Serum lactic dehydrogenase activity in acute abdominal disease

Serum lactic dehydrogenase activity in acute abdominal disease

Serum Lactic in Acute Dehydrogenase Activity Abdominal Disease ROBERT M. GOLDWYN, M.D.,Pittsburgb, Pennsylvania, ROBERT H. RESNICK, M.D., Boston, Ma...

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Serum Lactic in Acute

Dehydrogenase Activity Abdominal Disease

ROBERT M. GOLDWYN, M.D.,Pittsburgb, Pennsylvania, ROBERT H. RESNICK, M.D., Boston, Massachusetts, AND WALTER P. ELLERBECK, M.D.,Los Angeles, California

From tbe Departments of Surgery and Medicine, Harvard Medical School and tbe Medical Clinic, Peter Bent Brigbam Hospital, Boston, Massachusetts.

a definitive tissue diagnosis. In the remaining group, the diagnosis was based upon the result of clinical criteria inciuding appropriate Iaboratory and roentgenoIogic studies. We excluded from this study patients with acute myocardinl infarction, pulmonary embolism, metastatic malignancy and parenchyma1 disease of the Iiver revealed bv the patient’s history and the results of physica examination or tests of hepatic function. The presence of complicating circulatory coIIapse or renal damage was noted, since these factors may also influence the enzyme \,alue [7,8]. Serum for L. D. H. assay was obtained in almost alI instances within sixteen hours prior to operation, Determinations were carriec1 out postoperativeIy within the first forty-eight hours and in most cases between the Fifth and seventh days. Additiona observations were undertaken when warranted by the clinica course. The method employed for the determination of the serum L. D. H. assay has been described previously [r]. In this Iaboratory, the mean activity and standard deviation in healthy subjects is expressed as IOO + 20 units at 2g’c. Since 140 units represents the peak Ievel attainabIe within two standard deviations of the mean, this degree of activity is arbitrarily considered to be the upper Iimit of the normal L. D. H. values are range. For CIariiication, recorded in terms of four ranges of enzyme activity. (TabIes I and II.)

MONG the serum enzymes employed as Iaboratory aids in making a differential diagnosis, the Iactic dehydrogenase (L. D. H.) determination has received considerable attention. Elevations of L. D. H. activity have been recorded for patients with acute myocardial infarction [I], Iiver and renal disease [2],disseminated cancer [j] and progressive muscular dystrophy [4]. Th ese diverse states probabIy reflect the occurrence of L. D. H. isoenzymes in widespread tissues. In support of this concept, activities have been established in homogenates of tissue from cardiac and skeIeta1 muscIes, the pancreas, spleen, Iung and cervix [5] and, under certain conditions, in salivary, biliary, gastric and duodena1 secretions [6]. Therefore, it seemed reasonabIe to us to search for derangements in the serum L. D. H. pattern in a group of patients with acute abdomina1 disorders characterized by tissue necrosis and/or inflammation. The purpose of this study was threefold: (I) to determine whether or not specific patterns of L. D. H.
A

PROCEDURE Serum lactic dehydrogenase activity was measured in IOO hospitalized patients with acute abdomina1 disease. AI1 patients studied were admitted directly to the SurgicaI Service or were seen in consuItation by that department. Of the total number, fifty-seven patients underwent abdominal surgery which permitted

RESULTS The reIationship of serum Iactic dehydroactivity to diagnostic findings in genase medically and surgicaIIy treated patients is recorded in Tables I and II,respectiveIy. The data for patients in both treatment groups 643

American Journal

o/ Surgery,

Volume

102,

Nouemher

I y6r

GoIdwyn,

Resnick

and EIIerbeck

TABLE L. D. l-l. ACTIVITY

IN PATIENTS

I

WITH

MEDICALLY

TREATED

DISORDERS

No. of Observations Clinicat

of L. D. H. Activity

No. of

State

‘atientz

50 to 140 Units

41 to 300 Units

> 600 Units

3;OI to 600 Units

_ 2 I I I

Pelvic inAammatory disease ......................... .............................. Acute gastroenteritis. RegionaI ileitis ..................................... DiverticuIitis with bIeeding. ......................... .......................... Large bowel obstruction. Small bowel obstruction ............................ Hematemesis (peptic ulcer, gastritis, hiatal hernia*). .................................. Acutepepticulcer Acute pancreatitis .................................. UIcerative cohtis ...................................

3 I

4 3 16

...

2

I

4 6

2

4

6

20

6

5 7 3

IO

* This category

incIudes one case of gastric

-

malignancy.

