Baylor University Medical Center Proceedings April 2017 - 178

Table. Quantitative photometric determination (Cobas Roche) of
serum lipase and amylase values during 5 consecutive days

Test
Lipase (U/L)
Amylase (U/L)

Normal
value
0-60

Day
1

211 276

187 215 518

20-100 210 230

196 202 260

DISCUSSION
Guidelines for diagnosis of pancreatitis are based on the
presence of two of the three following criteria: typical abdominal pain, characteristic imaging ﬁndings, and elevated lipase
and/or amylase levels of threefold or higher than the upper
limit of normal (5). However, high amylase and/or lipase levels
do not automatically conﬁrm the diagnosis because there are
numerous diﬀerential diagnoses, including renal insuﬃciency,
inﬂammatory bowel disease, pathologies of the hepatobiliary
tract system, neoplastic diseases, diabetes mellitus, drugs, and
infections (6). Diagnosis of Gullo syndrome is made if all evaluations for pancreatic diseases are normal during the time period
of at least 1 year, and if elevations and signiﬁcant undulations of
pancreatic enzyme serum concentrations occur on a day-to-day
basis for 5 consecutive days (Table) (7). It is speculated that a
defect in the intracellular transport of pancreatic enzymes in
exocrine pancreatic cells may be responsible for the increased
passage of enzymes into the blood circulation (8).
However, if certain foods consumed before the tests might
inﬂuence enzyme levels, it was reported that the ingestion of
various meals did not increase pancreatic enzymes (1). Since
in our patient lactose- or histamine-rich or -reduced food
did not inﬂuence enzyme levels, we conﬁrmed this conclusion. The clinical importance in asymptomatic individuals
with Gullo syndrome is to diﬀerentiate a myriad of diﬀerential
diagnoses, and multiple complex diagnostic tests and/or hospital
admissions may be prevented (7).
Gastrointestinal malabsorption syndromes are caused by
carbohydrates (mainly lactose and fructose), proteins (gluten),
and biogenic amines (e.g., histamine). Unabsorbed food results

178

in symptoms due to bacterial metabolism and fermentation
in the colon. Various combinations of malabsorption were
reported in patients with gastrointestinal malabsorption syndromes (2).
Lactose malabsorption is related to lactase deﬁciency and
causes nonspeciﬁc gastrointestinal complaints with the ingestion
of dairy products (9). Histamine intolerance is a disproportionate amount of histamine in the body caused by the consumption of histamine-containing food and/or a reduced ability of
diamine oxidase to catalyze histamine within the gastrointestinal
tract. In the patient described here, the diagnosis of this condition was based on a diamine oxidase value <10 U/mL in serum
and more than two typical gastrointestinal symptoms allegedly belonging to histamine malabsorption (10). Nonspeciﬁc
abdominal symptoms in this patient with benign pancreatic
hyperenzymemia (Gullo syndrome) were due to lactose and/
or histamine malabsorption and were treated eﬀectively with
an individually tailored diet.
1.

Gullo L. Day-to-day variations of serum pancreatic enzymes in benign
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Reininghaus EZ, Bengesser SA, Schnedl WJ. Concomitant prevalence of
low serum diamine oxidase activity and carbohydrate malabsorption. Can
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malabsorption-which one is the best? BMC Gastroenterol 2009;9(1):82.
5. Quinlan JD. Acute pancreatitis. Am Fam Physician 2014;90(9):632-639.
6. Hameed AM, Lam VWT, Pleass HC. Signiﬁcant elevations of serum
lipase not caused by pancreatitis: a systematic review. HPB (Oxford)
2015;17(2):99-112.
7. Gullo L, Lucrezio L, Migliori M, Bassi M, Nesticò V, Costa PL.
Benign pancreatic hyperenzymemia or Gullo's syndrome. Adv Med Sci
2008;53(1):1-5.
8. Cook LJ, Musa OA, Case RM. Intracellular transport of pancreatic
enzymes. Scand J Gastroenterol 1996;219(Suppl):1-5.
9. Goebel-Stengel M, Stengel A, Schmidtmann M, van der Voort I, Kobelt P,
Mönnikes H. Unclear abdominal discomfort: pivotal role of carbohydrate
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