Department of Pathology
and Laboratory Medicine

Akron Children's Hospital
One Perkins Square
Akron, OH 44308
Laboratory
Ph: (330) 543-8573
Fax: (330) 543-3659

LABORATORY TEST REQUISITION


PATIENT INFO
Patient Name:
Medical Record #:
BD:        /        /              Sex:    F    M

PHYSICIAN INFO
Physician Name :
Address:
Ph: (        )        -              Fax: (        )        -              
Additional Report to:
Ph: (        )        -              Fax: (        )        -              

TESTS REQUESTED
Test Name: ICD9 Code: (required)
1. Pancreatic Elastase Panel   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Pancreatic Elastase Panel
CPT Code: 82656

Specimen Type: Stool

Tube Type/Collection Container: Stool container

Collection Volume: 1 gram stool

Storage: Frozen

Availability: Sent to reference lab

Methodology: Enzyme-Linked Immunosorbent Assay

Special Instructions: Collect 1 gm random formed stool, ship frozen. Separate specimens must be submitted when multiple tests are ordered. Note: 1. Pancreatic enzyme supplementation therapy should be discontinued prior to sample collection. 2. A watery, diarrheal stool is not recommended for this test as some dilutions during the assay may give lower E1 concentrations than are actually present.

TAT: 1-10 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: >200 ug Elastase/g stool = Normal 100 - 200 ug Elastase/g stool = Moderate to slight exocrine pancreatic insufficiency <100 ug Elastase/g stool = Severe exocrine pancreatic insufficiency

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Cindy Maurer at (330)543-8689.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: