freshly every week, stoppered, and value. This study is a critical evaluation of a rapid refrigerated between estimations. " side-room" serum amylase estimation in conditions (e) The difficulty of recognition of the end-point in which often present as a differential diagnosis of acute artificial light or with bile-stained serum was obviated pancreatitis. In addition, the case histories of those by the use of a white tile, on to which equal volumes conditions other than acute pancreatitis where a rise of the sample and iodine were placed. was encountered have been analysed to try to demon- strate any common factors. Acute Pancreatitis For the purposes of this study serum amylase The ranges of serum amylase encountered in the 41 estimations were carried out on 454 patients, divided as cases of acute pancreatitis can be seen in Table I. follows: (a) 45 cases of pancreatitis (41 acute and 4 Twenty-four were 1,100 units or above, and all chronic) in which the diagnosis was made in 32 cases determined within 24 hours of the onset of symptoms on clinical grounds in conjunction with a raised serum were 533 units or greater. A pre-operative diagnosis amylase, in 11 cases by laparotomy, and 2 cases at of acute pancreatitis was made only once without the necropsy (Table II); (b) 337 cases of conditions aid of enzyme studies, and here laparotomy had to be recorded as the differential diagnosis of acute resorted to for confirmation (Case 35, Table II). Four pancreatitis; and (c) 72 miscellaneous causes of acute of the 15 other cases proved by laparotomy (Cases 3, abdominal pain. 5, 19, and 57) died post-operatively, whereas only 2 of Method.-The method used was a modification of the 25 with a raised serum amlyase treated conserva- Somogyi's iodometric technique as described by King tively were fatal. 7 OcT. 3, 1959 SERUM AMYLASE ESTIMATIONS IN BRasH 603 DIAGNOSIS MIDICA4L JOU1UL TABLE II.-Serum Amylase Values in Acute and Chronic TABLE II (continued) Pancreatitis Mode Serum Even- I Case Differentia of Amy- tual ~~~~oeSerumEvnAmy Even- N Sex Age Difeetil Confir- lase Out- Connnents Cas'e DifeetMlode ase tul Comments No. SxAge!Sx DifrniloDiagnosis Confir- (ntf Out- No. Diagnosis mation (Units! come 100o mi.) come _______ ~~~~100 mi.) - -~~~~~~mation 50 F 73 Biliary colic Clinical 1,600 F 45 Acute cholecyst- Clinical 3,200 Recov- 51 F 65 Ac. cholecystitis t, 533 I day after itis ery onset M 68 Ac. cholecystitis 1,600 52 F 66 go ,, 91 1,600 and perforation 53 F 68 go Laparo- None Chronic 3 F 40 Perforation . Laparo- 650 Death tomy tomy 54 M 55 Pancreatitis Clinical 2,400 4 M 65 Ac. cholecystitis Clinical 533 Recov- 55 F 45 Ac. exacerbation S, 1,600 and int. obstruc- ery or perforation tion or ac. chole- 5 F 6C6 Perforation Laparo- None Death cystitis tomy 56 F 35 Ac. cholecystitis 9. 1,600 .. Post-puer- 6 F 65 Int. obstruction 100 Recov- Chronic peral pat- ery creatitis 7 F 59 Perforation and Clinical 3,200 57 F 70 Perforation Laparo- 1,100 Death 1 day after ac. cholecystitis tomy onset 8 F 46 Perforation and 3,200 58 F 43 Ac. cholecystitis Clinical 400 Recov- 3 days after biliary colic ery onset 9 F 66 Cor. thrombosis, ',,I 1,600 Confirmed perforation, at laparo- and exacerba- tomy 6 tion ofduodenal months ulcer later The age range was 25 to 78 years, with an arithmetric 10 F 73 Perforation or 533 mean of 59 years (see Chart). The ages recorded exacerbation of duodenal ulcer showed two well-marked frequency peaks between 40 11 F 72 Cor. thrombosis 1,600 and exacerba- and 45 years and again between 60 and 70 years. tion of duo- Forty-one cases were female and only 17 denal ulcer male. 121 M 160 Ac. cholecystitis 8001 Laparotomy and exacerba- refused tion of duo- denal ulcer 13 M 66 Perforation 1,100 Death P.M. refused 14 F 47 Pancreatitis 1,600 Recov- ery 15 M 44 Perforation 3,200 16 M 67 Perforation of Laparo- 400 et.. duodenal ulcer tomy 17 M 55 Pancreatitis Clinical 1 1,600 18 M 50 Exacerbation of 533 to Amylase 2 duodenal ulcer days after onset 19 F 78 Ac. cholecystitis Nec- None Death ropsy 20 F 66 Clinical 1,600 Recov- ery 21 F 69 Laparo- 533 Laparotomy tomy 2/12 later ,, confirmed 22 F 68 Ac. appendicitis None 23 F Perforation P. Is o 24 F 6365 Perforation or cor. thrombosis I,J. 25 M 72 Carcinoma of Clinical 320 ., Chronic Age incidence of patients with acute stomach pancreatitis. 26 F 68 Perforation Laparo- 400 Post-op. tomy,, amylase 27 F 55 Biliary colic Clinical 800 The serum amylase generally fell rapidly in 48 to 72 28 F 67 Stone in common 800 ., X-ray con- hours in those cases with an initially high bile duct firmation level, but was 29 M 61 Cholecystitis . Laparo- 620 still above the upper limit of normal in a moderate tomy 30 M 47 Exacerbation of 640 number of cases after seven days.
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