Benign pancreatic hyperenzymemia or Gullo's syndrome

Asymptomatic Elevation of Pancreatic Enzymes: A Case of Gullo's Syndrome

Benign pancreatic hyperenzymemia (BPH) or Gullo's syndrome is a benign condition consisting of an oscillating elevation of pancreatic enzymes without the identification of pancreatic disease. Its diagnosis is usually incidental and by excluding other conditions that occur with elevated pancreatic enzymes. To the best of our knowledge, there are no reports of this diagnosis to this day in Portugal. A 65-year-old female was referred to an internal medicine consultation for complaints of xerostomia, xerophthalmia, and xeroderma with one year of evolution. From the study carried out by the patient prior to the consultation, an incidental elevation of amylase stands out. The sicca symptoms were attributed to sertraline since, after excluding other causes, its discontinuation resolved the symptoms. Regarding the elevation of pancreatic enzymes, the patient underwent an extensive diagnostic study for clarification without identifying any condition. The serial measurement of amylase and lipase revealed an oscillating increase in pancreatic enzymes with temporary normalization. After one year of follow-up, the diagnosis of Gullo's syndrome was established. The identification of Gullo's syndrome is extremely important as it avoids carrying out unnecessary tests in the future and allows the patient to be reassured in the face of this benign alteration of pancreatic enzymes. A follow-up of at least one year is crucial since some pancreatic tumors course with an asymptomatic increase in pancreatic enzymes.

Benign Pancreatic Hyperenzymemia, Also Known as Gullo's Syndrome

Benign pancreatic hyperenzymemia, also known as Gullo's syndrome, is a little-known syndrome first described in 1996 in patients studied for an elevation of pancreatic enzymes while otherwise being asymptomatic. We describe the case of a 2-year-old patient who was found to have significant elevation of amylase and lipase levels while he was asymptomatic. Blood tests and imaging tests were performed to determine the etiology, but they gave normal results. The enzyme elevation can even be 10 times the normal value of the enzyme, and only 1 enzyme may elevate, although most often all pancreatic enzymes are elevated. The etiology is not known, although several hypotheses have been suggested. This enzyme elevation is described both in adults and children and also sporadically or with a familial pattern. Knowledge of it can limit the performance of the multiple complementary test, some of which are very invasive in patients who have elevated pancreatic enzymes while they are asymptomatic. It knowledge allows us to confirm a benign prognosis about it and reassure the family about this disease and that in the end it will not require aggressive treatments such as surgery or chemotherapy.

Non-alcoholic fatty pancreas disease - practices for clinicians

Obesity is a growing health burden worldwide, increasing the risk for several diseases featuring the metabolic syndrome - type 2 diabetes mellitus, dyslipidemia, non-alcoholic fatty liver disease and cardiovascular diseases. With the increasing epidemic of obesity, a new pathologic condition has emerged as a component of the metabolic syndrome - that of non-alcoholic fatty pancreas disease (NAFPD). Similar to non-alcoholic fatty liver disease (NAFLD), NAFPD comprises a wide spectrum of disease - from deposition of fat in the pancreas - fatty pancreas, to pancreatic inflammation and possibly pancreatic fibrosis. In contrast with NAFLD, diagnostic evaluation of NAFPD is less standardized, consisting mostly in imaging methods. Also the natural evolution of NAFPD and its association with pancreatic cancer is much less studied. Not least, the clinical consequences of NAFPD remain largely presumptions and knowledge about its metabolic impact is limited. This review will cover epidemiology, pathogenesis, diagnostic evaluation tools and treatment options for NAFPD, with focus on practices for clinicians.

Prevalence and correlates of Benign Pancreatic Hyperenzymemia in a large general population sample: The Damocles sword perception

BACKGROUND

Benign Pancreatic Hyperenzymemia (BPH) is characterized by a long-term increase of serum pancreatic enzymes (PE) in otherwise healthy subjects. The study investigates the prevalence and correlates of the condition using data from Electronic Health Records (EHR) in a large sample of general population, to identify subjects potentially affected by BPH.

