52

Article

Serum amylase and lipase levels in type 2 diabetes mellitus

Noor-E-Jannat Tanvi1, Qazi Shamima Akhter2, Sharmin Nahar3, Mahmuda Nasrin Sumi4, Mobarak Hosen5

Abstract Background: In diabetes mellitus, impaired pancreatic endocrine activity may affect its exocrine function causing mal digestion and malnutrition. Objective: To assess serum amylase and lipase levels in subjects with type 2 diabetes mellitus (T2DM). Methods: This cross sectional study was conducted in the Department of Physiology, Dhaka Medical College, Dhaka from January 2015 to December 2015. Fifty type 2 diabetic subjects with age ranging from 40 to 55 years of both sexes were enrolled in this study and 50 age matched healthy subjects were control group. Patients were enrolled from Outpatient Department of Endocrinology, Dhaka Medical College Hospital, Dhaka. Serum amylase and serum lipase levels were estimated by spectrophotometry. For statistical analysis, unpaired Student ‘t’ test was done. Results: In this study, serum amylase and lipase levels were significantly lower (P<0.001) in comparison to control group. Conclusion: From this study, it is concluded that, exocrine derangement of pancreas may occur in type 2 diabetes mellitus. Key words: Serum amylase, serum lipase, type 2 diabetes mellitus.

J Bangladesh Soc Physiol. 2017, December; 12(2): 52-56 For Authors Affiliation, see end of text. http://www.banglajol.info/index.php/JBSP

Introduction iabetes mellitus (DM) is a metabolic of the pancreas, disease of one portion, may affect disease caused by either absolute the other one5,6. The exocrine acinar cells are D insulin deficiency or impaired sensitivity exposed to high concentration of islet hormones as of tissues to insulin1. Diagnostic criteria of they receive blood flow coming through the nearby diabetes mellitus are fasting blood glucose (FBG) islets7. Evidence suggested that the pancreatic ≥7.0 mmol/L or 2 hour after 75 gm glucose ≥11.1 exocrine function is influenced by the pancreatic mmol/L or Random blood glucose (RBG) ≥11.1 endocrine hormones specially insulin, which has a mmol/L or gycosylated haemoglobin (HbA1c) ≥ trophic effect on the exocrine acinar cells8. 6.5%2. Prevalence of diabetes in Bangladesh was 5.1 million in the year 20133. The pancreatic exocrine acinar cells produce several types of enzymes including amylase and The pancreas is a mixed gland, with the exocrine lipase that helps in digestion of particular food portion making up the greatest volume of 84%, while the endocrine part comprises 2% of it4. As particles. Amylase is the primary enzyme there is a close anatomical and functional responsible to cleave starch into maltose, interaction prevails between these two portions maltotriose and α-limit dextrins in the process of digestion. Lipase is primarily coming from Received 28 August 2017; Accepted 10 Oct. 2017 pancreas, travels all the way down to the intestine

