A rare convergence: Gangrenous bowel secondary to closed-loop obstruction with elevated urine amylase levels – A comprehensive case report

• Published in: Malaysian family physician 2024-01, Vol.19, p.1-4
• Main Authors: Hassan, Ahmed Abrizan, Mohamad, Ikhwan Sani, Wan, Mokhzani Wan Mokhter, Merican, Rahmah Hashim Isa, Yahya, Maya Mazuwin, Aziz, Hassan Syed Abd
• Format: Article
• Language: English
• Subjects: Abdomen; Case reports; Cost analysis; Gangrene; Intestinal obstruction; Laparotomy; Ovaries; Pain; Pancreas; Pancreatitis; Patients; Tomography; Ulcers; Urine; Vomiting
• ISSN: 1985-2274; 1985-2274

Conversely, asymptomatic hyperamylasaemia is commonly associated with systemic diseases such as tumours, mumps and kidney failure or drug usage.1 Acute pancreatitis is a frequently encountered condition, carrying substantial risks of mortality and morbidity.3 According to the United Kingdom guidelines for the management of acute pancreatitis, the diagnosis of acute pancreatitis relies on the combination of clinical features (e.g. abdominal pain and vomiting) and an elevation in the plasma concentration of pancreatic enzymes.3 The assessment of an acute abdomen often relies on the measurement of total serum amylase due to its cost-effectiveness and technical simplicity, making it widely utilised. Estimates suggest a specificity approaching 95% when considering the threshold level to be more than three times the upper limit of the normal range.4 Hyperamylasaemia is not exclusive to pancreatic conditions and has been documented in various non-pancreatic disorders, such as mumps, parotitis, perforated peptic ulcer, perforated appendicitis, intestinal obstruction, mesenteric infarction, pulmonary embolism, pneumonia, myocardial infarction, lung cancer, breast cancer, lymphoma and several tubo-ovarian disorders.3 Lipase is recommended over amylase for diagnosing acute pancreatitis, as supported by various studies indicating its superior sensitivity and specificity (>95%) over total amylase in identifying pancreatic disease.4 Lipase has demonstrated higher diagnostic accuracy than pancreatic amylase.5 However, akin to pancreatic amylase, lipase is not exclusive to the pancreas, being present in the tongue, oesophagus, stomach, duodenum, small bowel, liver, lung and adipose tissue.6 Consequently, hyperlipasaemia has been associated with conditions such as cholecystitis, oesophagitis, peptic ulcer disease, enteritis, peritonitis and bowel obstruction and infarction.7 Official guidelines in the United Kingdom currently advise limiting the use of CT in diagnosing acute pancreatitis to cases where clinical and biochemical findings are inconclusive.3 The present case underscores the limitations of relying solely on amylase and lipase measurements and highlights the importance of emergency CT as a diagnostic adjunct in cases of acute abdominal pain. Elevated amylase levels can indicate conditions beyond pancreatitis, such as bowel obstruction, necessitating thorough clinical evaluation. * Treatment guidance: In summary, while amylase-level elevation is often linked to p