You are in: eMedicine Specialties > Gastroenterology > Pancreas HyperamylasemiaArticle Last Updated: Nov 20, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 7
  Author: Abraham Mathew, MD, MS, Assistant Professor of Medicine, Department of Internal Medicine, Division of Gastroenterology and Hepatology, Pennsylvania State University College of Medicine; Medical Director of Endoscopy, Hershey Medical Center Abraham Mathew is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy Coauthor(s): Albert F Chiemprabha, MD, Department of Internal Medicine, Division of Gastroenterology, Fellow, River Region Health System, Vicksburg, Mississippi; Shirley Donelson, MD, Program Director, Assistant Professor, Department of Internal Medicine, Division of Digestive Diseases, University of Mississippi Medical School Editors: Tushar Patel, MD, Associate Professor, Department of Internal Medicine, Texas A&M College of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Oscar S Brann, MD, FACP, Associate Clinical Professor, Department of Medicine, University of California at San Diego; Consulting Staff, Mecklenburg Medical Group; Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine; Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania Author and Editor Disclosure Synonyms and related keywords: elevated amylase, pancreatitis, pancreatic necrosis, parotitis, pseudocysts, pancreatic ascites, pancreatic trauma, choledocholithiasis, salivary glands, intestinal disease BACKGROUNDSection 2 of 7
  Amylase is a digestive enzyme that normally acts extracellularly to cleave starch into smaller carbohydrate groups and, finally, into monosaccharides, by hydrolysis of internal alpha-1,4-glycoside bonds, which results in the production of maltose and oligosaccharides. Among healthy individuals, the pancreas and the salivary glands account for almost all serum amylase, 40-45% from the pancreas and 55-60% from the salivary glands. Serum amylase is increased in at least 75% of pancreatitis cases; however, serum amylase can be normal, even in the face of massive pancreatic necrosis. The major limitation of using serum amylase measurement in diagnosing pancreatitis is the lack of specificity because numerous clinical situations can result in elevated amylase. PATHOPHYSIOLOGYSection 3 of 7
Origins of serum amylase A variety of organs and secretions contain amylase activity, including the pancreas, salivary glands, fallopian tubes and cyst fluid, testes, lungs, thyroid, tonsils, breast milk, sweat, tears, and some malignant neoplasms. The pancreas and salivary glands contain amylase concentrations several orders of magnitude greater than other organs. Because large quantities of amylase are required to maintain the serum amylase level, it is unlikely that the other listed organs are important sources of amylase. This is demonstrated clearly in electrophoresis studies of normal serum. Electrophoresis shows that serum amylase is of 2 main types, as follows: (1) P-type amylase from the pancreas, and (2) S-type amylase from the salivary glands. Fallopian tube secretions, tears, breast milk, and sweat have amylases with a similar electrophoretic mobility of salivary isoamylase. However, the salivary glands account for almost all of the S-type isoamylase. Metabolic clearance of serum amylase The exact mechanisms of serum amylase metabolism are still not fully understood. Humans who have had a nephrectomy or have renal insufficiency have average serum amylase levels 50% higher than healthy individuals. Therefore, the kidneys can be assumed to play a major role in amylase metabolism. However, the kidney is not the sole organ responsible for amylase clearance in humans. The extrarenal mechanisms of amylase clearance have not been clearly defined. Because of the high serum amylase levels also observed in hepatic necrosis and cirrhosis, the liver is thought to play a role in amylase metabolism. Factors influencing serum amylase Many conditions have been reported to cause hyperamylasemia. Although hyperamylasemia is commonly assumed to be due to the release of amylase into the serum by the diseased organ, the precise relationship between hyperamylasemia and an affecting condition is not entirely clear. Hyperamylasemia is most commonly a result of (1) pancreatitis or parotitis, (2) decreased metabolic clearance of amylase, or (3) amylase released from an involved organ. CAUSESSection 4 of 7
