Article

Diamine oxidase in diagnosis of acute mesenteric ischemia

Unlabelled imageDiamine oxidase in diagnosis of acute me”>American Journal of Emergency Medicine (2013) 31, 309-312

Original Contribution

Diamine oxidase in diagnosis of Acute mesenteric ischemia

Keziban Ucar Karabulut MD a, Huseyin Narci MD a,?, Mehmet Gul MD b,

Zerrin Defne Dundar MD b, Basar Cander MD b, A. Sadik Girisgin MD b, Sami Erdem MD c

aDepartment of Emergency Medicine, Baskent University Medical Faculty, Konya, Turkey

bDepartment of Emergency Medicine, Necmettin Erbakan University Meram Medical Faculty, Konya, Turkey

cDepartment of Biochemistry Medicine, Necmettin Erbakan University Meram Medical Faculty, Konya, Turkey

Received 25 June 2012; revised 19 July 2012; accepted 19 July 2012

Abstract

Objective: Acute mesenteric ischemia (AMI) is an important clinical condition with a high mortality rate in Abdominal emergencies due to Delay in diagnosis in spite of the new strategies in the management. We have studied the role of diamine oxidase (DAO) in the early diagnosis of AMI. Methods: In the study, 21 New Zeland rabbits were used. Subjects were named as the groups of controls, sham, and ischemia. No intervention was performed in the subjects in the control group. In the subjects from sham and ischemia groups, laparotomy was performed with middle line incision. However, Superior mesenteric artery was found and tied in those from ischemia group after the performance of laparotomy. From the animals in 3 groups, blood was drawn at the hours of 0, 1, 3, and 6, and DAO and amylase were studied in these samples.

Results: The increase in serum amylase levels was found to be statistically significant in the ischemia group compared with the control and the sham groups (P b .05). The decrease in serum DAO levels was found to be statistically significant in the ischemia group compared with the control and the sham groups (P b .05). Diamine oxidase levels were found to decrease, beginning from the 1 hour after ischemia had been developed, and this rise was found to continue for 6 hours (P b .05).

Conclusion: Serum DAO levels were decreased in ischemia. Further clinical and experimental inves- tigations would be valuable to confirm the probable role of DAO in AMI.

(C) 2013

Introduction

Acute mesenteric ischemia (AMI) is still a highly fatal condition (70%) despite the improvements in diagnostic and therapeutic methods [1]. The most important factor affecting the outcome of AMI is the duration of the ischemia. Reinstating the blood supply of the bowel in the first 6 hours

* Corresponding author. Emergency Department, Baskent University Medical Faculty, Hocacihan Mah. Saray Cad. No 1, Selcuklu/ Konya, Turkey. Tel.: +90 5063053233 (Mobile).

E-mail address: [email protected] (H. Narci).

of ischemia improves the prognosis, especially in emboli- related ischemia [2].

The optimum biochemical marker for the early diagnosis of AMI must be released from the intestinal mucosa, must avoid the hepatic first pass effect, and must be detected in the peripheral blood. Novel diagnostic markers studied in recent years based on this opinion are promising [3-5].

Diamine oxidase (DAO) is an enzyme found in high concentrations in the intestinal mucosa of humans and other mammalian species. It metabolizes histamine and prevents absorption of polyamines and histamine. It provides oxidative deamination of diamines such as putrescine. Plasma DAO activity appears to come primarily from the

0735-6757/$ – see front matter (C) 2013 http://dx.doi.org/10.1016/j.ajem.2012.07.029

310 K.U. Karabulut et al.

Small intestine, placenta, thymus, and the kidneys. Inftam- mation, trauma, injury, or ischemia of the small intestine causes a decrease in DAO activity and increase in plasma histamine. Diamine oxidase is metabolized in the liver [6]. Therefore, plasma DAO is considered to be an important marker in the early diagnosis of AMI. Serum amylase is a well-studied parameter in diagnosis of AMI. In this experimental study, we studied the role of serum DAO and amylase in early diagnosis of AMI [7].