J Bangladesh Soc Physiol. 2017, December; 12(2): 52-53 52 53

Serum amylase and lipase in diabetes Tanvi et al and promotes breakdown of triglycerides into In the human diabetic research of our country, fatty acids and monoglycerides. Due to deficiency very little concern has been given on exocrine of pancreatic enzymes, foods are not properly pancreatic function, as less published data digested and the consequences are mal digestion available regarding this topic. Majority of the and malnutrition9. For many years, it has been studies focused the metabolic derangement due thought that low serum amylase level reflects to impaired insulin action and persistent diffuse pancreatic damage due to advanced hyperglycemia. Therefore, the present study has pancreatic disease. But now a days, several been designed for evaluating exocrine pancreatic studies shown that this low level of serum function by measuring serum amylase and lipase amylase is also associated with metabolic in type 2 diabetic subjects. 10 syndrome and diabetes mellitus . Methods A study investigating the effect of hyperglycemia This cross sectional study was done in the on pancreatic exocrine functions in type 2 diabetic Department of Physiology, Dhaka Medical patients reported that serum amylase and lipase College, Dhaka from January 2015 to December levels significantly increased with the regulation 2015. Protocol of this study was approved by of glycemic control, but still lower as compared Ethical review committee of Dhaka Medical with control. They found a significant negative College. For this study 50 diagnosed type 2 correlation of serum amylase and lipase with basal diabetic patients of both sexes with age ranging FBG and HbA 11. 40-55 years were selected as study group. They 1c were selected from Outpatient Department of In diabetic patients, insulin resistance leads to Endocrinology, Dhaka Medical College Hospital, an increase in the activity of anti-insulin Dhaka. Diagnosis was done by FBG level ≥7.0 hormones and atrophy of exocrine acinar cells. 2 mmol/L or HbA1C ≥ 6.5% . Fifty age matched Thus, exocrine pancreatic enzyme synthesis and healthy subjects were considered as control for secretion is decreased12.The communication comparison. After selection,the nature, purpose between the endocrine islets and the exocrine and benefits of the study were explained to each acinar cells were also lost with the development subject andinformed written consent was taken of type 2 diabetes mellitus. The pancreatic from the participants. Before taking blood, exocrine tissue becomes fibrosed and it shows a detailed family and medical history were taken. reduced response to the hormonal stimulation13. Anthropometric measurement of the subjects In diabetes mellitus, hyperglycemia and/or insulin was recorded and blood pressure was measured. inactivity due to hypoinsulinemia or insulin All the information were recorded in a prefixed resistance may induce pancreatic exocrine questionnaire. With aseptic precaution, 5 ml of dysfunction and the development of pancreatic venous blood was collected from ante-cubital exocrine insufficiency14. vein by a disposable plastic syringe from each subject for biochemical tests. FBG, serum amylase Diabetic subject with pancreatic exocrine and serum lipase were estimated in the insufficiency commonly presents with Department of Laboratory Services of National gastrointestinal symptoms such as loose bowel Institute of ENT, Dhaka. HbA1C was estimated movement, abdominal discomfort and in the laboratory of the Department of flatulance15. In diabetes mellitus, this exocrine Biochemistry of BSMMU, Dhaka. Data were insufficiency can also give rise to deficiency of expressed as Mean±SE. For statistical analysis macronutrients, steatorrhoea and consequent unpaired Student’s ‘t’ test and Pearson’s malnutrition7. correlation coefficient (r) test were done.The P

53 J Bangladesh Soc Physiol. 2017, December; 12(2): 52-56 54

Serum amylase and lipase in diabetes Tanvi et al value of <0.05 was accepted as level of <23 U/L significance. Statistical analysis was performed 28% by using a computer based statistical program SPSS (version 22).

Results General characteristics are presented in Table I. There were no significant differences in any >23 U/L variables between study group and control. 72%

Table I: General characteristics of the subjects in Figure 1: Frequency distribution of serum both groups (n=100) amylase level in study group (n=50)

Variables Control Diabetics <5 U/L (n=50) (n=50) Age (years) 45.64±0.59 47.06±0.65

Male no.(%) 24 (48.0%) 22 (44.0%) 100% Female no.(%) 26 (52.0%) 28 (56.0%) BMI (kg/m2) 25.77±0.50 25.77±0.58 Systolic BP (mmHg) 116.20±1.41 122.70±1.75 Diastolic BP (mmHg) 76.40±1.08 78.70±1.07 Figure 2: Frequency distribution of serum lipase Sex distribution has been shown in number and level in study group (n=50) percentage. All other results are expressed as mean±SE. Unpaired Student’s ‘t’ test was performed for Correlation analysis showed significant negative comparison between groups. n=number of subjects. correlation between serum amylase level and duration of disease in study group (Figure 3). Mean serum amylase and lipase were significantly This study also showed negative correlation (p<0.001) lower in type 2 diabetic patients (study between serum lipase level and duration of disease in study group (Figure 4). group) compared to those of control (Table II).

100.00 r=-0.321, Table II: Serum amylase and serum lipase levels p=0.023 of the subjects in both groups (n=100) 80.00

Variables Control Diabetics 60.00 (n=50) (n=50) *** Serum amylase (U/L) 56.37±1.84 33.37±2.36 40.00 ***

Serum lipase (U/L) 29.34±0.43 21.58±1.69 Serumamylase (U/L) 20.00 Data were expressed as mean±SE. Unpaired Students ‘t’ test was performed for comparison between groups. *** p<0.001. .00 .00 2.00 4.00 6.00 8.00 10.00 12.00 14.00 This study showed that 28% subjects with type Duration of disease (years) 2 DM had serum amylase level <23 U/L (Figure 1) Figure 3: Correlation of serum amylase level with and 100% of subjects had serum lipase level <5 duration of disease in study group (n=50). Correlation was done by Pearson’s correlation U/L (Figure 2). coefficient test.

