Clavien P A, Robert J, Meyer P, Borst F, Hauser H, Herrmann F, Dunand V, Rohner A
Department of Surgery, University Hospital, Geneva, Switzerland.
Ann Surg. 1989 Nov;210(5):614-20. doi: 10.1097/00000658-198911000-00008.
A consecutive series of 352 attacks of acute pancreatitis (AP) was studied prospectively in 318 patients. AP was ascertained by contrast-enhanced CT scan in all but four cases in which diagnosis was made at operation or autopsy. Sixty-seven of these cases (19%) had normal serum amylase levels on admission (i.e., less than 160 IU/L, a limit that includes 99% of control values), a figure considerably higher than generally admitted. When compared to AP with elevated serum amylase, normoamylasemic pancreatitis was characterized by the following: (1) the prevalence of alcoholic etiology (58% vs. 33%, respectively, p less than 0.01), (2) a greater number of previous attacks in alcoholic pancreatitis (0.7 vs. 0.4, p less than 0.01); and (3) a longer duration of symptoms before admission (2.4 vs. 1.5 days, p less than 0.005). In contrast AP did not appear to differ significantly in terms of CT findings, Ranson's score, and clinical course, when comparing normo- and hyperamylasemic patients, although there was a tendency for normoamylasemic patients to follow milder courses. Serum lipase was measured in 65 of these normoamylasemic cases and was found to be elevated in 44 (68%), thus increasing diagnostic sensitivity from 81% when amylase alone is used to 94% for both enzymes. A peritoneal tab was obtained in 44 cases: amylase concentration in the first liter of dialysate was greater than 160 IU/L in 24 cases (55%), and lipase was greater than 250 U/L in 31 cases (70%). Twelve of these 44 cases had low peritoneal fluid and plasma concentrations for both enzymes. Thus little gain in diagnostic sensitivity was obtained when adding peritoneal values (96%) to serum determinations. AP is not invariably associated with elevated serum amylase. Multiple factors may contribute to the absence of hyperamylasemia on admission, including a return to normal enzyme levels before hospitalization or the inability of inflamed pancreases to produce amylase. Approximately two thirds of cases with normal amylasemia were properly identified by serum lipase determinations. AP does not appear to behave differently when serum amylase is normal or elevated, and should therefore be submitted to similar therapeutic regimens in both conditions.
对318例患者的352次急性胰腺炎（AP）发作进行了前瞻性连续研究。除4例在手术或尸检时确诊的病例外，所有病例均通过增强CT扫描确诊。其中67例（19%）入院时血清淀粉酶水平正常（即低于160 IU/L，该界限涵盖99%的对照值），这一数字远高于普遍认可的比例。与血清淀粉酶升高的AP相比，正常淀粉酶血症性胰腺炎具有以下特点：（1）酒精性病因的患病率更高（分别为58%和33%，p<0.01）；（2）酒精性胰腺炎既往发作次数更多（0.7次对0.4次，p<0.01）；（3）入院前症状持续时间更长（2.4天对1.5天，p<0.005）。相比之下，在比较正常淀粉酶血症和高淀粉酶血症患者时，AP在CT表现、兰森评分和临床病程方面似乎没有显著差异，尽管正常淀粉酶血症患者的病程有更轻的趋势。对其中65例正常淀粉酶血症病例检测了血清脂肪酶，发现44例（68%）升高，从而使诊断敏感性从仅使用淀粉酶时的81%提高到两种酶联合使用时的94%。44例患者获取了腹腔灌洗标本：第一升透析液中的淀粉酶浓度在24例（55%）中大于160 IU/L，脂肪酶在31例（70%）中大于250 U/L。这44例中有12例腹腔液和血浆中两种酶的浓度均较低。因此，将腹腔液检测值（96%）加入血清检测时，诊断敏感性提高不大。AP并非总是与血清淀粉酶升高相关。多种因素可能导致入院时无高淀粉酶血症，包括住院前酶水平恢复正常或胰腺炎症无法产生淀粉酶。大约三分之二淀粉酶血症正常的病例通过血清脂肪酶检测得以正确识别。当血清淀粉酶正常或升高时，AP的表现似乎没有差异，因此在这两种情况下都应采用类似的治疗方案。
