High serum alanine aminotransferase level to identify the cause of pancreatitis
Date First Published:
July 13, 2006
Last Updated:
July 19, 2006
Report by:
Charleen Liu, Medical Student (Manchester Royal Infirmary)
Three-Part Question:
In [patients with acute pancreatitis of non-alcoholic cause], does [a high serum alanine aminotransferase level] correctly identify [the cause of pancreatitis as biliary origin]?
Clinical Scenario:
A 50 year old man presents to the accident and emergency department with epigastric pain. Acute pancreatitis is suspected. You have carried out several diagnostic tests and results are awaiting. You wonder if carrying out a serum alanine aminotransferase test can help identifying the cause of pancreatitis in this patient.
Search Strategy:
Medline, EMBASE and CINAHL 1966 to June Week 4 2006 using Ovid Interface.
Search Details:
(([pancreatitis.mp. or exp Pancreatitis, Acute Necrotizing/ or exp Pancreatitis/ or exp Pancreatitis, Alcoholic/] AND [alanine aminotransferase.mp. or exp Alanine Transaminase/] AND {[ biliary.mp. or exp Biliary Tract Diseases/] OR [gallstone.mp. or exp Gallstones/]}) limit to human and English)
Outcome:
152 papers were found in total, of which 6 were relevant. They are shown in the table below.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Predicting gallstone pancreatitis with laboratory parameters: a meta-analysis Tenner, S. Dubner, H. Steinberg, W 1993 USA | 8 studies published between 1963 and 1993 in English retrieved by a MEDLINE search were included. | Meta-analysis | Accurate prediction of gallstone pancreatitis | ALT level is the most useful parameter amongst bilirubin, alkaline phosphatase, aspartate transminase and alanine aminotransferase. | Alcohol-induced pancreatitis were not isolated. |
| ALT>150IU/L: specificity 96%, sensitivity 48%, PPV 95%. p value 0.05 | |||||
| Enzymatic markers of gallstone-induced pancreatitis identified by ROC curve analysis, discriminant analysis, logistic regression, likelihood ratios, and information theory. Kazmierczak, S C. Catrou, P G. Van Lente, F 1995 USA | 53 patients diagnosed with acute pancreatitis by serum lipase/amylase. | Diagnostic study | Acute gallstone pancreatitis | ALT and AST are most accurate at diagnosing gallstone pancreatitis | Small sample size Variable gold standards Ethical approval not mentioned |
| ALT spec 83%; sens 91%); ppv 87%. Cut-off 84U/L. ROC AUC 0.92 | |||||
| Usefulness of alanine and aspartate aminotransferases in the diagnosis of microlithiasis in idiopathic acute pancreatitis. Grau, F. Almela, P. Aparisi, L. Bautista, D. Pascual, I. Pena, A. Rodrigo, J M. 1999 Spain | 91 patients with idiopathic pancreatitis who underwent microscopic examination of stimulated duodenal bile sediments | Diagnostic study, retrospective | Positive biliary drainage | ALT within first 24hrs: spec 86%, sens 73%. PPV 92%. | Awaiting full article |
| Cut-off: >1.2 fold upper limit of normal | |||||
| The biochemical detection of biliary etiology of acute pancreatitis on admission: a revisit in the modern era of biliary imaging. Ammori, B J. Boreham, B. Lewis, P. Roberts, S A 2003 UK | 68 patients with acute pancreatitis treated between Oct 2000 and Dec 2001. 44 had gallstone pancreatitis diagnosed by USS (38), EUS (5) and post-mortem (1) | Diagnostic study | Gallstone pancreatitis | ALT spec 100%, sens 91%, PPV 100%, NPV 86%. Cut-off >80IU/L within initial 24 hrs of admission. CI 95% | Estimation of sample size was not done. Ethical approval not mentioned |
| USS spec 100%, sens 86%, PPV 100%, NPV 80% | |||||
| USS+LFT spec 100%, sens 98%, PPV 100%, NPV 96% | |||||
| Conclusion: USS + LFT is more reliable | |||||
| Diagnostic criteria in predicting a biliary origin of acute pancreatitis in the era of endoscopic ultrasound: multicentre prospective evaluation of 213 patients. Levy P. Boruchowicz A. Hastier P. Pariente A, et al 2005 France | 213 patients with acute pancreatitis from 14 centres in France and Switzerland between 01/2000 and 01/2002. 132 had biliary pancreatitis EUS was used as a gold standard |
Diagnostic study | Biliary acute pancreatitis | ALT >2N (N times the upper limit of normal) : spec 84%, sens 74%, PPV 88%, NPV 66%. >3N: spec 91%, sens 61%, PPV 92%, NPV 59%. P=0.0004 | |
| Age >50: spec 65% sens 73% PPV 70% NPV 60%. Age >60: spec 79% sens 61% PPV 82% NPV 52% p=0.0001 | |||||
| Female sex: spec 82% sens 60% PPV 84% NPV 56%. P= 0.008 | |||||
| Clinico-biochemical prediction of biliary cause of acute pancreatitis in the era of endoscopic ultrasonography. Liu, C L. Fan, S T. Lo, C M. Tso, W K. Wong, Y. Poon, et al. 2005 Hong Kong, China | 139 patients with acute pancreatitis diagnosed by raised serum amylase level between 1998 and 2002 EUS used as a gold standard |
Diagnostic study | No. of patients with biliary cause of acute pancreatitis | ALT <150U/L=66%, >150U/L=93%, P<0.001 | |
| Female sex, age>58 and ALT>150U/L were independent predictive factors for the biliary cause of acute pancreatitis. |
Author Commentary:
A high serum ALT level combined with female sex and age is has a high predictive value for gallstone pancreatitis. The higher the ALT level, the more sensitive and specific the test is. However, a cut-off point has yet to be determined.
Bottom Line:
A high serum ALT can be used as a tool in predicting gallstone pancreatitis.
References:
- Tenner, S. Dubner, H. Steinberg, W. Predicting gallstone pancreatitis with laboratory parameters: a meta-analysis
- Kazmierczak, S C. Catrou, P G. Van Lente, F. Enzymatic markers of gallstone-induced pancreatitis identified by ROC curve analysis, discriminant analysis, logistic regression, likelihood ratios, and information theory.
- Grau, F. Almela, P. Aparisi, L. Bautista, D. Pascual, I. Pena, A. Rodrigo, J M.. Usefulness of alanine and aspartate aminotransferases in the diagnosis of microlithiasis in idiopathic acute pancreatitis.
- Ammori, B J. Boreham, B. Lewis, P. Roberts, S A. The biochemical detection of biliary etiology of acute pancreatitis on admission: a revisit in the modern era of biliary imaging.
- Levy P. Boruchowicz A. Hastier P. Pariente A, et al. Diagnostic criteria in predicting a biliary origin of acute pancreatitis in the era of endoscopic ultrasound: multicentre prospective evaluation of 213 patients.
- Liu, C L. Fan, S T. Lo, C M. Tso, W K. Wong, Y. Poon, et al.. Clinico-biochemical prediction of biliary cause of acute pancreatitis in the era of endoscopic ultrasonography.