J Bangladesh Soc Physiol. 2017, December; 12(2): 52-56 54 55

Serum amylase and lipase in diabetes Tanvi et al

damage of the exocrine pancreas and leads to impaired synthesis of pancreatic digestive enzymes11. Some authors suggested that, hyperglycemia can cause disturbance in cellular signaling that controls both transcription and protein metabolism in the pancreas leading to pancreatic exocrine insufficiency in DM25.

Conclusion From the results of the study, it may be concluded that, lower serum amylase and lipase levels in T2DM may be associated with the derangement of exocrine-endocrine axis leading to impaired Figure 4: Correlation of serum lipase level with exocrine pancreatic function. duration of disease in study group (n=50). Correlation was done by Pearson’s correlation Conflict of Interest: None coefficient test. Acknowledgment Discussion The authors acknowledge the Department of In this study, the mean serum amylase level was Endocrinolog of Dhaka Medical College, the significantly lower in type 2 diabetic patients than Department of Laboratory Services of National that of adult healthy subjects. This finding was Institute of ENT and the Department of in agreement with results of some workers Biochemistry of BSMMU, Dhaka, for their kind 6,11,16,17,20-22. On the contrary, some researchers co-operation during sample collection and found serum amylase level was significantly analysis. higher in type 2 diabetic subjects23,24. Author Affiliation In the present study, mean serum lipase level 1. *Noor-E-Jannat Tanvi, Lecturer, Department of was significantly lower in type 2 diabetic subjects Physiology, Shaheed Suhrawardy Medical College, Dhaka. email: [email protected]. Cell :+88 than that of adult healthy subjects.Similar type 01712200914 of observations was found by some 2. Qazi Shamima Akhter, Professor and Head, researchers11,21,22. But some investigators found Department of Physiology, Dhaka Medical College, Dhaka. email: [email protected] higher serum lipase level in type 2 diabetic 3. Sharmin Nahar, Lecturer, Department of Physiology, 23 subjects . Dhaka Medical College, Dhaka. email: taharat [email protected]. In this study, serum amylase and lipase levels 4. Mahmuda Nasrin Sumi, Assistant Professor, showed negative correlation with duration of Department of Physiology, Jahurul Islam Medical disease in study group. The relationship between College, Bajitpur, Kishoregonj. email: serum amylase and duration of disease was [email protected]. 5. Mobarak Hosen, Officer on Special Duty (OSD), statistically significant.Similar finding was also Directorate General of Health Services, Ministry of made by other research workers20. Amylase in Health and Family Welfare, Dhaka. email: type 2 diabetic subjects became more severely [email protected]. affected in long-standing cases of diabetes *For correspondence mellitus16. References Literature review suggested that in diabetes 1. Hall JE. Insulin, Glucagon, and Diabetes Mellitus. In: Hall JE, editor. Guyton and Hall Text Book of mellitus, hyperglycemia may cause cellular Medical Physiology. 13th ed. Philadelphia