METHODS

Cross-sectional retrospective observational study integrated by a follow-up visit.

RESULTS

The database of a reference laboratory identified, out of 577.251 admittances from 2011 to 2015, 4964 patients tested at least for one PE assay and 1688 subjects who had at least 3 PE tests (normal or increased) over two years. Forty-two individuals showed an increase of PE at least three times throughout 2 years without any evidence of pancreatic disease, even after matching with the ICD 9-CM code in the GPs database. Data retrieved at follow-up visit showed that for 34 the diagnosis of BPH could be made.

CONCLUSIONS

Our data indicate that BPH prevalence among subjects underwent blood testing for multiple PE testing is 2%. This condition, even if not a disease, is perceived by nearly all the BPH patients as a serious threat to their life. Further studies are needed to manage its heavy psychological impact.

Chronic Asymptomatic Pancreatic Hyperenzymemia: A Long-term Follow-up

OBJECTIVES

Chronic asymptomatic pancreatic hyperenzymemia (CAPH) was described as a benign disease. However, we already described clinically relevant findings requiring surgery or follow-up in half of the subjects. The aim of this study was to evaluate the long-term outcome of CAPH in terms of symptoms and evolution toward chronic pancreatitis.

METHODS

Subjects previously enrolled in the first phase of the study (from 2005 to 2010) were reinvestigated from December 2013 to January 2017 with a phone call ± magnetic resonance cholangiopancreatography with secretin stimulation.

RESULTS

A total of 133 subjects were eligible for the follow-up study (75 males, 58 females; age, 48.4 [standard deviation {SD}, 14] years); 24 (18%) of them dropped out. During a mean follow-up of 9.3 (SD, 5.2) years after the first diagnosis of CAPH, no episode of acute pancreatitis or abdominal pain was reported. Sixty-three subjects (58%) of 109 underwent magnetic resonance cholangiopancreatography with secretin stimulation with a mean follow-up of 5.7 [SD, 3.1] years (range, 1-11 years). Secretin stimulation-MRCP resulted unchanged in 54 (90%) of 60 subjects, worsened in 3 (5%) and improved in 3 (5%). Two subjects died from causes unrelated to pancreatic disease.

CONCLUSIONS

Excluding subjects with a pancreatic disease at index magnetic resonance imaging, CAPH is a benign condition.

Gullo's Syndrome: A Case Report

Benign Pancreatic Hyperenzymemia (BPH) or Gullo's Syndrome is a new entity with only few reported cases till date. It is characterized by persistently elevated pancreatic enzymes without any clinical or pathological evidence of pancreatic disease. Gullo's syndrome is a diagnosis of exclusion and clinician should be aware of various other conditions which can cause elevation of pancreatic enzymes. There are no reported cases of Gullo's syndrome from Indian subcontinent till date. A 42-year-old lady presented to us with complaints of fever and cough for which she was evaluated and diagnosed to be having left upper zone pneumonia. However, her routine investigations showed persistently elevated serum amylase and lipase levels. She was extensively worked up for pancreatic hyperenzymemia but no pancreatic disease was detected. She was followed up for a period of one year and raised levels of serum lipase and amylase persisted even after a year.

