Detection of colipase in serum and urine of pancreatitis patients

Serum amylase and lipase and urinary trypsinogen and amylase for diagnosis of acute pancreatitis

BACKGROUND

The treatment of people with acute abdominal pain differs if they have acute pancreatitis. It is important to know the diagnostic accuracy of serum amylase, serum lipase, urinary trypsinogen-2, and urinary amylase for the diagnosis of acute pancreatitis, so that an informed decision can be made as to whether the person with abdominal pain has acute pancreatitis. There is currently no Cochrane review of the diagnostic test accuracy of serum amylase, serum lipase, urinary trypsinogen-2, and urinary amylase for the diagnosis of acute pancreatitis.

OBJECTIVES

To compare the diagnostic accuracy of serum amylase, serum lipase, urinary trypsinogen-2, and urinary amylase, either alone or in combination, in the diagnosis of acute pancreatitis in people with acute onset of a persistent, severe epigastric pain or diffuse abdominal pain.

SEARCH METHODS

We searched MEDLINE, Embase, Science Citation Index Expanded, National Institute for Health Research (NIHR HTA and DARE), and other databases until March 2017. We searched the references of the included studies to identify additional studies. We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively. We also performed a 'related search' and 'citing reference' search in MEDLINE and Embase.

SELECTION CRITERIA

We included all studies that evaluated the diagnostic test accuracy of serum amylase, serum lipase, urinary trypsinogen-2, and urinary amylase for the diagnosis of acute pancreatitis. We excluded case-control studies because these studies are prone to bias. We accepted any of the following reference standards: biopsy, consensus conference definition, radiological features of acute pancreatitis, diagnosis of acute pancreatitis during laparotomy or autopsy, and organ failure. At least two review authors independently searched and screened the references located by the search to identify relevant studies.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the included studies. The thresholds used for the diagnosis of acute pancreatitis varied in the trials, resulting in sparse data for each index test. Because of sparse data, we used -2 log likelihood values to determine which model to use for meta-analysis. We calculated and reported the sensitivity, specificity, post-test probability of a positive and negative index test along with 95% confidence interval (CI) for each cutoff, but have reported only the results of the recommended cutoff of three times normal for serum amylase and serum lipase, and the manufacturer-recommended cutoff of 50 mg/mL for urinary trypsinogen-2 in the abstract.

MAIN RESULTS

Ten studies including 5056 participants met the inclusion criteria for this review and assessed the diagnostic accuracy of the index tests in people presenting to the emergency department with acute abdominal pain. The risk of bias was unclear or high for all of the included studies. The study that contributed approximately two-thirds of the participants included in this review was excluded from the results of the analysis presented below due to major concerns about the participants included in the study. We have presented only the results where at least two studies were included in the analysis.Serum amylase, serum lipase, and urinary trypsinogen-2 at the standard threshold levels of more than three times normal for serum amylase and serum lipase, and a threshold of 50 ng/mL for urinary trypsinogen-2 appear to have similar sensitivities (0.72 (95% CI 0.59 to 0.82); 0.79 (95% CI 0.54 to 0.92); and 0.72 (95% CI 0.56 to 0.84), respectively) and specificities (0.93 (95% CI 0.66 to 0.99); 0.89 (95% CI 0.46 to 0.99); and 0.90 (95% CI 0.85 to 0.93), respectively). At the median prevalence of 22.6% of acute pancreatitis in the studies, out of 100 people with positive test, serum amylase (more than three times normal), serum lipase (more than three times normal), and urinary trypsinogen (more than 50 ng/mL), 74 (95% CI 33 to 94); 68 (95% CI 21 to 94); and 67 (95% CI 57 to 76) people have acute pancreatitis, respectively; out of 100 people with negative test, serum amylase (more than three times normal), serum lipase (more than three times normal), and urinary trypsinogen (more than 50 ng/mL), 8 (95% CI 5 to 12); 7 (95% CI 3 to 15); and 8 (95% CI 5 to 13) people have acute pancreatitis, respectively. We were not able to compare these tests formally because of sparse data.

AUTHORS' CONCLUSIONS

As about a quarter of people with acute pancreatitis fail to be diagnosed as having acute pancreatitis with the evaluated tests, one should have a low threshold to admit the patient and treat them for acute pancreatitis if the symptoms are suggestive of acute pancreatitis, even if these tests are normal. About 1 in 10 patients without acute pancreatitis may be wrongly diagnosed as having acute pancreatitis with these tests, therefore it is important to consider other conditions that require urgent surgical intervention, such as perforated viscus, even if these tests are abnormal.The diagnostic performance of these tests decreases even further with the progression of time, and one should have an even lower threshold to perform additional investigations if the symptoms are suggestive of acute pancreatitis.

