Urinary trypsinogen for the diagnosis of pancreatitis on admission
Date First Published:
July 8, 2012
Last Updated:
July 12, 2012
Report by:
Adam Ting, Medical Student (Manchester Royal Infirmary)
Three-Part Question:
In [adult patients with abdominal pain], can [urinary trypsinogen] be used to [diagnose acute pancreatitis]?
Clinical Scenario:
A 44 year old man presents to the emergency department with severe epigastric pain. With a working diagnosis of acute pancreatitis, the result of serum amylase were inconclusive. As urinary trypsinogen have been recommended as an adjunct in supporting the diagnosis of pancreatitis, you wonder if it would be worthwhile performing a urine dipstick for this purpose.
Search Strategy:
EMBASE 1974 to 2012 July 06
Search Details:
[({abdominal pain.mp. OR exp Abdominal Pain/} OR {exp Pancreatitis, Acute Necrotizing/ OR exp Pancreatitis/ OR exp Pancreatitis, Chronic/ OR exp Pancreatitis, Alcoholic/ OR pancreatitis.mp.}) AND ({exp "Sensitivity and Specificity"/ OR sensitivity.mp. OR specificity.mp.} OR {diagnosis.mp. OR exp Diagnosis/}) AND ({exp trypsinogen activation peptide/ or exp trypsinogen/ or trypsinogen.mp. AND exp urine/ or urine.mp.} OR urinary trypsinogen.mp.)] LIMIT to Human AND English Language.
Outcome:
66 papers were found of which 52 papers were irrelevant or unavailable. The other 14 available are as follows.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Point-of-care Urine Trypsinogen-2 Test for Diagnosis of Acute Pancreatitis P. Abraham Apr-11 India | Total of 124 patients with abdominal pain of which 69 were diagnosed with acute pancreatitis. | Prospective cohorts study comparing accuracy of UT with other methods at diagnosing acute pancreatitis. | Accuracy of UT | Sensitivity - 73.9% (95% CI 61.9% to 83.8%) | Criteria of urine collection was not monitored. Study performed in single specialist center. Amylase and lipase used to determine diagnosis was used to compare accuracy of UT |
| Specificity - 94.6% (95% CI 84.9% to 98.9%) | |||||
| PPV - 94.4% | |||||
| NPV - 74.3% | |||||
| Urinary Trypsinogen Test in Diagnosing Acute Pancreatitis. F. Kurti et al Feb-11 Albania | 45 patient presenting with abdominal pain to the emergency unit; 18 cases of which were due to AP. | Prospective cohort study evaluating and comparing the values of UT with serum amylase and lipase. | Performance of UT | True positive: 16/18 (88.8) | Only journal abstract available. Aims of study were not met; results were not explored in detail and were not compared. Single center study with small sample. Conclusion was largely subjective |
| False negative: 2/18 (11.2%) | |||||
| False positive: 3/27 (11.1%) | |||||
| The role of urine trypsinogen-2 test in the differential diagnosis of acute pancreatitis in the Emergency Department Y. Cevik et al Mar-10 Turkey | Total of 87 patients with abdominal pain of which 32 were diagnosed with AP. | Prospective cohort study evaluating the role of UT in excluding differentials of AP during admission and comparing the results with other conventional methods | Predictive value of UT | Sensitivity - 64%; Specificity - 85%; PPV - 72%; NPV - 81%; p<0.01 | Single center study with small sample. |
| Effectivity of qualitative urinary trypsinogen-2 measurement in the diagnosis of acute pancreatitis: a randomized, clinical study E. Aysan et al. Dec-08 Istanbul | Total of 99 patients of which 50 were diagnosed with AP through abdominal CT | Prospective cohort study evaluating and comparing the value of UT with other methods of diagnosing AP | Predictive value of UT | Sensitivity - 56%; Specificity - 90.9% | Only journal abstract available. Single center study. |
| Early diagnosis and prediction of severity in acute pancreatitis using the urine trypsinogen-2 dipstick test: A prospective study K. Erdinc et al Dec-07 Turkey | Total of 92 patients presenting with abdominal pain of which the 25 patients with non-pancreatic abdominal pain where considered the control group. | Prospective cohort study evaluating the use UT test for early diagnosis and prediction of severity in AP. | Predictive value of UT | Sensitivity - 91%; Specificity - 72%; PPV - 96.6%; NPV - 70.4%; PLR - 3.4; NLR - 0.1 | |
| Point-of-care Urine Trypsinogen Testing for the Diagnosis of Pancreatitis T. Jang et al Jan-07 United States | 191 patients in total of which 17 patients were diagnosed with AP through an extensive inclusion criteria | Prospective cohort study evaluating the use UT test for early diagnosis of AP during admission with a 3 minute UT test. | Accuracy of UT | Sensitivity: 100% (95% CI 77%-100%); Specificity - 96% (95% CI 92%-98%) | Urine sample were collected by different research assistant. Non-conventional inclusion criteria due to varying definition of AP. Single center study. Urinary test were confirmed in the laboratory instead of at the emergency unit. |
| Clinical value of rapid urine trypsinogen-2 test strip, urinary trypsinogen activation peptide, and serum and urinary activation peptide of carboxypeptidase B in acute pancreatitis Saez J. et al Dec-05 Spain | A total of 50 patients with abdominal pain of which 22 patients were extrapancreatic in origin. | Prospective cohort study assessing value of UT, urinary trypsinogen activation peptide (TAP), and serum and urine concentrations of the activation peptide of carboxypeptidase B (CAPAP) in the diagnosis of acute pancreatitis. | Accuracy of UT | Sensitivity: 68%; Specificity: 86.4%; PPV: 91.9%; NPV: 54.3% | Single center study. |
