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Excerpt
O'Brien et al.1 recently reported on a series of 10 patients with leptospirosis in whom they made a diagnosis of pancreatitis. They described the clinical examination in all of these patients as having a soft abdomen without rebound tenderness or other signs of peritoneal irritation. Of these 10 patients 5 had an ultrasound of the right upper quadrant and all were found to have a normal pancreas. The above clinical data would argue against the diagnosis of pancreatitis. More importantly all of their patients had acute renal failure, and the authors conceded that "there appeared to be an association between the renal failure and the development of pancreatitis or the elevation of serum amylase and lipase levels." Edwards and Everard2 showed that 65% of 88 patients with severe leptospirosis had elevated serum amylase levels. The serum amylase, lipase and trypsinogen are all elevated in renal failure,3 with the serum amylase elevation >3 times the upper limit in many cases. As a consequence only 2 cases of pancreatitis could be documented in that series of 88 patients. The diagnosis of pancreatitis in the setting of acute renal failure would require the appropriate clinical findings on examination in most cases along with the presence of an enlarged segment of pancreas on ultrasound or computerized tomography scan because the elevation in the amylase, lipase or trypsinogen may reflect the lack of excretion secondary to the renal failure and not necessarily inflammation in the pancreas. The cases described by O'Brien et al. lack the necessary evidence to substantiate the diagnosis of pancreatitis in the presence of renal failure.