Lipid-based intravesical drug delivery systems with controlled release of trospium chloride for the urinary bladder

The overactive bladder (OAB) is a common disease with an overactivity of the detrusor muscle in the bladder wall. Besides peroral administration of anticholinergic drugs and bladder irrigations, there is a need for a sustained release formulation in the urinary bladder. In order to realise a local long-term treatment of the overactive urinary bladder, lipidic drug delivery systems were prepared. Requirements for an intravesical application are a long-term controlled release of trospium chloride, a high drug loading and small sized drug carriers to permit an insertion through the urethra into the urinary bladder. The drug delivery systems were manufactured by using compression (mini-tablets), solid lipid extrusion (extrudates) and a melting and casting technique (mini-moulds) with different amounts of trospium chloride and glyceryl tristearate as matrix former. Drug release depended on the drug loading and the preparation method. Mini-tablets and lipidic extrudates showed a drug release over five days, whereas that from mini-moulds was negligibly small. The appearance of polymorphic transformations during processing and storage was investigated by using differential scanning calorimetry and X-ray diffraction. In contrast to mini-tablets and mini-moulds, lipidic extrudates showed no polymorphic transformations. In summary, lipids are suitable matrix formers for a highly water-soluble drug, like trospium chloride. Despite a drug loading of up to 30%, it was feasible to achieve a drug release ranging from several days up to weeks. In addition, small dosage forms with a size of only a few millimetres were realised. Therefore, an insertion and excretion through the urethra is possible and the requirements for an intravesical application are fulfilled.

Integrated proteomic profiling of cell line conditioned media and pancreatic juice for the identification of pancreatic cancer biomarkers

Pancreatic cancer is one of the leading causes of cancer-related deaths, for which serological biomarkers are urgently needed. Most discovery-phase studies focus on the use of one biological source for analysis. The present study details the combined mining of pancreatic cancer-related cell line conditioned media and pancreatic juice for identification of putative diagnostic leads. Using strong cation exchange chromatography, followed by LC-MS/MS on an LTQ-Orbitrap mass spectrometer, we extensively characterized the proteomes of conditioned media from six pancreatic cancer cell lines (BxPc3, MIA-PaCa2, PANC1, CAPAN1, CFPAC1, and SU.86.86), the normal human pancreatic ductal epithelial cell line HPDE, and two pools of six pancreatic juice samples from ductal adenocarcinoma patients. All samples were analyzed in triplicate. Between 1261 and 2171 proteins were identified with two or more peptides in each of the cell lines, and an average of 521 proteins were identified in the pancreatic juice pools. In total, 3479 nonredundant proteins were identified with high confidence, of which ∼ 40% were extracellular or cell membrane-bound based on Genome Ontology classifications. Three strategies were employed for identification of candidate biomarkers: (1) examination of differential protein expression between the cancer and normal cell lines using label-free protein quantification, (2) integrative analysis, focusing on the overlap of proteins among the multiple biological fluids, and (3) tissue specificity analysis through mining of publically available databases. Preliminary verification of anterior gradient homolog 2, syncollin, olfactomedin-4, polymeric immunoglobulin receptor, and collagen alpha-1(VI) chain in plasma samples from pancreatic cancer patients and healthy controls using ELISA, showed a significant increase (p < 0.01) of these proteins in plasma from pancreatic cancer patients. The combination of these five proteins showed an improved area under the receiver operating characteristic curve to CA19.9 alone. Further validation of these proteins is warranted, as is the investigation of the remaining group of candidates.

In vitro assessment of the bioaccessibility of tocopherol and fatty acids from sunflower seed oil bodies

The in vitro digestibility (proteolytic and lipolytic) and bioaccessibility of nutritionally important compounds (alpha-tocopherol and fatty acids) have been studied for natural sunflower ( Helianthus annuus ) oil body suspensions in comparison to artificial emulsions emulsified with polyoxyethylene-20-sorbitan-monolaurate (Tween 20) or whey protein isolate. Proteolytic digestion of emulsions with pepsin (pH 2) promoted significant increases in mean particle size of the whey protein isolate stabilized emulsion (1.8-2.9 mum) and oil bodies (2.3-22.5 mum) but not the Tween 20 stabilized emulsions. SDS-PAGE of proteolytic digestion products suggested degradation of the stabilizing oleosin protein (ca. 18-21 kDa) in oil bodies. The rate of oil body hydrolysis with lipase was significantly slower than the lipase-catalyzed hydrolysis of the artificial emulsions and exhibited a prolonged lag phase. Results from simulated human digestion in vitro suggested that the mean bioaccessibility of alpha-tocopherol and total fatty acids from oil bodies (0.6 and 8.4%, respectively) was significantly lower than that from the Tween 20 stabilized emulsion (35 and 52%, respectively) and the whey protein isolate stabilized emulsion (17 and 33%, respectively). These in vitro results suggest that oil bodies could provide a natural emulsion in food that is digested at a relatively slow rate, the physiological consequence of which may be increased satiety.

