From the Guidelines
Elevated amylase levels in the blood typically indicate inflammation or damage to the pancreas, a condition known as pancreatitis, though other conditions can also cause this finding. When encountering elevated amylase, clinicians should first assess for symptoms like severe abdominal pain, nausea, vomiting, and fever, which may suggest acute pancreatitis. Initial management includes NPO (nothing by mouth), intravenous fluids (typically crystalloids at 250-500 mL/hour initially, then adjusted based on response), pain control with medications like morphine (2-4 mg IV every 4 hours as needed), and monitoring for complications. It's essential to identify and address underlying causes such as gallstones, alcohol use, medications, hypertriglyceridemia, or hypercalcemia. Additional diagnostic tests should include lipase levels (often more specific for pancreatic inflammation), complete blood count, metabolic panel, liver function tests, and abdominal imaging (ultrasound or CT scan) 1. Elevated amylase can also occur in conditions unrelated to the pancreas, including salivary gland disorders, intestinal obstruction, macroamylasemia, renal insufficiency, and certain cancers, so clinical correlation is essential for proper diagnosis and treatment. The choice of diagnostic technique at admission must be based on the hemodynamic status, and contrast-enhanced CT-scan is the fastest and most comprehensive technique for evaluating duodeno-pancreatic injuries 1. Repeated and combined measurement of serum amylase and lipase levels, starting from 3 to 6 h after the initial injury, is a useful tool to support clinical evaluation in suspicion of pancreatic injury 1. Lipase levels are considered a more reliable diagnostic marker of acute pancreatitis than serum amylase, with higher sensitivity and a larger diagnostic window 1. In cases of trauma, the diagnosis of duodeno-pancreatic injuries represents a challenge, and clinical signs are highly non-specific, especially in the early post-traumatic period 1. The presence of free fluid in the absence of solid organ injury on E-FAST may be a sign of hollow viscus injury, but it has limited role in diagnosing acute pancreatic or duodenal injuries 1. Serum lipase is more specific than amylase, and serum lipase may support targeted screening of patients with clinical suspicion of PI 1. Given the potential for missed diagnoses and the importance of early intervention, a thorough and multidisciplinary approach is crucial in managing patients with elevated amylase levels.
From the Research
Elevated Amylase: Causes and Diagnostic Approaches
- Elevated serum amylase levels can be caused by various conditions, including acute pancreatitis, chronic pancreatitis, gastrointestinal tract obstruction, malignancies, and other disease conditions 2
- A systematic approach to patients with elevated amylase and/or lipase is critical to making an accurate diagnosis and initiating appropriate treatment 2
Management of Pancreatic Necrosis
- Pancreatic necrosis is associated with substantial morbidity and mortality, and optimal management requires a multidisciplinary approach, including gastroenterologists, surgeons, interventional radiologists, and specialists in critical care medicine, infectious disease, and nutrition 3
- Antimicrobial therapy is best indicated for culture-proven infection in pancreatic necrosis or when infection is strongly suspected, and broad-spectrum intravenous antibiotics with ability to penetrate pancreatic necrosis should be favored 3
- Drainage and/or debridement of pancreatic necrosis is indicated in patients with infected necrosis, and may be required in patients with sterile pancreatic necrosis and persistent unwellness or associated complications 3
Treatment of Infected Pancreatic Necrosis
- Appropriate treatment of infected necrosis is essential to reduce morbidity and mortality, and overall knowledge of the treatment options within a multidisciplinary team is essential in the treatment of this complex disease 4
- Invasive diagnostics, such as fine-needle aspiration, are advocated, and antimicrobial stewardship principles apply, including de-escalation of broad-spectrum therapy once cultures become available, and early withdrawal of antibiotics once source control has been established 4
- Prophylactic treatment with effective antibiotics, such as imipenem, may reduce the rate of septic complications in patients with severe pancreatitis 5
Diagnostic Strategies
- Serum amylase and lipase tests are routinely performed in patients presenting with abdominal pain or during regular health screening, and elevated serum levels of these two enzymes are often encountered in clinical practice 2
- A systematic approach to patients with elevated amylase and/or lipase is critical to making an accurate diagnosis and initiating appropriate treatment, and includes considering the broad differential diagnosis and using diagnostic strategies such as imaging and laboratory tests 2