Review article: Diagnosing acute pancreatitis in diabetes mellitus

Abstract

Acute pancreatitis is a common reason for presentation to EDs. The criteria for diagnosis of acute pancreatitis are defined by the revised Atlanta classification. Patients with diabetes mellitus are at increased risk of acute pancreatitis. Uncomplicated diabetes mellitus, complications such as ketoacidosis and newer medications used in the treatment of hyperglycaemia may all be associated with elevated serum lipase and amylase in the absence of acute pancreatitis. Checkpoint inhibitors may also precipitate acute type 1 diabetes mellitus and be associated with elevated lipase and amylase. Finally, individuals with diabetes mellitus are at increased risk of hypertriglyceridaemic pancreatitis, which may be associated with falsely normal lipase and amylase because of laboratory interference. Awareness of these factors in individuals with diabetes mellitus presenting to EDs with symptoms suggestive of acute pancreatitis is important for accurate diagnosis.

Serum lipase in acute pancreatitis associated with hypertriglyceridaemia

“…Serum lipase may be elevated in T2DM alone, as a result of treatment with dipeptidyl peptidase-4 inhibitors and glucagon-like peptide 1 receptor agonists, in the setting of a fatty pancreas, and with diabetic ketoacidosis. 17 The sample size is small with respect to risk factors and assessing a correlation between serum lipase and triglyceride levels. Serum triglyceride levels were checked in all individuals within 24 h of presentation, but may have been done after initiation of insulin/dextrose infusion, resulting in a lowering of triglyceride levels.…”

“…More than half of the patients identified with HTG‐AP had T2DM. Serum lipase may be elevated in T2DM alone, as a result of treatment with dipeptidyl peptidase‐4 inhibitors and glucagon‐like peptide 1 receptor agonists, in the setting of a fatty pancreas, and with diabetic ketoacidosis 17 . The sample size is small with respect to risk factors and assessing a correlation between serum lipase and triglyceride levels.…”

Investigating gastrointestinal disorders in pregnancy

“…Individuals with hypertriglyceridaemic pancreatitis may have falsely normal lipase and amylase levels due to hypertriglyceridaemia interfering in vitro with the laboratory assay. 48…”

Epigastric pain and partial ptosis

“…The biochemical diagnosis of AP in people with diabetes is complicated by the greater than the threefold elevation of serum lipase in the absence of AP in 0.4%-2.1% of people with uncomplicated diabetes, 16%-25% of individuals with DKA, and 1.5%-8.3% of patients taking glucagon-like-peptide agonists. 4 Elevated serum lipase is also seen in 39% of individuals taking dipeptidyl peptidase-4 inhibitors. HTG-AP may occur without significant elevation of lipase due to assay interference.…”

“…The Atlanta criteria for diagnosis of AP require 2 or more typical abdominal pain, serum lipase more than 3 times normal, and characteristic imaging findings. The biochemical diagnosis of AP in people with diabetes is complicated by the greater than the threefold elevation of serum lipase in the absence of AP in 0.4%–2.1% of people with uncomplicated diabetes, 16%–25% of individuals with DKA, and 1.5%–8.3% of patients taking glucagon‐like‐peptide agonists 4 . Elevated serum lipase is also seen in 39% of individuals taking dipeptidyl peptidase‐4 inhibitors.…”