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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.
(([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)

Search Outcome

152 papers were found in total, of which 6 were relevant. They are shown in the table below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
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
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
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
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
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
Liu, C L. Fan, S T. Lo, C M. Tso, W K. Wong, Y. Poon. 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.

Comment(s)

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.

Clinical Bottom Line

A high serum ALT can be used as a tool in predicting gallstone pancreatitis.

References

1. Tenner, S. Dubner, H. Steinberg, W Predicting gallstone pancreatitis with laboratory parameters: a meta-analysis American Journal of Gastroenterology 89(10):1863-6, 1994 Oct
2. 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. Clinical Chemistry. 41(4):523-31, 1995 Apr
3. 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. International Journal of Pancreatology. 25(2):107-11, 1999 Apr.
4. 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. Pancreas. 26(2):e32-5, 2003 March
5. 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. Pancreatology 5(4-5):450-6, 2005.
6. 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. Alimentary Pharmacology & Therapeutics. 22(5):423-31, 2005 Sep 1.