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Abstract

Introduction: Hypertriglyceridemia is associated with a number of severe diseases such as acute pancreatitis and coronary artery disease. Severe hypertriglyceridemia induced pancreatitis is a treatable medical emergency which demands quick therapeutic measures.Case Presentation:34-year-old healthy, non alcoholic junk food addict developed acute onset of abdominal pain, nausea, and vomiting and was found to have acute non-necrotizing pancreatitis on imaging. At admission, his triglyceride levels were approximately 3000mg/dl. Patient subsequently developed respiratory failure requiring mechanical ventilation. He was started on gemfibrozil 600 twice a day and insulin drip of about 1 unit/hour. Repeat Triglyceride levels after 6 hours were still above 2000mg/dl, so patient was given therapeutic apheresis. Subsequently, he underwent just one session of therapeutic apheresis leading to reduction in triglyceride levels from 2978 to 651 mg/dl. This resulted in marked reduction of pancreatic inflammation and a rapid resolution of concurrent acute respiratory distress syndrome(ARDS). He was extubated within 24 hours and was transferred from the ICU in 48 hours after admission. Total length of stay(LoS) in the hospital was 7 days. Discussion: In severe hypertriglyceridemia (SHTG, triglycerides >1000 mg/dl), rapid lowering of plasma triglycerides (TG) has to be achieved. Treatment regimes include nutritional intervention, the use of antihyperlipidemic drugs, and therapeutic apheresis. In our patient, use of oral agents was not possible because of severe ARDS and subsequent intubation. Using continuous insulin therapy to reduce triglyceride levels(degradation of chylomicrons) is another alternative but may take a longer time and would need closer monitoring of blood glucose levels. Even though it is expensive and has limited availability, apheretic treatment is able to remove the causative agent for pancreatic inflammation. Removal of TG-rich lipoproteins by therapeutic plasma exchange (TPE) also prevents relapses of acute pancreatitis episodes. Data suggests that the use of apheresis in patients with SHTG should be performed as early as possible in order to achieve best results. Our patient was initiated with TPE within 6 hours of admission. Conclusion Plasmapheresis appears to be a safe and useful therapeutic tool in patients suffering from SHTG. Our case reports highlights the importance of evidence based management in reducing inhospital LoS and improving patient outcomes.