Asymptomatic and persistent elevation of pancreatic enzymes in an ulcerative colitis patient

Azathioprine has been extensively used in the management of inflammatory bowel diseases. It might cause pancreatic damage in the form of either asymptomatic elevation in serum amylase/lipase or overt acute pancreatitis. Here we report the case of a 61-year-old patient with ulcerative colitis who had been treated with azathioprine for three years, achieving clinical remission. During treatment he presented an asymptomatic elevation of serum pancreatic enzymes, without any signs of pancreatitis at imaging. This evidence brought us to reassess the drug dosage, without achieving a normalization of biochemical analysis. Autoimmune pancreatitis was excluded. One year after the suspension of azathioprine, we still face persistent high levels of amylase/lipase. Normalization of enzymatic values in patients who develop intolerance to azathioprine, in the form of either asymptomatic elevation in serum amylase/lipase or overt acute pancreatitis, is usually achieved in about two months after stopping drug intake. Asymptomatic elevation in serum pancreatic enzymes in the absence of pancreatic disease is reported in the literature and defined as “Gullo's syndrome,” but nobody of the subjects studied had been treated in the past with pancreatotoxic drugs. Might this case be defined as “benign pancreatic hyperenzymemia”?

Increased variability and abnormalities in pancreatic enzyme concentrations in otherwise asymptomatic subjects with type 2 diabetes

BACKGROUND

Recent studies have demonstrated an increased incidence of pancreatitis in patients with type 2 diabetes compared with obese nondiabetic individuals. Serum lipase and pancreatic amylase concentrations are used in conjunction with clinical findings to diagnose pancreatitis.

METHODS

In two large clinical trials of overweight/obese nondiabetic and type 2 diabetic subjects, lipase and pancreatic amylase were measured at screening and 2-5 weeks later at baseline (prior to treatment with study medication).

RESULTS

Lipase and pancreatic amylase concentrations were above the upper limit of normal (ULN) in 13% and 6% of type 2 diabetic subjects, respectively, and were approximately three-fold (3 ×) higher than the proportion of nondiabetic subjects with levels above ULN. Elevations exceeding ULN were seen in many subjects asymptomatic for pancreatitis; however, elevations >2 × ULN and >3 × ULN were uncommon, and elevations >3 × ULN were often associated with a history of dyslipidemia, hyperlipidemia, and gastrointestinal disorders. Additionally, enzyme concentrations varied within this 2-5-week screening period, including shifts between elevated and normal levels.

CONCLUSION

Results from this post hoc analysis suggest that, although pancreatic enzymes can be a useful marker for pancreatitis within the proper clinical context, diagnosis of pancreatitis may be confounded in populations known to have asymptomatic elevations associated with disease, such as type 2 diabetes. Further effort is needed to clarify the etiology and epidemiology of pancreatic enzyme elevations in type 2 diabetes.

Chronic asymptomatic hyperamylasemia unrelated to pancreatic diseases

PURPOSE

This study was addressed to assess the clinical characteristics of patients presenting with chronic hyperamylasemia unrelated to pancreatic diseases (CHUPD). Almost all patients presenting with chronic hyperamylasemia undergo expensive, long, difficult, and often unnecessarily repeated diagnostic procedures. This is in conjunction with the poor knowledge of the fact that besides hyperenzymemia secondary to pancreatic diseases and systemic illnesses, various non-pathological forms of chronic hyperamylasemia without relevant pathologic consequence can occur in clinical practice.

MATERIAL AND METHODS

Data of all patients with CHUPD were retrospectively reviewed (June 1997-December 2009). Fifty one patients were included in the study; median follow up was 48 months (range 8-112 months). Their pre-enrolment diagnoses were: chronic pancreatitis in 31 cases (60.7%) and recurrent pancreatitis in 13 cases (25.4%); the remaining 7 patients (13.7%) were without a specific diagnosis.

RESULTS

Our observations, supported by diagnostic procedures (Ca19-9 serum levels, abdominal ultrasonography, computed tomography and magnetic resonance, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography) revealed that CHUPD was secondary to: a) benign pancreatic hyperamylasemia, 20 patients (39.2%); b) macroamylasemia, 18 patients (35.2 %) and c) salivary hyperamylasemia, 13 patients (25.4%).

CONCLUSIONS

Due to the poor familiarity with CHUPD, the occurrence of this condition quite frequently leads to unnecessarily repeated diagnostic procedures.