Le Pancreatiti: aspetti di diagnosi e terapia

1 le pancreatiti : aspetti di diagnosi e terapiaBolzano Vicentino, 4 febbraio 2011LE IPERAMILASEMIEDott. Alessandro D GastroenterologiaVicenza IPERAMILASEMIAAMILASI PANCREATICA La -amilasi un enzimaappartenente alla classe delle idrolasi, che catalizza l'endoidrolisidei legami 1,4- -D-glucosidiciin oligosaccaridie polisaccaridicontenenti tre residui o pi . L'enzima agisce in modo casuale su amido, glicogenoe molecole ad esse correlate. Il termine si riferisce alla configurazione degli zuccheri prodotti (che presentano infatti una configurazione ), e non al tipo di legame glucosidico che viene scisso. La -amilasi principalmente prodotta nel pancreas(isoamilasi P) e nelle ghiandoleparotidee(isoamilasi S) ma anche dal fegato, dall'intestino tenuee dai reni. Il catabolismo dell' -amilasi in parte a carico del sistema reticolo-endoteliale ed in parte (25%) per via renale.

2 Il glomerulo filtra liberamente la molecola per il suo peso molecolare relativamente basso (circa 50kDa) ma il tubulo la riassorbe poi quasi In acinar cellsdigestive enzymes,synthesized in the endoplasmic reticulum, are transported byzymogen granulias inactive pro-enzymes the enzymes are transported into theduodenumvia the ductal system andactivated after contact with the brush-border enzyme enterokinase(enteropeptidase) in the lumen of the small difficulties have limited lipaseassays in the past, but reliable techniques arenow available which may offer improvedsensitivity and greater specificitythan estimations of serum , Pounder and Venables Disease of the Gutand Pancreas 1995 Pag 431 Blackwell ScienceIPERAMILASEMIA Which serum pancreatic enzyme shouldbe measured in order to diagnose acute pancreatitis?

3 Answer:Although amylase is widely available andprovides an acceptable level of accuracy in diagnosis ,lipase estimation, where available, is preferred for thediagnosis of acute pancreatitis (recommendation A)Practical Guidelines for Acute PancreatitisR. Pezzilli A. Zerbi V. Di Carlo C. Bassi Delle Faveand the Working Group of the Italian Association for theStudy of the Pancreas on Acute Pancreatitis Pancreatology 2010;10:523 535 IPERAMILASEMIAM ulticentrica italiana AISP (56 centri) 1910059100010203040506070809010020002005 lipasi amilasi Dig Liver Dis 39 (2007)IPERAMILASEMIALABORATORIO ANALISI SAN BORTOLOIPERAMILASEMIAPANCREATITI (TOT) AL SAN BORTOLO ANNI 2009 E 2010641321396344116120092010diagnosipanc reatitiindaginiiperamilasemiaFrulloni L. et al, PANCREATICA ASSOCIATA A DOLORE ADDOMINALE NON PANCREATICO GutBiliary lithiasisPeptic ulcerAcute cholecystitisAcute abdomenIntestinal obstructionObstruction of the afferent intestinal loop after gastrectomyPeriampullar diverticulumIntestinal infarctionInflammatory bowel diseasesGastroenteritis Genital tractOvarian tumoursAcute salpingitisEndometriosisEctopic pregnancy VascularThrombosisDissecting aortic aneurysmRuptured abdominal aortic aneurysmAbdominal traumaFrulloni L et al, JOP 2005 IPERAMILASEMIA PANCREATICA ASSOCIATA A DOLORE ADDOMINALE NON Donna 31 anni.

4 Pancreatite acuta nel 1992 (non documentazione). Riferisce allergia ad antibiotici . Il 21 12 1997, alla 30 settimana di gravidanza entra in Ostetricia per colica addominale con screzio pancreatico. Amilasi 400, gli altri nella norma. In V giornata trasferita in Medicina per > amilasi ed enzimi epatici (pancreatite acuta biliare). Eco: pancreas regolare e colecisti alitiasica. Seguono 10 giorni di relativo benessere con due episodi di dolore addominale e vomito nei primi giorni. In 15ma giornata battito fetale in peggioramento. Trasferita in Ostetricia, sottoposta a cesareo con riscontro di perforazioneileale tamponata da utero gravido. (Successivamente ascesso subfrenico, sepsi, trasferimento in rianimazione e graduale miglioramento fino a guarigione)Frulloni L. et al, PANCREATICA CRONICA ASINTOMATICA Paracetamol Steroids Azathioprine Ephedrine Chemotherapy Roxithromycin Cyclosporine Clozapine PentamidineIPERAMILASEMIA PANCREATICACRONICA ASINTOMATICA HYPERAMYLASEMIA IN KIDNEY TRANSPLANT RECIPIENTS: A FREQUENT AND BENIGN EVENT D Alessandro A, Rigato ML, Bertin T, *Dissegna D, *Chiaramonte S, Salvagnini MII Division of Internal Medicine and * Division of Nefrology - San Bortolo Hospital - VicenzaINTRODUCTION : Elevated serum pancreatic (p) amylase values have been reported after kidney transplant (KTX), with various frequence butwithout any clinical evidence of acute pancreatitis.

