CASE FILES: BIOCHEMISTRY
A N SW E R S TO C A SE 19: PA N C R E A T IT IS
40-year-old female with history of intermittent right upper-quadrant
pain worsening after “greasy” meals and now with constant midepigastric pain,
nausea, and vomiting with elevated liver function tests and amylase.
Diagnosis: Gallstone pancreatitis.
Role of amylase: Enzyme for carbohydrate metabolism, used to digest
glycogen and starch.
C L IN IC A L C O R R E L A T IO N
Acute pancreatitis is an inflammatory process in which pancreatic enzymes
are activated and cause autodigestion of the gland. In the United States, alco-
hol use is the most common cause, and episodes are often precipitated by
binge drinking. The next most common cause is biliary tract disease, usually
passage of a gallstone into the common bile duct. Hypertriglyceridemia is also
a common cause, and that occurs when serum triglyceride levels are greater
than 1000 mg/dL, as is seen in patients with familial dyslipidemias or diabetes.
When patients appear to have “idiopathic” pancreatitis, that is, no gallstones
are seen on ultrasound, and no other predisposing factor can be found, biliary
tract disease is still the most likely cause: either biliary sludge (microlithiasis),
or sphincter of Oddi dysfunction. Abdominal pain is the cardinal symptom
of pancreatitis, and it is often severe, typically in the upper abdomen with
radiation to the back. The pain is often relieved by sitting up and bending
forward and is exacerbated by food. Patients also commonly have nausea and
vomiting, also precipitated by oral intake. The treatment includes nothing by
mouth, intravenous hydration, pain control, and monitoring for complications.
A PPR O A C H TO A M Y L A SE A N D C A R B O H Y D R A T E
M E T A B O L ISM
Be aware of the role of amylase in carbohydrate metabolism.
Understand the cause for increased amylase in pancreatitis.
Understand why conservative treatment (intravenous [IV] fluids, NPO,
pain medication, and possibly a nasogastric tube) is effective in treat-
ment of this condition.
a-Amylase: An endosaccharidase that catalyzes the hydrolysis of a(1^4)
glycosidic bonds present in glycogen and starch. It is present in both
saliva and pancreatic digestive juice. (See Figure 25-1b in Case 25 for a
diagram showing the a(1^4) glycosidic bonds in starch.)