the interpretation of a raised amylase in the acute surgical patient is crucial yet complicated as it is raised in a large number of conditions but with a low specificity .
this report argues that a transient rise in serum amylase not caused by sepsis or pancreatitis can be caused by a splenic infarction
. therefore any cause of a non - diagnostic amylase rise must not be over- looked as it may be of diagnostic value in a life threatening surgical condition .
a 49-year - old previously well male , presented with a 24 hour history of vomiting , abdominal pain and fever .
his abdominal pain was of rapid onset and localised to the epigastrium and left upper quadrant .
there was no history of trauma but he did admit to a recent history of alcohol excess .
clinical examination revealed diffuse upper abdominal tenderness , a mild tachycardia and a low grade pyrexia .
blood work up revealed an amylase of 270 u / l and crp of 125mg / l .
ct showing evidence of splenic infarction secondary to infective endocarditis a provisional diagnosis of alcohol - induced pancreatitis was made .
he received standard management as mild pancreatitis ( glasgow score 0 ) with ward level care .
an ultrasound showed no abnormality . due to diagnostic uncertainty and failure of symptoms and signs to rapidly resolve ,
subsequent echocardiogram for a source of emboli showed multiple valvular vegetations , aortic regurgitation and a 16 mm pericardial effusion .
treatment with intravenous flucloxacillin and gentamicin was undertaken and transfer to the regional cardio - thoracic unit was arranged .
there he underwent urgent aortic valve replacement with a tissue valve following which he made an uncomplicated recovery .
these can be broadly grouped into 3 subdivisions : 
 pancreatic ( eg . pancreatitis , pancreatic tumour or trauma)extra - pancreatic intra - abdominal disease ( eg . cholecystitis , perforated duodenal ulcer , bowel ischaemia)extra - abdominal processes ( eg . macro - amylasaemia ) 
  pancreatic ( eg . pancreatitis , pancreatic tumour or trauma ) extra - pancreatic intra - abdominal disease ( eg .
cholecystitis , perforated duodenal ulcer , bowel ischaemia ) extra - abdominal processes ( eg . macro - amylasaemia ) interpretation of a raised amylase in the surgical patient is crucial , potentially avoiding dangerous misdiagnosis .
many conditions cause hyperamylasaemia making the specificity of elevated serum amylase level less than 70% .
its low specificity drops further after the first 24 hours of hospital admission ( 1,2 ) .
elevated serum amylase activity in pancreatitis is attributed to pancreatic auto - digestion , but its pathophysiology is unknown in many other causes .
endocarditis is a well known cause of splenic thrombosis and consequent infarction and first described in germany in 1869 ( 3 ) .
there have been reports of raised amylase in non - pancreatic sepsis , some showing that this could be used as a prognostic marker in the septic patient ( 4 ) . however , in this patient the transient amylase rise dropped despite worsening sepsis , suggesting an alternative cause for the disturbance .
recent studies by antopolsky et al examined clinical presentations in 49 episodes of acute splenic infarction .
the most common symptom was abdominal or left flank pain ( 80% of episodes ) with the most common sign being upper left quadrant tenderness ( 35% of episodes ) ( 5 ) .
clinicians should be aware of splenic infarction as a clinical entity , and consider it in cases of upper abdominal pain , particularly if there is a non - diagnostic amylase rise .
 we present what maybe the only case of splenic infarction causing hyperamylasaemia in a patient with bacterial endocarditis . 
 a 49-year - old gentleman presented a 24 hour history of vomiting , abdominal pain and fever . 
 clinical examination showed diffuse upper abdominal tenderness , a mild tachycardia and a low grade pyrexia . 
 blood investigations showed a hyperamylasaemia . 
 his failure to improve on treatment for a provisional diagnosis of alcohol induced pancreatitis lead to a ct abdomen , which showed a splenic infarct and an echo showing aortic valve vegetation 's as a source of emboli . 
 he underwent urgent aortic valve replacement with a tissue valve following which he made an uncomplicated recovery . 
INTRODUCTION
CASE REPORT
DISCUSSION