A CASE OF RECURRENT PANCREATITIS DUE TO HYPERTRIGLYCERIDEMIA

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Hypertriglyceridemia (HTG) accounts for 10% of all cases of acute pancreatitis (AP). It can present as acute or recurrent episodes of AP typically in the presence of coexistent conditions, such as inadequately controlled diabetes (DM), excess alcohol consumption or medication use. We present a case of recurrent pancreatitis in a patient with history of HTG and non-compliance with medication. CASE PRESENTATION: A 39-years-old female with history of HTG, DM and alcohol dependance disorder presented to the ED with 1-day history of severe epigastric pain radiating to her back, associated with nausea and non-bilious vomiting. On examination she was hemodynamically stable. There was marked tenderness to palpation in the epigastric region. Her initial laboratory findings were significant for fasting serum glucose (FSG) of 323 mg/dL, severe hyponatremia 118mEq/L, Calc Osmolality 249mOsm/L, total cholesterol 794 mg/dL and triglycerides 6088 mg /dl. Computed tomogram of the abdomen showed moderate fluid and diffuse peripancreatic inflammatory stranding. The patient was managed for AP with intravenous fluids (IV D5-NS), fixed rate insulin infusion and narcotics for pain control. She was also commenced on Atorvastatin 40mg and Gemfibrozil 600mg, twice daily. Once the patient's condition stabilized, she was discharged with subcutaneous insulin, Metformin and lipid lowering agents. DISCUSSION: Hypertriglyceridemia is a rare but well-known cause of acute pancreatitis. Although the precise mechanism is not known, it is proposed that HTG causes an excess of free fatty acids (FFAs) and elevated chylomicrons leading to rise in plasma viscosity, which may induce ischemia in pancreatic tissue and trigger organ inflammation.[1] The clinical presentation includes epigastric pain, increased serum levels of pancreatic enzymes and typical AP findings on imaging.[2] Serum triglyceride levels rapidly decrease within the first 48 hours of onset of acute AP, therefore earliest possible determination of serum triglyceride levels is crucial [3].Multiple treatment modalities including Insulin and/or heparin, plasmapheresis and oral lipid lowering agents have been evaluated. Fibrates have been proven effective in lowering triglyceride levels and raising HDL levels, and are generally considered to be first-choice drugs for the treatment of HTG [4,5]. Our patient showed good response to treatment with Insulin infusion and fibrates. She refused plasmapheresis trial. CONCLUSIONS: We suggest routine testing of triglyceride levels in patients presenting with signs and symptoms suggestive of acute pancreatitis especially in those with pre-existing medical co-morbidities. REFERENCE #1: 1.Nicolò de Pretis, Antonio Amodio, Luca Frulloni Hypertriglyceridemic pancreatitis: Epidemiology, pathophysiology and clinical managementUnited European Gastroenterol J. 2018 Jun; 6(5): 649–655. REFERENCE #2: 2. Scherer J, Singh VP, Pitchumoni CS, Yadav D Issues in hypertriglyceridemic pancreatitis: an update.J Clin Gastroenterol. 2014 Mar; 48(3):195-203. REFERENCE #3: 3. Maki KC, Bays HE, Dicklin MR. Treatment options for the management of hypertriglyceridemia: strategies based on the best-available evidence. J. Clin. Lipidol. 6(5), 413–426 (2012) DISCLOSURES: no disclosure on file for Moses Bachan; no disclosure on file for Zinobia Khan; No relevant relationships by Dileep Kumar, source=Web Response No relevant relationships by Ambreen Shahzadi, source=Web Response