Pancreatitis/Pregnancy

  My wife (33) is 11 weeks pregnant (3rd, first two normal with
  alot of nausea but not HG) and was diagnosed with acute
  pancreatitis 3 weeks ago (&dehydration/hyperemesis).  She has
  has been on TPN for 21 days (in patient)plus fluids and Zofran
  for nausea.  An ECRP was performed 7 days ago and found no
  obstructions, possibly sludge, and 9mm sphincterotomy was
  performed at papilla of vater, ducts looked OK.  4 days later CT
  scan showed no abnormal growths, and swelling of pancreas was
  less than expected, no stones (gallbladder removed 3 years ago).
  The problem is, the blood count of serum lipase is still
  hovering around 1800 (amylase ~250) which it has been at for at
  least 20 days.  She has very little abdominal pain, no fever,
  and glucose has never exceded 120.  All of our Dr.'s are unsure
  as to the cause (3 gastro 4ob/gyn 1 perinat) and out of state
  gastroenterologist consulted says idiopathic.
  What could be the cause of the elevated lipase/continued
  pancreatitis?
  Any suggestions are greatly appreciated.
  Thanks,
  Taylor C.
  
Dear Taylor C.,
I should first state that the height of elevation of the serum amylase, lipase or trypsinogen levels during an attack of acute pancreatitis does not correlate with the severity of disease. Secondly, approximately three quarters of patients with initially diagnosed "idiopathic" pancreatitis (that is patients in whom alcohol use, gallstones, drugs or elevated triglycerides have been excluded as a cause) are found to have gallstones or microlithiasis (small stones or crystals) on subsequent repeat imaging or microscopic examination of bile.
Serum amylase is a sensitive marker of disease when the patient presents within several hours of the onset of abdominal pain but becomes less sensitive than serum lipase if the patient presents later. However, not all patients with elevated amylase levels will have pancreatitis. Elevated amylase can arise from various nonpancreatic sources, such as the salivary glands, lungs, fallopian tubes (especially during pregnancy), ovarian cysts, gallbladder, small intestine and in various tumors.
Serum lipase has a greater sensitivity and specificity for acute pancreatitis after the first hospital day. Nonetheless, lipase is also not completely specific for the pancreas. Lingual, gastric, intestinal and hepatic lipases have been isolated.
Therefore, there could be several possibilities to explain the continued elevation in lipase. First, that the enzymes are from non-pancreatic origin. Second, that there is decreased clearance of this enzyme due to impaired renal function. Thirdly, there is evidence of recurrent pancreatitis or a complication present such as a pseudocyst. From your description, it sounds like your wife's condition has markedly improved which would make the third possibility less likely. Nevertheless, a repeat sonogram, or if necessary a repeat CT scan, may be helpful to rule out complications and to make sure that her condition is improved. If there is a problem with renal function then that needs to be addressed. Finally, if the elevated lipase is from a nonpancreatic origin or if the lipase is pancreatic in origin but she is clinically stable, then I would recommend just following the trend to make sure it is coming down with time. I hope you find this information helpful. Good luck to you.
This response is being provided for general informational purposes only and should not be considered medical advice or consultation. Always check with your personal physician when you have a question pertaining to your health.
If you wish to be seen at our institution please call 1-800-653-6568, our Referring Physicians' Office and make an appointment to see Dr. Wong, one of our experts in Gastroenterology and Pancreaticobiliary Disorders.
HFHSM.D.-ym
*Keywords: acute pancreatitis, amylase, lipase

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