| Rapid Urinary Trypsinogen-2 Test Strip in the Diagnosis of Acute Pancreatitis Y. Chen et al Apr-05 Taipei | 165 patients with acute abdominal pain of which 67 were diagnosed with AP and 98 with other acute abdominal diseases. | Prospective cohort study evaluating the diagnostic value of UT in AP, using a cut-off of 50mug/L, with comparisons with serum amylase and serum lipase. | Predictive value of UT | Sensitivity - 89.6%; Specificity - 85.7%; PPV - 81.1%; NPV - 92.3% | Operators were not blinded. Single center study with small sample. |
| Comparison of urine trypsinogen-2 test strip with serum lipase in the diagnosis of acute pancreatitis. ML. Kylänpää-Bäck et al Aug-02 Finland | Total of 237 patient with abdominal pain admitted to emergency unit. | Prospective cohort study comparing accuracy of UT with serum amylase and lipase in diagnosing AP. | Predictive value of UT | Sensitivity - 93%; Specificity - 92% | Only journal abstract available. Small single center study with small sample. |
| Time-course and clinical value of the urine trypsinogen-2 dipstick test in acute pancreatitis. R. Pezzilli et al Mar-01 Italy | A total of 90 patients were involved: 30 patient diagnosed with AP 30 patient with abdominal of extrapancreatic causes 30 healthy patient as control |
Prospective cohort study evaluating the value to UT in diagnosing AP according to admission dates in comparison to serum/urine amylase and serum lipase. | Predictive value of UT | Sensitivity: 53.3% (95% CI 34.3± 71.6%) | Single center study with smal sample. Researchers and patients were not blinded |
| Urine trypsinogen-2 as marker of acute pancreatitis J. Hedstorm et al May-96 Finland | Total of 122 patient: 63 patients without abdominal diseases 59 patients with AP 42 with acute abdominal diseases of extrapancreatic origin |
Diagnostic cohort study comparing the value of UT with serum trypsinogen and lipase and urinary amylase. | AUC of UT | 0.978 | Single center study with small cohort |
| Urinary trypsinogen-2 test strip for acute pancreatitis J. Hedstom et al Mar-96 Finland | 57 patients with AP; 40 patients with extrapancreatic abdominal pain | Prospective cohort study comparing the accuracy of urinary and serum trypsinogen | Accuracy of UT | True Positives: 52; False Negative - 5; False Positives - 4 | Single center study with small cohort |
| Urinary Trypsinogen-2 Dipstick in Acute Pancreatitis A.M. Andersen Jan-10 Denmark | 75 patients with AP; 35 patients with extrapancreatic abdominal pain as control | Prospective cohort study evaluating accuracy of UT. | Accuracy of UT | Sensitivity - 77% (95% CI 66-86%); Specificity of 97% (95% CI 84-99.9%). | Single center study with small cohort |
| Rapid measurement of urinary trypsinogen-2 as a screening test for acute pancreatitis. E.A. Kemppainen et al Jun-97 Finland | 500 patients in total with abdominal pain at two emergency units. | Diagnostic study using the UT to identify patients with AP. Result were compared with serum amylase, lipase and trypsinogen and urinary amylase. | Accuracy of UT | Sensitivity - 94%; Specificity 95% (95% CI 66-86%); Specificity of 97% (95% CI 84-99.9%). |
Author Commentary:
Currently, laboratory marker available for the diagnosis of AP include serum amylase, lipase and trypsinogen and urinary amylase. It's always been recognised that urinary trypsinogen can supplement the diagnosis with a relatively accurate predictive value. Literatures have quoted sensitivities and a specificities ranging from 53.3%-96% and 85.7%-95%. With the added benefit of being quick and easy to use, it may replace the current dependency on serum amylase as the standard diagnostic procedure in determining patients with AP.
Bottom Line:
UT should be implemented in the process of AP diagnosis this decision should be confirmed with other diagnostic technique.
References:
- P. Abraham. Point-of-care Urine Trypsinogen-2 Test for Diagnosis of Acute Pancreatitis
- F. Kurti et al. Urinary Trypsinogen Test in Diagnosing Acute Pancreatitis.
- Y. Cevik et al. The role of urine trypsinogen-2 test in the differential diagnosis of acute pancreatitis in the Emergency Department
- E. Aysan et al.. Effectivity of qualitative urinary trypsinogen-2 measurement in the diagnosis of acute pancreatitis: a randomized, clinical study
- K. Erdinc et al. Early diagnosis and prediction of severity in acute pancreatitis using the urine trypsinogen-2 dipstick test: A prospective study
- T. Jang et al. Point-of-care Urine Trypsinogen Testing for the Diagnosis of Pancreatitis
- Saez J. et al. Clinical value of rapid urine trypsinogen-2 test strip, urinary trypsinogen activation peptide, and serum and urinary activation peptide of carboxypeptidase B in acute pancreatitis
- Y. Chen et al. Rapid Urinary Trypsinogen-2 Test Strip in the Diagnosis of Acute Pancreatitis
- ML. Kylänpää-Bäck et al. Comparison of urine trypsinogen-2 test strip with serum lipase in the diagnosis of acute pancreatitis.
- R. Pezzilli et al. Time-course and clinical value of the urine trypsinogen-2 dipstick test in acute pancreatitis.
- J. Hedstorm et al. Urine trypsinogen-2 as marker of acute pancreatitis
- J. Hedstom et al. Urinary trypsinogen-2 test strip for acute pancreatitis
- A.M. Andersen. Urinary Trypsinogen-2 Dipstick in Acute Pancreatitis
- E.A. Kemppainen et al. Rapid measurement of urinary trypsinogen-2 as a screening test for acute pancreatitis.