Pain at 24 hours associated with amylase levels greater than 5 times the upper normal limit as the most reliable indicator of post-ERCP pancreatitis

doi:10.1067/mge.2001.111390

Gastrointestinal Endoscopy

Volume 53, Issue 1, January 2001, Pages 33-39

https://doi.org/10.1067/mge.2001.111390 Get rights and content

Abstract

Background: The frequency of post-ERCP/sphincterotomy pancreatitis is between 1.3% and 7.6% in prospective studies. This range likely reflects differences in definitions of pancreatitis and methods of data collection. Methods: To identify clinical findings and enzymatic values consistent for clinical pancreatitis at 24 hours, the post-ERCP/sphincterotomy course of 1185 procedures was prospectively recorded. Patients were evaluated for pancreatic-type pain, white blood cell count, and serum amylase before and 24 hours after the procedure; pain and amylase levels were also recorded 6 to 8 hours after the procedure. CT was performed in all patients with pain associated with amylase levels greater than 3 times normal. All patients were evaluated clinically at 48 hours. Results: Pancreatic-type pain never occurred in cases with amylase levels lower than 3 times normal; it was significantly (p < 0.001) associated with amylase levels greater than 5 times normal, either 6 to 8 hours or 24 hours after the procedure. Leukocytosis and CT findings consistent with pancreatitis were observed only in patients (41.7% and 29.5%, respectively) with 24-hour amylase levels greater than 5 times normal. None of the 18 patients with pain at 24 hours and serum amylase lower than 5 times normal had symptoms that persisted at 48 hours. Twenty-five (41.7%) of the 60 patients with pain at 24 hours and amylase higher than 5 times normal had 48-hour pain at 48 hours and hyperamylasemia. Conclusions: Features consistent with clinical pancreatitis were present only among patients with pancreatic-type pain at 24 hours and amylase levels higher than 5 times normal. Additional follow-up is required for these patients. (Gastrointest Endosc 2001;53:33-9.)

Section snippets

Material and methods

The clinical course and amylase levels after 1185 consecutive endoscopic procedures on the major and minor duodenal papilla in 1020 patients over a 36-month period were evaluated. Endoscopic procedures were performed by the same endoscopist either in a university (559) or in a university-affiliated institution (626). Patient age ranged between 5 and 94 years. All procedures (biliary or pancreatic sphincterotomy, drainage procedures, and diagnostic ERCP) were included, whether successful or

Results

Postprocedural hyperamylasemia occurred in 452 cases (38.1%): 351 of 798 therapeutic procedures (44.0%); 83 of 312 diagnostic procedures (26.6%); and 18 of 75 unsuccessful procedures (24.0%). Unsuccessful procedures were those in which neither duct was cannulated. The overall number and percentage of procedures in which serum amylase values, measured 6 to 8 hours and 24 hours after, were normal, greater than 2 times, between 3 and 5 times, or greater than 5 times the upper normal limit, and the

Discussion

The definition of pancreatitis still remains a controversial issue in relation to post-ERCP/-sphincterotomy complications; the amplitude and duration of serum amylase rise and the occurrence of pancreatic-type pain are crucial points in the definition and grading of the pancreatic reactions.

The rise in serum pancreatic enzymes may vary considerably after ERCP and sphincterotomy without clinical significance. Hyperamylasemia occurs in about 70% of cases within 2 to 4 hours after endoscopic

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Citation Excerpt :
Pancreatitis severity and outcomes of all patients, and their relevant clinical and biochemical data, were obtained by searching the data base systems of the hospital as a whole, and the Division of Gastroenterology. Duration of abdominal pain, pancreatic enzymes elevation, hospital stay, type of analgesia administered, and non-ERCP- and ERCP-related pancreatitis complications were available on the basis of a standard post-ERCP monitoring protocol and were retrieved for all patients [9,10]. The aetiology of AP attacks unrelated to ERCP was obtained on the basis of clinical history, imaging techniques such as computed tomography (CT) scan, magnetic resonance imaging (MRI) or magnetic resonance cholangio-pancreatography (MRCP) with/without secretin, trans-abdominal or endoscopic ultrasound, and blood samples (liver function, cholestasis markers, lipids, autoantibodies and tumoural markers).
Acute pancreatitis is a complication of endoscopic retrograde cholangio-pancreatography. Aim of the study was to compare endoscopic retrograde cholangio-pancreatography-related acute pancreatitis with attacks caused by other factors.
A series of consecutive patients with non-endoscopic retrograde cholangio-pancreatography-related acute pancreatitis referred to our hospital in 2007–2008 were examined retrospectively, and compared with the same number of patients with post-endoscopic retrograde cholangio-pancreatography acute pancreatitis done in the same institution. Both groups comprised 116 patients and were comparable for mean age, sex, and body mass index. Duration of abdominal pain, pancreatic enzyme elevation, hospital stay, and type of analgesia administered were retrieved.
There were no differences between the groups as regards the severity of pancreatitis, mortality rate and hospitalisation, although mortality was double in severe post-endoscopic retrograde cholangio-pancreatography acute pancreatitis. In the mild acute pancreatitis cases, serum amylase fell 50% from the peak in a mean of 46.4 h (range 24–72) in group 1 and 38.9 h (range 24–72) in group 2 (p < 0.001). The peak amylase serum level halved within 48 h in 73.6% of cases with non-endoscopic retrograde cholangio-pancreatography-related acute pancreatitis, and in 92% of patients with endoscopic retrograde cholangio-pancreatography-related acute pancreatitis (p < 0.001).
Non-endoscopic retrograde cholangio-pancreatography- and endoscopic retrograde cholangio-pancreatography-induced pancreatitis did not differ as regards severity, hospital stay or mortality; in mild pancreatitis, serum amylase halved significantly sooner in post-endoscopic retrograde cholangio-pancreatography cases.
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^☆: Reprint requests: Pier Alberto Testoni, MD, Division of Gastroenterology and Gastrointestinal Endoscopy, University Vita-Salute San Raffaele, IRCCS San Raffaele Hospital, Via Olgettina, 60 - 20132 Milano, Italy.

^☆☆: Gastrointest Endosc 2001;53:33-9

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Original ArticlesPain at 24 hours associated with amylase levels greater than 5 times the upper normal limit as the most reliable indicator of post-ERCP pancreatitis☆,☆☆

Abstract

Section snippets

Material and methods

Results

Discussion

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Endoscopic sphincterotomy-induced pancreatitis: increased risk associated with nondilated bile duct and sphincter of Oddi dysfunction

Am J Gastroenterol

Complications of endoscopic biliary sphincterotomy

N Engl J Med

Original Articles
Pain at 24 hours associated with amylase levels greater than 5 times the upper normal limit as the most reliable indicator of post-ERCP pancreatitis☆,☆☆