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Three Part Question

In [patients with abdominal pain] is [a urinary trypsinogen test] sufficiently sensitive as a diagnostic marker [to rule in/out pancreatitis]?

Clinical Scenario

A 45 year old female attends the emergency department with a 4-hour history of acute onset of epigastric pain. She has a history of alcohol usage. On examination you can elicit tenderness in the epigastrium but no peritonism. You are concerned that the patient may have pancreatitis. You wonder whether a urinary trypsinogen can be used as a diagnostic marker to rule out pancreatitis in this patient.

Search Strategy

Medline 1966-04/2000 and EMBASE using the OVID interface.
[{exp Trypsinogen/ or trypsinogen.mp} AND {exp Urine/ OR urine.mp}] LIMIT to English AND Human.

Search Outcome

21 papers were found in total of which 17 were irrelevant or of insufficient quality for inclusion. The remaining 4 papers are shown below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hedstrom J, et al 1996 Finland	59 patients with pancreatitis 42 controls admitted with abdominal pain	Diagnostic study looking at ROC curves of urinary trypsinogen, serum trypsinogen, serum amylase and urinary amylase	Diagnosis of pancreatitis	Urinary trypsinogen had similar ROC curve results as serum amylase	Selected patients Gold standard
Tenner S, et al 1997 USA	189 patients; 139 with pancreatitis, 50 without	Diagnostic study looking at urinary trypsinogen as a marker of pancreatic injury compared with CT diagnosis.	Urinary trypsinogen (10 ng/ml)	NPV = 100%
Kemppainen EA, et al 1997 Finland	500 consecutive patients attending A&E in 2 centres with abdominal pain	Diagnostic study to assess the usefulness of urinary trypsinogen as a diagnostic marker.	Urinary trypsinogen (50 ng/ml)	Sensitivity 94% (92-96%); Specificity 95% (93-97%)	Diagnosis based on amylase >900 or clinical + CT scan in patients with normal amylase Autopsy Surgery
			Serum amylase (300IU)	Sensitivity 85%; Specificity 91%
			Urinary Amylase (2000IU/L)	Sensitivity 83%; Specificity 88%
Kylanpaa-Back M, et al 2000 Finland	525 consecutive patients with acute abdominal pain presenting to 2 emergency departments Urinary trypsinogen 2 test strip used	Diagnostic study looking at test strips for urinary trypsinogen and quantitative urinary trypsinogen measurements. Gold standard measurement was clinical features, amylase and CT findings.	Diagnosis of pancreatitis	45 patients had pancreatitis. Sensitivity 96% (94-97%); Specificity 92% (90-95%). All patients with severe disease were detected.	Gold standard

Comment(s)

The diagnosis of pancreatitis often needs to be excluded as a matter of routine in patients who present to the emergency department with acute abdominal pain. The relevant papers demonstrate that pancreatitis can be excluded with a high level of sensitivity by measuring the urinary trypsinogen levels.

Clinical Bottom Line

Urinary trypsinogen can be used as a sensitive diagnostic tool to exclude pancreatitis in patients presenting to the emergency department with abdominal pain.

References

1. Hedstrom J, Sainio V, Kemppainen E, Puolakkainen P, et al. Urine trypsinogen-2 as marker of acute pancreatitis. Clinical Chemistry. 1996;42(5):685-90.
2. Tenner S, Fernandez-del Castillo C, Warshaw A et al. Urinary trypsinogen activation peptide (TAP) predicts severity in patients with acute pancreatitis. Int J Pancreatology. 1997;21(2):105-10.
3. Kemppainen EA, Hedstrom JI, Puolakkainen PA, et al. Rapid measurement of urinary trypsinogen-2 as a screening test for acute pancreatitis. NEJM 1997;336(25):1788-93.
4. Kylanpaa-Back M, Kemppainen E, Puolakkainen P et al. Reliable screening for acute pancreatitis with rapid urine trypsinogen-2 test strip. Br J Surgery 2000;87(1):49-52.