Pancreatic Elastase Panel
| PATIENT INFO |
| Patient Name: |
| Medical Record #: |
| BD: / / Sex: F M |
| PHYSICIAN INFO |
| Physician Name : |
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| Ph: ( ) - Fax: ( ) - |
| Additional Report to: |
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| TESTS REQUESTED | |
| Test Name: | ICD9 Code: (required) |
| 1. Pancreatic Elastase Panel | |
| 2. | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
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Test ID :
PELAS
Test Workstation :
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:
3-5 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:
82653