Materials and methods

Approval was obtained from the Experimental Animals Ethics Committee of Experimental Medicine Research and Training Center. The study was carried out in Selcuk Uni- versity Experimental Medicine Research and Training Center. A total of 21 New Zealand rabbits weighing 3000 to 3500 g were used in the study. The animals were fed with the same standard feed until 12 hours before the experiment. They were made to fast for 12 hours before the beginning of the test. The subjects were randomly divided into 3 groups with 7 animals in

each. The groups were named control, sham, and ischemia.

Fifty milligrams per kilogram of ketamin and 15 mg/kg of xylasin were administered into the hind legs of the subjects in all 3 groups. Vascular access was established on the dorsal auricular veins of the the animals using a 22 G needle after anesthesia was provided with the aim of drawing blood and administering ftuid. Without any inerventions, 3 mL of blood was drawn into gelly vacutainer tubes to study DAO and amylase at the 0, 1, 3, and 6 hours in the subjects in the control group. Five milliliters of 0.9% normal saline was administered using the same vascular access following every Blood draw.

Blood was drawn at 0 hour from the subjects of the sham and the ischemia groups similarly. The abdominal sites of the subjects in each of the 2 groups were shaved and cleaned using 10% povidone iodine. Laparatomy was performed through a Midline incision. Only the peritoneum was passed in the sham group. Thereafter, the abdominal wall and the peritonum were sutured again using 2/0 silk. In the ischemia group, the superior mesenteric artery (SMA) was found and ligated using 0 silk following laparatomy. Thereafter, the abdominal wall and the peritoneum were closed by suturing again. Three milliliters of blood was drawn from the subjects of the 2 groups at the 1, 3, and 6 hours following these procedures. Five milliliters of 0.9% normal saline was administered following every blood draw. Subjects in the

ischemia group were sacrificed by administering 50 mL/kg of ketamin IV.

Keeping the samples

Every 5 mL of blood sample placed into gelly vacutainer tube was centrifuged at 3000 rpm for 10 minutes and then kept waiting for 30 minutes for coagulation. The obtained serum samples were placed in ependorf tubes by pipetting.

Biochemical evaluation

An ELISA kit appropriate for determination of DAO (Rabbit Diamine Oxidase ELISA Kit Catalog No. CSB- E13018Rb; Cusabio, Hubei, China) was used. A routine biochemistry kit was used for determination of serum amylase levels.

Statistical analysis

The collected data were recorded in the forms formerly prepared. Statistical analyses were performed using the SPSS

16.0 package program (SPSS, Chicago, IL). Intergroup com- parisons were made using the variance analysis post hoc Tukey test in repeated measurements. The Bonferroni correction paired t test was used to find the difference between mea- surments. P b .05 was considered statistically significant.

Results

Serum DAO values

Serum DAO levels at 0, 1st, 3rd, and 6th hours were lower in the ischemia group compared with those of the control and the sham groups (P = .001 for the ischemia and the control groups, P = .004 for the ischemia and the sham groups) (Table 1). Serum DAO levels at the first, third, and sixth hours were found to be significantly lower than the levels at 0 hour in the ischemia group (P = .005 for hour 1, P = .001 for hour 3, P = .00 for hour 6). There were no differences between the control and the sham groups (P = .902) (Fig. 1).

Serum amylase values

Serum amylase levels at 0, 1st, 3rd, and 6th hours were significantly higher in the ischemia group compared with the

Table 1

The serum DAO levels (uIU/mL)

DAO

0 h mean +- SD

1 h mean +- SD

3 h mean +- SD

6 h mean +- SD

Control

24.65 +- 3.08

31.57 +- 2.46

23.54 +- 2.74

23.98 +- 3.00

Sham

27.48 +- 5.41

23.24 +- 2.35

24.86 +- 3.47

23.16 +- 3.62

Ischemia

22.77 +- 1.61

19.19 +- 0.96

16.61 +- 1.72

15.88 +- 1.51

Diamine oxidase acute mesenteric ischemia

Fig. 1 time-dependent changes of serum DAO levels (uIU/mL).

control and the sham groups (P = .00 for both) (Table 2). There were no significant differences between the control and the sham groups (P = .55). The elevations in serum amylase levels at the first, third, and sixth hours were significant compared with the levels at 0 hour in the ischemia group (P = .001 for hour 1, P = .00 for hour 3, P = .00 for hour 6) (Fig. 2).