TABLE L. D. H. ACTIVITY

-

IN PATIENTS

II

WITH

-

SURGICALLY

I No. CIinicaI

State

TREATED

No. of Observations

6io to 140 Units

of F‘atients iPre
Postaperative

6

141 to 300

301 to 600

Units

Units

Preoperative

Post-

Preoperative

,operative

8 I

3 4

5

4

5 1

3 3 I I

9 2 4 2 I

3 4 4 2 I

* Died within six hours postoperatively. t Died within six hours postoperativeIy.

-

-

644

DISORDERS

of L. D. H. Activity

-Large bowe1 obstruction ............ .......... SmaII bowe1 obstruction., SmaII bowel obstruction and gangrene .......................... Superior mesenteric artery occlusion* ................... Hematemesis. Obstructing duodena1 ulcer. ....... Perforated uIcer ................... Acute pancreatitis ................. Acute choIecystitis ................ Acute choIecystitis and choledochoIithiasis. .................... Vaginal bIeeding. ................. Twisted ovarian cyst. ............. ..... Benign paroxysma peritonitis. Peritonitis (perforated viscus) ...... Peritonitis with shock and anuria. .. ..................... Appendicitis. Mesenteric adenitis ............... UIcerative coIitist ................

2

II

4

Post-

,aperative

>600

Preoperative

Units

Serum Lactic

Dehydrogenase

in AbdominaI

TABLE III ABDOMINAL DISEASES ASSOCIATED WITH DEFINITE No. of Patients

Disease

L. D. H. ELEVATIONS

No. 01 Observations ~ Ipreoperative)

I

)

:\lw I, V;IlUc (preoperative)

Range ~i’“‘““““t’“‘i

_ Superior mesenteric artery occlusion., Peritonitis (with shock and anuria). Acute cholecystitis and choletlucholithiasis Acute pancreatitis (no operation). Acute cholecystitis.. I .argebowel obstruction requiring operation. Small bowel obstruction and gangrene.

843 383 342 218

191 163 144

04 t0 I. j92 100 to

756 121 to 303 78 t.0 j3H x2 to 910 90 to 2j2 100 to

$02

not effect the enzyme level, all four patients with diffuse peritoneal infIammation shelved increased serum L. D. H. activity, presumably as a result of accompanying shock and renal failure. (Table III.)

indicate the serum L. D. H. assay was not elevated in the majority of acute abdominal conditions. With the exception of four cases of subtotal gastric resection, postoperative increases rarely occurred when L. D. H. values were normal prior to Iaparotomy. However, the processes of certain diseases do produce a prominent rise in the mean L. D. H. determination. (Table III.) A characteristic feature of these patients was a modest eIevation of L. D. H. activity (usually 140 to 300 serum units) in serial studies. Four of nine patients with acute choIecystitis and five of eight with acute pancreatitis had initial serum L. D. H. levels above 140 units. Of particular interest was the persistent postoperative increase in the IeveI of serum enzyme in five of twelve pa.tients who had had surgery involving the gallbladder, biliary tract or pancreas. Elevated serum L. D. H. activity \VZlS also seen preoperativeIy in two of five cases of obstruction of the smaI1 bowe1 comwith plicated by gangrene. In three patients obstruction of the smal1 bowe1 who were treated conservatively and in live without \.isible bowel necrosis at operation, no alteration of the enzyme assav was found. The inffucnce of massive intestina1 infarction on the I,. D. H. [eve1 is emphasized by the serum \.aIue of 1,592 units in the patient with occlusion of the superior mesenteric artery. Obstruction of the large bowel which required surgery produced a rise in the IeveI of enzyme in four of six patients. In three of these four patients, a Iocalized coIonic malignancy was responsibIe for the obstruction. Although Iocalized peritonitis associated with perforated viscus and benign (nonseptic) paroxysmal peritonitis (Mediterranean fever) did

COMMENTS In reports of previous cIinical studies, it has been stated that the serum L. D. H. determination may aid in the diagnosis of intestinal infarction [9,10]. The observations presented in this paper suggest that the enz,vme [eve1 is of Iimited sensitivity in the evaluation of these patients. The serum L. D. H. assay was normal in a11 eight patients with small intestinal obstruction without tissue necrosis ancl in three of five patients with gangrenous bowel. mav accompan? Striking increases, h onever, I massive intestinal infarction secondary to mesenteric vascular occlusion, as previously reported [ ro]. In this series, the highest L. D. H. value was produced by a thrombosis of the superior mesenteric artery. Even in patients with intestinal infarction lvhere the L. D. H. assay was elevated, other evidence of a necrotizing process existed; i.e., fever, abdominal tenderness or spasm, iIeus and leukocytosis. indicates that an IVIoreover, our experience elevated level of serum L. D. H. was never an isolated finding in a)zy of our patients and was not significantly heIpfu1 in diagnosis. Earlier reports [o, IO] did not show that this enzyme test was the soIe or most sign&ant index of InfIammation or infarction of tissue in patients with acute abdomina1 disease. Six of tweIve patients with acute inflammatory disease of the gaIIbIadder, biIiary tract or pancreas had a preoperative rise in the leve1 of serum L. D. H., and in five it persisted post645

