Pancreatic Elastase Panel

Centralized Core Laboratory : Chemistry

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:

Hospital:

Test ID/Workstation :

PELAS MAYO

Specimen Type:

Stool

Tube Type:

Stool container

Collection Volume:

5 grams (minimum 1 gm) stool

Storage:

Frozen

Availability:

Sent to reference lab

Methodology:

Enzyme-Linked Immunosorbent Assay (ELISA)

Special Instructions:

Collect 5 grams random formed stool, ship frozen if greater than 72 hours. Separate specimens must be submitted when multiple tests are ordered. Note: Consistency of raw fecal sample may affect analytical performance.

Lab/Phone:

330-543-8418

TAT:

3 days

Additional Info:

Reference Values: Normal = >200 ug Elastase/g stool Moderate Pancreatic Insufficiency = 100 - 200 ug Elastase/g stool Severe pancreatic insufficiency = <100 ug Elastase/g stool Reference values apply to all ages.

CPT Code:

83520

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