Case Report

Elevated amylase in childhood

Alan J Howieson and Gordon A MacKinlay

Abstract
Addresses A 3-year-old boy was referred to a regional centre with an acute abdomen. On
Department of Paediatric Surgery, Royal admission, his abdomen was clinically benign but an extremely high serum amylase
Hospital for Sick Children, Sciennes Road, titre noted. The patient was treated with simple observation and over the following
Edinburgh, UK period he was found to have an inflamed parotid gland.
Correspondence Ann Clin Biochem 2006; 43: 318–319
Dr Alan J Howieson
Email: alanjhowieson@hotmail.com

Case history Pancreatic isoamylase is responsible for appro-

A 3-year-old boy with known sickle cell trait was
admitted with a suspected acute abdomen. There was
a 12-h history of non-speci¢c abdominal pain, which
had woken him from sleep. He had vomited once, but
had no other symptoms of note. Patient agitation made
examination di⁄cult, but vital signs and abdominal
examination were normal.
Serology showed an elevated amylase titre of
1175 U/L and, when repeated,1477 U/L (reference range
16--90 U/L). Full blood count, urea and electrolytes,
calcium, glucose, liver function tests and a capillary
blood gas were normal. C-reactive protein was 11mg/L
(reference range o10 mg/L). Radiographs of the chest
and abdomen were unremarkable.
The child was treated with intravenous £uids over-
night and an abdominal ultrasound scan performed
the following day was normal. Repeat amylase showed
a continued rise to 1690 U/L. Blood and urine cultures,
serology for mumps, Epstein--Barr virus and cyto-
megaly virus were negative (mumps titre consistent
with immunization). Serum lipase was 26 U/L (refer-
ence range 22--51 U/L).
After 48 h, a unilateral facial swelling was noted and
US examination of the relevant parotid gland showed
that it was enlarged and contained a number of reactive
lymph nodes. The patient was discharged the following
day with a diagnosis of parotitis and a ¢nal amylase titre
of 230 U/L. Outpatient follow-up was normal.
Discussion
This case emphasizes that a history of abdominal pain
in association with a raised amylase titre does not
always indicate pancreatitis.
ximately 40% of normal serum amylase activity.1
Column isoelectric focusing of serum shows that there
are three peak levels, with the pancreas secreting one
isoamylase and the parotid gland secreting several
isoamylases, which are responsible for two peaks.
Hyperamylasaemia often occurs due to elevation of
salivary-type amylase, and mumps, parotid tumours,
trauma and obstruction may be the cause, although it
can occur without any clinically recognized pathology
a¡ecting the parotid gland.1
Speci¢c biochemical techniques can be used to
isolate the various isoenzymes, but these were unfor-
tunately not available in our hospital. Lipase is, how-
ever, a more sensitive marker of acute pancreatitis,
with levels over two times the upper limit of normal
being signi¢cant.
Pancreatitis is an uncommon disease in childhood
and usually occurs secondary to blunt abdominal
trauma. It is associated with sudden onset of upper
abdominal pain and vomiting, and this, in conjunction
with an amylase concentration four times the upper
value of normal, is frequently taken as diagnostic. A
recent case series by Goh et al.2 identi¢ed 12 children
with pancreatitis who presented over a 4-year period
with amylase concentrations ranging from 190 to
1370 U/L (median 512 U/L). All patients had evidence
of abdominal tenderness and the diagnosis was
con¢rmed by computerized tomography or abdominal
ultrasound scanning. However, based on a study of
children admitted with recurrent abdominal pain from
all causes,3 Wheeler et al. advocate that serum amylase
is not a particularly helpful test, given the rarity of
non-traumatic childhood pancreatitis.
Of the other possible reasons for a raised amylase in
childhood (Table 1), acute parotitis normally presents

318 r 2006 The Association for Clinical Biochemistry

 Elevated amylase in childhood 319

Table 1 Causes of hyperamylasaemia in childhood 6 nosed in a 6-year-old boy who underwent extensive in-
Pancreatic origin Salivary origin Mixed/unknown vestigations for recurrent abdominal pain and who had
origin a persistently raised amylase in the absence of macro-
amylasaemia.5 His amylase levels ranged between 160
Acute appendicitis Mumps Renal failure and 336 U/L over a two-year period. On testing various
Peritonitis Trauma Head trauma family members, they were also found to have raised
Mesenteric Surgery Burns concentrations of amylase.
ischaemia In summary, we present the case of a young child
Bowel obstruction Salivary duct Postoperative referred with abdominal pain and a high amylase titre,
obstruction which the unwary could attribute to pancreatitis. Our
Biliary obstruction Diabetic Macroamylasaemia case emphasizes the importance of assessing the clini-
ketoacidosis cal condition of the patient in conjunction with appro-
Anorexia nervosa priate investigations.
Bulimia
Ovarian References
1 Pieper-Bigelow C, Strocchi A, Levitt MD. Where does serum
amylase come from and where does it go? Gastroenterol Clin North
with a low-grade fever and bilateral painful swollen
Am 1990; 19: 793–810
glands. Pus can sometimes be expressed from the paro- 2 Goh SK, Chui CH, Jacobsen AS. Childhood acute pancreatitis in a
tid duct and there may be a degree of trismus. It is also children’s hospital. Singapore Med J 2003; 44: 453–6
important to exclude a choledochal cyst, which typi- 3 Wheeler RA, Colquhoun-Flannery WA, Johnson CD. Plasma
cally presents with the triad of jaundice, abdominal amylase estimation in recurrent abdominal pain in children. Ann
pain and a palpable mass. It can lead to pancreatitis, R Coll Surg Engl 1992; 74: 335–6
although there is also a high amylase content within 4 Stringel G, Filler RM. Fictitious pancreatitis in choledochal cyst.
the cyst itself.4 J Pediatr Surg 1982; 17: 359–61
An incidental ¢nding of hyperamylasaemia may be 5 Cuckow PM, Foo AY, Jamal A, Stringer MD. Familial hyper-
due to macroamylasaemia, a condition a¡ecting 1.5% amylasaemia. Gut 1997; 40: 689–90
6 Wyllie RW, Hyams JS. Pediatric Gastrointestinal Disease. 2nd edn.
of the adult population. An elevated serum amylase
Philadelphia: WB Saunders, 1999
but low urinary amylase is noted due to amylase circu-
lating in the blood in a polymer form too large to be
excreted by the kidneys.1 There has also been one case
report of apparently familial hyperamylasaemia, diag- Accepted for publication 28 April 2006

Ann Clin Biochem 2006; 43: 318–319