Beyond the Pancreas: A Lesson in Lipase Elevation Ryan Threadgill MD, Adam Obley MD Portland VA Medical Center

[ ] Introduction Discussion This is a case of an elderly man with When one encounters an elevation in gastrointestinalDevelopment of bleeda New Practice from Model duodenal lipase, especially one that is greater ulcerations and an elevation in than 3 times the upper limit of lipase >600 in which the elevated normal it is natural to jump to lipase is thought to be from his pancreatitis or other pancreatic duodenal ulcers. It serves as an pathology as the primary cause. opportunity to review the However, it is important to differential diagnosis of an elevated remember that lipase is also lipase and as a reminder that not all produced in the hepatobiliary system elevations in lipase are due to and in many parts of the intestine. pancreatitis. Especially in patients with chronic kidney disease, any hepatobiliary Case Description pathology (cholecystitis, liver injury) A 76 year-old man presented to the or intestinal injury (enterocolitis, hospital[ ] with an acute inflammatory bowelReferences disease, celiac gastrointestinal bleed and was found disease,1. [ ] and peptic ulcer disease) can to have ulcers of the duodenal bulb produce a clinically significant not requiring endoscopic elevation in lipase. There are other intervention. He was treated with an rarer causes such as macrolipasemia, intravenous proton pump inhibitor sarcoidosis, and drug-induced and once he was found to be elevations (DPP4 inhibitors, GLP1 hemodynamically stable he was agonists) that should be considered discharged home. as well. Pancreatitis Diagnostic Criteria Where is Lipase Made? Teaching Points PMH and Medications • Has to meet 2 of 3 criteria • Pancreas 1)Not all lipase is from the pancreas Stage 3 chronic kidney disease, • Lipase >3x the upper limit of • Liver – in hepatocytes and Type 2 diabetes, diet controlled 2)Lipase is cleared by the kidney, so in normal endothelial cells patients with chronic kidney disease Atrial fibrillation, on aspirin • Imaging findings consistent • Intestine – gastric chief cells Heart failure with preserved ejection maintain a broader differential with pancreatitis of stomach, epithelial cells 3)All that being said, lipase has good fraction, on furosemide • Mid-epigastric abdominal pain, of the esophagus, gastro- sensitivity, specificity, and likelihood classically radiating straight esophageal junction, ratios in the diagnosis of pancreatitis Labs: through to back duodenal bulb, and colon CBC: Hg 6.7 g/dL (baseline 15), 3 WBC 14,000/mm How good is lipase in Where is Lipase Cleared? References Lipase >600 IU/L (no prior) pancreatitis? • Kidneys Hameed AM, Lam VWT, Pleass HC. Significant elevations of serum lipase not caused by pancreatitis: a • Sensitivity: 64-100% systematic review. HPB : The Official Journal of the Imaging: International Hepato Pancreato Biliary Association. • Specificity: 99-100% What are the relative 2015;17(2):99-112. doi:10.1111/hpb.12277. CT scan was performed 2 months • +LR: 87 concentrations of lipase? Chao C-T, Chao J-Y. Furosemide and pancreatitis: after discharge given continued Importance of dose and latency period before • -LR: 0.13 • The concentration of lipase reaction. Canadian Family Physician. 2013;59(1):43-45. elevation in lipase and did not reveal is 100 times greater in the Tietz NW, Shuey DF. Lipase in serum – the elusive any evidence of pancreatitis enzyme: an overview. Clin Chem. 1993;39:746–756 pancreas than in the liver or McGee, Steven. Evidence-Based Physical Diagnosis. the bowel Philadelphia, PA: Elsevier Saunders; 2012.