Capillary diffusion capacity and tissue distribution of pancreatic procolipase in rat

The permeability-surface area product of procolipase and its apparent distribution volume in rat tissues were assessed using a tissue uptake technique. Procolipase was investigated together with 51Cr-EDTA, used as an inert extracellular marker, and 131I-albumin, used as a plasma volume marker. The tissue uptake of procolipase seemed to occur by passive transport in most of the organs studied, such as in muscle, liver, lung, adipose tissue, adrenal glands, colon, and skin. However, throughout the gastrointestinal tract, except in the colon, there was a high uptake of procolipase, greatly exceeding that of 51Cr-EDTA. This was especially evident in the stomach, in which the procolipase uptake was nonsaturable within the experimental period. Also, in the central nervous system (CNS), there was evidence of specific, possibly carrier-mediated, transport. These results suggest that procolipase may have specific, conceivably receptor-mediated, transport pathways across the microvascular endothelium in the stomach, pancreas, duodenum, ileum, and the CNS.

Development of enzyme-linked immunosorbent assay for free human pro-colipase activation peptide (APGPR)

Human pancreatic colipase is secreted as the inactive form procolipase. Activation involves tryptic cleavage of an N-terminal pentapeptide Ala-Pro-Gly-Pro-Arg (APGPR) which is known as procolipase activation peptide (CLAP). N-terminally haptenised synthetic APGPR was used to generate specific C-terminally directed anti-APGPR antibodies. The antiserum was used to develop a competitive enzyme linked immunosorbent assay (ELISA) specific for free CLAP with a detection limit of 12 nmol/l and an intra-assay coefficient of variation (CV) of 3.28% and an inter-assay CV of 5.82%. The release of immunoreactive CLAP from human pancreatic juice and chicken pancreas upon trypsinisation was demonstrated, as well as the absence of reactivity of the antisera with procolipase from which the CLAP is released. APGPR was found to be unstable in biological fluids. Immunoreactivity is rapidly lost with half life of 5 min and 4 h in human serum and urine respectively. This loss of reactivity can be significantly slowed by the addition of 20 mmol/l Zinc ions (Zn2+), while ethylenediaminetetra-acetic acid (EDTA) and other protease inhibitors were ineffective. In serum the moiety responsible for loss of immunoreactivity was found to have an estimated molecular mass of 200,000-300,000 Da. CLAP assay specifically reports procolipase activation and may help elucidate the mechanism of satiety as well as contribute to the recognition and understanding of the role of procolipase activation in diseases states such as pancreatitis.

Advances in the enzyme diagnosis of pancreatic diseases

This paper reviews recent developments of analytical methods for the determination of alpha-amylase, of its isoenzymes, and of lipase. The evaluation of severity and etiology of acute pancreatitis by enzyme assays, e.g., pancreatic elastase 1, phospholipase A2, and routine enzymes are discussed. The limited significance of enzyme determinations as compared to imaging and endoscopic procedures for the diagnosis of chronic pancreatitis is demonstrated. Indirect "tubeless" tests for the evaluation of pancreatic exocrine insufficiency with respect to the secretion of chymotrypsin (chymotrypsin in stool and NBT-PABA test) and cholesterol esterase (pancreolauryl test) are reviewed. Finally, the superiority of morphologic investigations over biochemical tests for the timely detection of pancreatic carcinoma is shown.

Immunoreactive pancreatic colipase, lipase and phospholipase A2 in human plasma and urine from healthy individuals

A radioimmunoassay for each of the human pancreatic proteins (colipase, lipase and phospholipase A2) is described. Determinations of the mean concentration of each protein in plasma and urine from healthy individuals were carried out with the radioimmunoassays. The values obtained in plasma were 0.5 nM (5.3 micrograms/l), 0.6 nM (32 micrograms/l) and 0.3 nM (4.3 micrograms/l) for colipase, lipase and phospholipase A2, respectively. In urine, the corresponding values were found to be 0.2 nM (2.4 micrograms/l), 0.09 nM (4.4 micrograms/l) and less than 0.017 nM (0.2 micrograms/l). No physical interaction between any of the three proteins and the lipid particles of plasma was demonstrated by centrifugation experiments or gel filtration. Gel filtration of plasma depleted of fat by centrifugation showed the proteins only in their monomeric form. The corresponding porcine proteins displayed a binding to antibodies against the human proteins, but with a lower affinity than the homologous interactions. The binding was weak but could differentiate between the porcine proforms and activated ones, i.e., procolipase and colipase87.