What are the next steps for a patient with a slight elevation of amylase and lipase (enzymes) levels?

From the Guidelines

For a patient with a slight elevation of amylase and lipase levels, the next steps should include a thorough clinical evaluation to determine the underlying cause, as mild elevations can indicate early pancreatitis or other conditions requiring specific treatment. The physician should take a detailed medical history focusing on risk factors for pancreatic disease such as alcohol consumption, medication use, gallstones, and family history 1. Physical examination should assess for abdominal tenderness, especially in the epigastric region.

Key Considerations

• Additional diagnostic tests are typically warranted, including abdominal imaging (ultrasound, CT scan, or MRI) to evaluate the pancreas and biliary system.
• Laboratory tests should be repeated to monitor enzyme levels and assess for other abnormalities in liver function tests, triglycerides, and calcium levels, as serum triglyceride levels over 11.3 mmol/l (1000 mg/dl) can indicate hypertriglyceridemia as the etiology 1.
• While waiting for further evaluation, the patient should avoid alcohol and fatty foods that might exacerbate pancreatic inflammation.
• Adequate hydration should be maintained, and over-the-counter pain medications like acetaminophen may be used for discomfort.

Diagnostic Approach

• The cut-off value of serum amylase and lipase is normally defined to be three times the upper limit 1, which guides the interpretation of the patient's enzyme levels.
• Other laboratory parameters such as C-reactive Protein, hematocrit, urea, and procalcitonin can provide prognostic information and help in the management of severe acute pancreatitis 1.
• In the absence of gallstones or significant history of alcohol use, measuring serum triglyceride and calcium levels is recommended 1.

From the Research

Next Steps for Patients with Slight Elevation of Amylase and Lipase

• The differential diagnosis for elevated serum levels of amylase and lipase is broad and includes 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.
• Extensive investigation of patients with mild elevations of serum amylase and/or lipase may be 'low yield' and the cost effectiveness and risk-benefit ratio of such investigations warrants further study 3.
• Serum amylase and lipase levels may be elevated in nonpancreatic disease processes of the abdomen, but significant elevations (greater than three times upper limit of normal) in either enzyme are uncommon in these disorders 4.
• Asymptomatic elevation of serum lipase and amylase can occur in patients with Crohn's disease and ulcerative colitis, and does not necessarily require specific pancreatitis therapy 5.
• Isolated elevation of lipase with normal amylase can be related to various conditions such as renal insufficiency, nonpancreatic sources of lipolytic enzymes, acute cholecystitis, esophagitis, delayed blood withdrawal, hypertriglyceridemia, or subclinical pancreatitis 6.

Diagnostic Considerations

• Serum lipase is a better test than serum amylase to exclude or support a diagnosis of acute pancreatitis 4.
• A simultaneous determination of both amylase and lipase is recommended for the evaluation of patients with abdominal pain 6.
• The correlation between elevation of admission serum amylase and lipase was observed in both extrapancreatic and pancreatic disease processes 4.

Treatment Implications

• The therapy for patients with asymptomatic elevation of lipase and amylase should be guided by the requirements of the underlying disease therapy, such as IBD therapy 5.
• Specific pancreatitis therapy is not necessary in cases where the increase of lipase or amylase is without typical symptoms of pancreatitis 5.