55 J Bangladesh Soc Physiol. 2017, December; 12(2): 52-56 56

Serum amylase and lipase in diabetes Tanvi et al

Pennsylvania; Saunders publications: 2011. p.983 ultrastructural abnormalities. J Cardiometab Syndr. – 999. 2008; Fall 3(4): 234–43. 2. Seino Y, Nanjo K, Tajima N, Kodawaki T, Kashiwagi 14. Nakajima K, Oshida H, Muneyuki T, Kakei M. A, Araki E et al. Report of the committee on the Pancrelipase: an evidence-based review of its use classification and diagnostic criteria of diabetes for treating pancreatic exocrine insufficiency. Core mellitus. J Diabetes Invest. 2010; 1(5): 212-8. Evid. 2012; 7: 77–91. 3. Guariguata L, Whiting DR, Hambleton I, BeagleyJ, 15. Cummings M. Pancreatic exocrine insufficiency in LinnenkampU, Shaw JE. Global estimates of diabetes type 1 and type 2 diabetes – more common than prevalence for 2013 and projections for 2035. you think?. J of Diabetes Nurs. 2014; 18: 320-3. Diabetes Res Clin Pract. 2014 Feb; 103(2):137- 16. Aughsteen AA, Abu-Umair MS, Mahmoud SA. 49. Biochemical analysis of serum pancreatic amylase and lipase enzymes in patients with type 1 and 4. Singh J, Yago MD, Adeghate E. The role of insulin, type 2 diabetes mellitus. Saudi Med J. 2004; 26(1): glucagon, somatostatin, cholecystokinin, 73-7. acetylcholine and nerve stimulation in the interactions between the endocrine and exocrine 17. Yadav R, Bhartiya JP, Verma SK, Nandkeoliar MK. pancreas in normal and diabetic conditions in rats. The Evaluation of Serum Amylase in the Patients Int J Diabetes 1999; 7(1): 114-9. of Type 2 Diabetes Mellitus, with a Possible Correlation with the Pancreatic Functions. J of 5. Pap Á. Effect of insulin and glucose metabolism on Clin and Diagn Res. 2013; 7(7): 1291-4. pancreatic exocrine function. Int J Diabetes and Metabolism 2004; 12(3): 30-4. 18. Srihardyastutie A, Soeatmadji DW, Fatchiyah, Aulanni’am. Relation of elevated serum lipase to 6. Jain R, Jain PK, Mangukiya K. Study of serum Indonesian type 2 diabetes mellitus progression. amylase in the patients of type 2 diabetes mellitus. Biomed Res. 2015; 26(2): 293-8. IJSN. 2014; 5(3): 553-6. 19. Mahmoud GMG, Ahmed SM. Assessment of plasma 7. Chakraborty PP, Chowdhury S. A Look Inside the Alpha amylase level in Sudanese with type 2 Pancreas: The “Endocrine-Exocrine Cross-talk”. diabetes mellitus. J Sci Technol. 2013; 14: 65-70. Endocrinol Metab Synd. 2015; 4: 1. 20. Ewadh MJ, Juda TM, Ali ZA, Ewadh MM. 8. Barreto SG, Carati CJ, Toouli J, Saccone GTP. The Evaluation of amylase activity in patients with islet-acinar axis of the pancreas: more than just type 2 daibetes mellitus. Am J of Biosci 2014; 2(5): insulin. Am J Physiol Gastrointest Liver 171-4. Physiol. 2010 Jul; 299(1):G10-22. 21. Ravisekar P, Selvi VSK, Devi AJM, Shanthi B. Study 9. Barrett KE, Barman SM, Boitano S, Brooks HL. of serum pancreatic enzymes in patients with type Ganong’s review of medical physiology. 24thed. New 2 diabetes mellitus. Res J Pharm Biol Chem Sci Delhi: Tata McGraw-Hill. 2012. Chapter 26, 2015; 6(6): 144-6. Digestion, Absorption and Nutritional Principles; 22. Ure O, Ata N, Kucukazman M, Tutal E, Caglar F, 477-495p. Hokkaomeroglu M et al. Glycemic control 10. Nakajima K, Nemoto T, Muneyuki T, kakei M, influences CA19-9, CEA and ferritin levels in type Fuchigami H, Munakata H. Low serum amylase in 2 diabetes. presented at society of endocrinology association with metabolic syndrome and diabetes: IECE 2012, Florance,Italy,endocrine abstracts A community-based study. Cardiovasc Diabetol. 2012;29: P512. [Internet] available from:http:// 2011; 10: 34. www.endocrine-abstracts.org/ea/0029/ ea0029p512.htm 11. Ata N, Dal K, Kucukazman M, Yeniova AO, 23. Farhood HB, Al-salih RMH, Radhi MN. Clinical Karakaya S, Unsal O et al. The effect of glycemic studies to evaluate pancreatic functions in the control on CEA, CA 19-9, amylase and lipase levels. patients of type 2 diabetes mellitus. IJIAS 2014; Open Med. 2015; 10: 8-13. 7(1): 413-20. 12. Demir K. Pancreatic dyspepsia: a place for 24. Abdelsalam KEA. Lipoprotein lipase, amylase and pancreatic insufficiency in dyspepsia. Eur J Surg triglyceride alteration: lean diabetic and obese (non- Sci. 2012; 3(1): 1-4. diabetic) patients. IJSBAR 2015; 23(2): 95-103. 13. Hayden MR, Patel K, Habibi J, Gupta D, Tekwani 25. Patel R, Atherton P, Wackerhage H, Singh J. SS, Whaley-Connell A et al. Attenuation of Signaling protein associated with diabetic-induced endocrine-exocrine pancreatic communication in exocrine pancreatic insufficiency in rats. Ann N Y type 2 diabetes: pancreatic extracellular matrix Acad Sci 2006 Nov; 1084:490-502.

J Bangladesh Soc Physiol. 2017, December; 12(2): 52-56 56