5 A role of Cyclosporine (CsA) and/or azathioprin toxicity has been evoked in the mechanism of hyperamylasemia, including the possibility of an indirect effect due to the liver or kidney toxicity causing a reduced enzyme clearance..AIM : In the present study we analyzed the incidence of p-hyperamylasemia in a large series of kidney transplant recipients with different immunosoppression regimens, including the new drug : 102 consecutive KTX recipients with double drug therapy CsA - prednisone or triple drug therapy CsA-azathioprina-prednisone ( Group A) were compared with 50 KTX recipients with double drug therapy tacrolimus-prednisone ( Group B) . Biohumoral parameters including serum p-amylase, AST, ALT, creatinine were regularly monitored , trice weekly, in the first month after KTX.

6 All patients with serum p-amylase above 110 U/L were defined as hyperamylasemic and underwent to abdominal ultrasound data are presented as mean + / standard error of the mean. T student test was applied and a P value of less than was considered to be statistically : P- hyperamylasemia was noted in 12/50 (24 %) KTX recipients with tacrolimus therapy (Group B) and in 28/103 (27,4%) KTX recipients with other immunosuppressive therapy(Group A). Serum amylase levels (U/L) were 221 +/ 18. 8 in Group A and 218 +/ 39. 6 in Group B ( P> ). Significant values of hyperamylasemia ( ) were found in 5 patients in Group A and in one patient only in Group B. One patient in each group had symptoms suggestive of acute correlation was found in both group between p amylases and creatinine and transaminases serum levels.

7 CONCLUSION :The present study has confirmed that asymptomatic hyperamylasemia after cadaveric renal transplantation is a frequent occurrence and rarely shows clinical relevance. Hyperamylasemia is more probably secondary to a pancreatic damage related to a possible not specific drug toxicity than to liver and renal decreased 2001 IPERAMILASEMIA PANCREATICA CRONICA ASINTOMATICA post chirurgicaChirurgia (nello studio AISP 2008 causa di nell dei casi) Pancreatica Addominale Epatica Biliare Cardiovascolare Trapianto epaticoIPERAMILASEMIA PANCREATICA CRONICA ASINTOMATICA post ERCP POST ERCP (nello studio AISP causa di nel 3% dei casi)IPERAMILASEMIA PANCREATICA CRONICA ASINTOMATICAASSOCIATA A MALATTIE SISTEMICHE AIDS Trauma Shock Diabetic chetoacidosis Eating disorders LES Rheumatic diseases Chronic liver diseases (virus C and B)

8 Hepatocellular carcinoma Renal diseases Sarcoidosis Retroperitoneal plasmacytoma Hematologic malignancies Colon cancer Renal cell carcinomaBreast carcinoma Lung tumoursIPERAMILASEMIA PANCREATICA CRONICA ASINTOMATICAASSOCIATA A MALATTIE EPATICHE VIRALIDig Dis Sci. 1999 Feb;44(2) pancreatic enzyme concentrations in chronic viral liver R, Andreone P, Morselli-Labate AM, Sama C, Billi P, Cursaro C, Barakat B, Gramenzi A, Fiocchi M, Miglio F, Bernardi Department, Sant' Orsola Hospital, University of Bologna, decreased liver metabolism of serum amylaseand lipase in patients with chronic infective liver disease, especially in those having liver cirrhosis, may lead to an accumulation of these enzymes in the PANCREATICA CRONICA ASINTOMATICA Alcologia , 2-1992 pag.

9 178-179 IPERAMILASEMIA PANCREATICA CRONICA ASINTOMATICAM acroamylasemiaMacrocomplex : serum amylasi + serum abnormal protein (IgA)High molecolar escape normal glomerular filtration and accumulate in plasma with a longer serum half-lifeSerum dosage: > 80%Urinary dosage: 24-hour urinary amylase, as aless expensive alternative: normal valueIPERAMILASEMIA PANCREATICA CRONICA ASINTOMATICACELIACHIA Pediatrics 2001 Macroamylasemia attributable to gluten-related amylase autoantibodies: a case G, Bazzigaluppi E, Viscardi M, Renzetti F, Bianchi C, Chiumello G, Bosi of Pediatrics, Scientific Institute H San Raffaele, University of Milan, Milan, Italy. Dig Dis Sci 2007 Hyperamylasemia, reactive plasmacytosis, and immuneabnormalities in a patient with celiac Z, Wang J, Qian J, Tang of Immunopathology, The Institute of Digestive Diseases, Department ofGastroenterology, The Second Affiliated Hospital of Zhengzhou University,Zhengzhou, China.

10 PANCREATICA CRONICA ASINTOMATICAI perenzimemia pancreatica benigna (S. di Gullo).. aumento di tutti gli enzimi sierici pancreatici (nella quasi totalit dei casi) in soggetti con pancreas del tutto normale all imaging forma sporadica forma famigliareGullo, Gastroenterology 1996 IPERAMILASEMIA ASINTOMATICAIPERENZIMEMIA CRONICA BENIGNA ( S. DI GULLO)Forma sporadica18 soggetti con enzimi pancreatici sierici elevati seguiti per 5 anni ( 1990-1995) sottoposti ad eco addome, TAC e/o degli enzimi con ampie fluttuazioni e rilevate anomalie all 1996 IPERAMILASEMIA ASINTOMATICAIPERENZIMEMIA CRONICA BENIGNAIPERAMILASEMIA ASINTOMATICAIPERENZIMEMIA CRONICA BENIGNA ( S. DI GULLO)Forma famigliareStudiati 19 soggetti di 7 famiglie coniperenzimemia pancreatica sierica ma senza malattia pancreaticaPancreas 2000 IPERAMILASEMIA ASINTOMATICAIPERENZIMEMIA CRONICA BENIGNAIPERAMILASEMIA ASINTOMATICAIPERENZIMEMIA CRONICA BENIGNA- Steatosi pancreatica?