Pancreatic diseases Acute or chronic pancreatitis is associated with increases in the P-type isoamylase. In acute pancreatitis, serum amylase is usually elevated 3-fold and then returns to normal by 3-7 days. Patients with pancreatitis associated with hypertriglyceridemia or those with considerable acinar cell injury due to previous episodes of pancreatitis or chronic pancreatitis may not exhibit hyperamylasemia. Other reasons for hyperamylasemia that are associated with pancreatitis are pseudocysts, pancreatic ascites, pancreatic trauma, and choledocholithiasis. Pancreatic trauma can be a result of blunt trauma, abdominal or retroperitoneal surgery, or endoscopic retrograde cannulation of pancreatic duct (ERCP). Trauma related to ERCP is thought to result from the regurgitation of amylase into the blood, which may occur in 75% of ERCPs, but most have no evidence of pancreatic injury. A 3- to 4-times increase in serum amylase levels 4 hours after ERCP predicts the occurrence of complicating postprocedure pancreatitis. In patients presenting with biliary-type abdominal pain, a 3-fold increase in serum amylase levels that returns to normal within 48-72 hours suggests stone passage through the common bile duct. Parotitis is associated with increases in the S-type isoamylase. Parotitis is usually caused by trauma or surgery to the salivary gland, radiation to the neck area involving the parotid gland and subsequently causing duct obstruction, or calculi of the salivary duct. Another cause of damage to the salivary gland is from chronic alcoholism. Salivary amylase levels are 3 times higher than normal in 10% of patients with alcoholism; this may be related to chronic liver disease. Decreased metabolic clearance Renal failure results in increased S-type and P-type isoamylases. Liver disease from hepatitis or cirrhosis also results in increased S-type and P-type isoamylases. Macroamylasemia Gut diseases, including mucosal inflammatory disease of the small intestine, mesenteric infarction, intestinal obstruction, appendicitis, and peritonitis, usually result in increased P-type isoamylase because of increased absorption of amylase from the intestinal lumen. Gut perforation leaks the contents into the peritoneum causing inflammation and absorption of amylase across the inflamed peritoneum. This can result in hyperamylasemia. Female reproductive tract disease Ruptured ectopic pregnancy, fallopian or ovarian cysts, and salpingitis can result in increased S-type isoamylase. Miscellaneous causes Ectopic amylase production by lung, ovary, pancreas, and colon malignancies; pheochromocytoma; thymoma; multiple myeloma (increased salivary amylase); and breast cancer (increased pancreatic amylase) are miscellaneous causes of hyperamylasemia. Acidosis, which can be due to (1) ketoacidosis that results in increased S-type and P-type isoamylases or (2) nonketotic acidosis that results in increased S-type isoamylase, can cause hyperamylasemia. Amylase increases may occur postoperatively, resulting in increased S-type and P-type isoamylases; however, an increase in salivary amylase is more common. This may occur after extracorporeal circulation or nonabdominal surgery (eg, 30% of patients undergoing cardiac surgery have elevated S-type isoamylase). Other causes of hyperamylasemia include pneumonia (increased salivary amylase), cerebral trauma, burns, abdominal aortic aneurysms (increased pancreatic amylase), drugs (increased salivary and/or pancreatic amylase), anorexia nervosa and bulimia (increased salivary amylase), nonpathologic (increased salivary and/or pancreatic amylase), and organophosphate poisoning. Rare cases of hyperamylasemia are reported in association with systemic lupus erythematosus (SLE), as well as ciprofloxacillin treatment. LAB STUDIESSection 5 of 7
The most widely used application of serum amylase measurements is to support a diagnosis of acute pancreatitis. In acute pancreatitis, the serum amylase is increased at least 3-fold in approximately 75% of cases on the initial day of symptoms; then, it usually returns to normal by 3-7 days. The specificity of the test increases with higher levels of the enzyme. Serum amylase measurements are not very sensitive or specific for pancreatic injury because they may be normal in patients with preexisting acinar injury or chronic pancreatitis and because many other causes of hyperamylasemia are described (see Causes). One should remember that a patient with asymptomatic chronic hyperamylasemia almost never has pancreatic disease as the cause of the amylase elevation. In cases of mild elevations of serum amylase, other methods may be used to help determine the cause of hyperamylasemia. The amylase-to-creatinine clearance ratio (ACR) can help differentiate acute pancreatitis from other conditions. This ratio is calculated using the following equation: An ACR of greater than 5% suggests acute pancreatitis. However, the ACR is also known to be increased in diabetic ketoacidosis and renal disease and after surgery. An ACR of less than 1% suggests macroamylasemia. Because findings of urinary amylase are relatively nonspecific, calculations for urinary amylase excretion have almost no clinical value. Generally, the ACR measurement has been abandoned, except to confirm a diagnosis of macroamylasemia, which is characterized by a low ACR. SPECIAL CONCERNSSection 6 of 7
In pancreatitis with associated hypertriglyceridemia, serum amylase levels may be erroneously normal. This is attributed to an inhibitor associated with triglyceride elevations that interferes with the assay for the enzyme. Diluting the serum can reduce the activity of the inhibitor such that a recalculation of serum amylase can uncover true serum amylase levels. REFERENCESSection 7 of 7
Article Last Updated: Nov 20, 2007 |