GoIdwyn,

Resnick

Acknowledgment: We wish to express our thanks to Dr. Francis D. Moore for his heIpfu1 suggestions in reviewing this manuscript.

operatively. The expIanation may be related to pancreatitis since simiIarIy increased L. D. H. activity (and high serum amylase) was seen in three patients after subtota1 gastric resection where operative injury to the pancreas presumabIy occurred. It is apparent that the serum L. D. H. assay is unaffected by a wide variety of acute intra-abdominal disorders. Moreover, surgical trauma per se cannot be considered a valid cause for postoperative eIevations in the IeveIs of serum L. D. H. If increased L. D. H. activity due to biIiary tract disease, pancreatitis, intestinal gangrene or hypotension is excIuded, onIy three patients of fifty-seven, who did not have a preoperative eIevation in the IeveI of serum L. D. H. had a postoperative rise. In the presence of an abnormaIIy high L. D. H. determination occurring for the first time postoperativeIy, the cIinician shouId consider cardiac, hepatic or renal damage as causative factors. L. D. H. assays may, therefore, heIp to diagnose “siIent” acute myocardia1 infarction in the surgical patient [11,12]. SUMMARY

AND

and EIIerbeck

REFERENCES

I. SNODGRASS, P. .I., WACKER, W. E. C., EPPINGER, E. C. and VALLEE. B. L. Metalloenzvmes and myocardial infarction. III. Lactic dehydrogenase activity of serum-a determinate diagnostic measure. New England J. Med., 261: 1259: 1959. 2. WACKER, W. E. C., ULMER, D. D. and VALLEE, B. L. MetaIIoenzymes and myocardial infarction. II. MaIic and lactic dehydrogenase activities and zinc concentrations in serum. New England J. Med., 255: 449, 1956. 2. HSIEH. K. M. and BLUMENTHAL. H. T. Serum Iactic dehydrogenase IeveIs in ‘various disease states. Proc. Sot. Exper. Biol. @ Med., 91: 626, _I

1956.

4. DREYFUS, J. C., SCHAPIRA, G. and SCHAPIRA, F.

5.

6.

CONCLUSIONS

Serial determinations of serum Iactic dehydrogenase activity were performed in IOO patients with acute abdomina1 disease. Moderate L. D. H. eIevations occurred in approximateIy 30 per cent of the patients with acute choIecystitis, acute pancreatitis or an infarcted smaI1 intestine secondary to mechanica obstruction. A patient with massive intestinal infarction due to mesenteric vascular occlusion showed a strikingIy high L. D. H. vaIue. Surgica1 trauma per se did not significantIy change the serum enzyme Ievel. An eIevated IeveI of serum L. D. H. was never the soIitary or most significant index of tissue necrosis; therefore, it is concIuded that this test has Iimited usefulness in making the differentia1 diagnosis of acute abdominal disease.

7.

8.

g.

IO.

I I.

12.

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Serum enzymes in physiopathoIogy of muscle. Ann. New York Acad. SC., 75: 235, 1958. WROBLEWSKI, F., Ross, C., GREGORY, K. Isoenzymes and myocardia1 infarction. New England J. Med., 263: 531, 1960. LEVITAN, R., GOL~B, M. and ZETZEL, L. Lactic dehydrogenase activity in saIiva, biIe, gastric and duodena1 contents. Am. J. Digest. Dis., 5: 458, 1960. FRANK, H. A. Correspondence. New England J. Med., 262: 421, 1960. WEST, M. and ZIMMERMAN, H. J. Serum enzymes in disease. IV. Lactic dehydrogenase and glutamic oxaIacetic transaminase levels in renaI disease. J. Lab. P? Clin. Med., 52: 185, 1958. CALMON, C., HERSHEY, F. B., SKAGGS, J. 0. and SPENCER, A. Serum lactic acid dehydrogenase in the diagnosis of the acute surgical abdomen. Surgery, 44: 43, 1958. BRAUN, R. M., HARRIS, P. D., SHERMAN,C. D., JR. and CHATARD, P. R. N. Serum Iactic dehydrogenase: an aid to the diagnosis of intestina1 ischemia. S. Forum, IO: 207, 1959. DRISCOLL, A. C., HOBIKA, J. H., ETSTEN, B. E. and PROGER, S. CIinicaIIy unrecognized myocardia1 infarction foIIowing surgery. New England J. Med., 264: 633, 1961. WEISBERG, R. L. and SAMPSON, J. J. Determinations of serum enzymes in surgica1 patients: value in diagnosis of complicating myocardia1 infarction. Am. Heart J., 57: 240, 1959.