Clinical utility and economic burden of routine serum lipase determination in the Emergency Department

Abstract

Background Serum lipase is a rapid and reliable laboratory test central to diagnosing acute pancreatitis (AP). Routine use in the emergency department (ED) setting for all cases of abdominal pain or as part of a standard laboratory biochemical profile may lead to unnecessary expenses. Aim To examine the utility of serum lipase determination at a tertiary care centre ED. Methods Retrospective cross‐sectional study of ED patients having serum lipase determination over a 12‐month period. Electronic medical records were reviewed for indication and interpretation leading to additional diagnostic imaging, specialist consultation, interventions or hospital admission. Results A total of 24 133 adult patients visited the ED during the study period: 4976 (20.6%) had serum lipase determination, 614 (12.4%) had abnormal lipase, 130 of which (21.1%) were above the diagnostic threshold for acutre pancreatitis (AP) (>3× ULN). A total of 75 patients had confirmed AP (0.3% of all adult ED visits). The positive and negative predictive values of serum lipase (>3× ULN) for AP were 43.6% and 99.6%, respectively. One thousand eight hundred and ninety patients (38.0%) had no abdominal pain on history or physical examination. In this group, the total charge associated with lipase determination was $51 030 with 251 (13.3%) elevated lipase values triggering cross‐sectional abdominal imaging in 61 (24.3%) patients and unwarranted gastroenterology consultation in three (1.2%) for an additional charge of $28 975. Conclusions Serum lipase is widely overutilised in the emergency setting resulting in unnecessary expenses and investigations. Evidence‐based review of clinical guidelines and more restrictive testing can result in substantial cost savings and improved patient care.

Utility of leucocytes, inflammatory markers and pancreatic enzymes as indicators of gangrenous cholecystitis

“…Despite the common use of amylase and lipase in patients presenting with abdominal pain, their clinical value was debated. Previous studies have shown an association between AC and GC,11–13 however, an increase in their serum levels may be confounded by accompanying pancreatitis. Our results and the results of other studies did not show a significant association between these biomarkers and GC.…”

Severe Acute Pancreatitis Rapidly Developed Into Pulmonary Edema and Diffuse Alveolar Hemorrhage Leading to Respiratory Failure: An Autopsy Case

“…Although CT can detect early pancreatitis with a sensitivity of 60-95%, measurement of blood pancreatic enzyme, which detects pancreatitis with a sensitivity of 96.6% and specificity of 99.4%, was not performed at the admission [ 7 , 8 ]. The appropriateness of routine blood testing of lipase as a screening tool for acute pancreatitis in the emergency room remains unestablished [ 9 ]. Even if he had developed pancreatitis undetectable by CT upon arrival at the emergency room, according to Ranson's criteria, he did not meet any of the risk factors except for the unknown blood glucose level [ 10 ].…”

No abdominal pain, no lipase

“…The article by El Halabi et al highlights the economic burden of test over-utilisation. 1 Inclusion of non-routine tests in laboratory test panels and inconsistent adherence to clinical guidelines leads to unnecessary testing in patients where no benefit is gained. It is often considered 'safer', for both the requester and patient, to request the test than not.…”