Discussion

The common opinion is that there is yet no marker with high early diagnostic power to increase survival, and of high sensitivity and high specificity for AMI. Such a marker should enable the early diagnosis of mucosa-limited injury before progressing to complete-layer infarct. Recently, studies on such new markers have gained emphasis [3,4].

It was shown that, in AMI, functional and structural changes in the mucosa begin with the interruption of ftow in the SMA for a short period such as 5 to 15 minutes and increase as time passes. Epithelial cells in the villi are lost after 30 minutes and mucosal permeability increases [8-10]. Diamine oxidase is localized to the small intestine, kidney, and placenta, with rapid cellular metabolic turnover. It metabolizes approximately one-third of the histamine and protects intestines from the harmful effects of histamine [11,12]. Diamine oxidase is located in the upper part of intestinal mucosa in human as well as in mammals and is a highly active intracellular enzyme. Changes in DAO activity are an ideal index to investigate intestinal barrier function damage after trauma, especially changes in plasma DAO

activity [13].

311

Fig. 2 Time-dependent changes of serum amylase levels.

In a study with a dog model intestinal ischemia, it was found that mucosal DAO levels decreased consistently with histopathologic injury as the duration of ischemia increased [14].

In a study examining the effects of histamine on ischemia reperfusion in the rat intestine, mucosal and serum DAO levels decreased after ischemia. It was also shown that free circulating and increased levels of histamine caused an increase in intestinal injury [15].

In another study, DAO levels at the 60th minute of ischemia were found to decrease below normal levels, and plasma histamine values showed a peak. Mucosal DAO decreased in the first minutes of ischemia [16].

In their experimental study, Cao et al [17] found that plasma DAO levels began to decrease at the end of the second hour after SMA occlusion. They reported that the levels were higher than the normal values at the end of 24 hours in the revascularization phase [17].

In this study, it was found that serum DAO levels started to decrease at 1 hour after ischemia. This progress continued in the subsequent hours. There was a correlation with amylase levels, which increased during ischemia.

Serum amylase level is one of the most studied parameter in the diagnosis of AMI. In a meta-analysis of 20 studies reviewing 18 different biochemical markers, the specificity and sensitivity of serum amylase levels in the diagnosis of AMI were found as 71% and 50%, respectively [4].

It was found that amylase levels in the dog model mesenteric ischemia were significantly elevated; however, these levels were moderately elevated in clinical studies. It was reported that amylase is not AMI specific and can be increased in other conditions causing acute abdomen [18,19].

Table 2

The serum amylase levels (mg/dL)

Amylase

0 h mean +- SD

1 h mean +- SD

3 h mean +- SD

6 h mean +- SD

Control

122.7 +- 5.93

168.7 +- 5.05

161.0 +- 24.31

158.0 +- 17.3

Sham

121.4 +- 4.61

121.5 +- 8.79

140.4 +- 24.1

131.2 +- 15.1

Ischemia

160.7 +- 11.44

381.8 +- 102.2

533.4 +- 83.1

636.5 +- 175.4

312 K.U. Karabulut et al.

As elevations of amylase and mortality are related, it was suggested that hyperamylasemia had a prognostic value in patients with AMI [20].

Acosta-Merida et al [2] reported that High-risk factors for massive intestinal necrosis preoperatively include shock, hemoconcentration, and hyperamylasemia, especially in elderly patients.

The early diagnosis of AMI studies has been conducted on the role of liver function tests. For example, Zhang et al, their Experimental model of AMI in the ischemia group 6 and 9 hours found a significant rise in aspartate aminotransferase and alanine aminotransferase values [21]. Zhang et al [22] in another experimental model of AMI, in the ischemia group 3 from the time of serum aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and ? glutamyl transferase levels, observed that significant increase. In this study, we can not evaluate the serum liver function tests. Instead, we looked at the values of serum amylase with the DAO.

In this study, there was no significant change in the amylase levels in the control and the sham groups. There was an increase in the amylase levels starting from the first hour in the ischemia group, and it continued in the subsequent hours.

Conclusion

In this study, it was found that DAO levels began to decrease in the early periods of ischemia. We think that DAO levels in the early period may help in the early diagnosis of patients presenting to the emergency department with suspicion of AMI. Further clinical and experimental studies with other markers will help demonstrate the role of DAO in the early diagnosis of AMI.

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