Acute Pancreatitis in the Transgender Population.

Arslan Chaudhry,Christopher Biggiani,Rishitha Yelisetti,Christopher Millet,Shivanck Upadhyay

doi:10.7759/cureus.16140

Abstract

Hypertriglyceridemia (HTG) is an uncommon but well-established etiology of acute pancreatitis (AP) leading to significant morbidity and mortality. Hormone replacement therapy in the transgender population is an underrecognized cause of elevated triglyceride (TG) levels and may put this group at a higher risk for severe pancreatitis. We present a case of AP in a genetically male patient receiving hormone therapy for female gender transformation.A 51-year-old with a past medical history of type 2 diabetes mellitus presented with severe epigastric abdominal pain associated with nonbilious, nonbloody vomiting and anorexia for two days. The patient was diagnosed with hypertriglyceridemia-induced acute pancreatitis (HTG-AP) in the setting of elevated lipase levels of 2,083 u/L and TGs of >5,000 mg/dL. In addition, a computerized tomography scan of the abdomen showed pancreatitis without evidence of necrosis. The patient was admitted to the medical intensive care unit for the management of AP in the setting of elevated TG levels. She was treated with intravenous fluids and an insulin drip. Her home medications including estradiol and Aldactone were held. Once the TG levels were reduced to <500 mg/dL, she was taken off the Insulin drip and transitioned to a subcutaneous insulin regimen along with gemfibrozil and omega-3 fatty acid over the next three days, and then discharged to home. HTG accounts for only about 7% of pancreatitis cases and increases in severity as TG levels increase. The clinical presentation of patients suffering from HTG-AP is similar to patients with AP from other etiologies and presents in a relatively younger population compared to AP from other causes. Treatment options for HTG-AP usually utilize insulin and heparin; however, plasma exchange and venovenous filtration may be used for severe cases of HTG-AP. The goal of treatment is to lower the TG levels. Physicians should be aware of such complications and should counsel patients while utilizing hormone replacement therapy, especially in patients with a prior family history of dyslipidemia.

Highlights

Hypertriglyceridemia (HTG) is an uncommon but well-established etiology of acute pancreatitis (AP) leading to significant morbidity and mortality
Hormone replacements in the transgender population are underrecognized as a cause of elevated TG levels and places this group at a higher risk for severe pancreatitis
The exact mechanism of hypertriglyceridemia-induced acute pancreatitis (HTG-AP) is poorly understood, it is thought to be related to high levels of free fatty acids (FFA)

Summary

Introduction

Hypertriglyceridemia (HTG) is an uncommon but well-established etiology of acute pancreatitis (AP) leading to significant morbidity and mortality. The pain was described as sudden in onset, sharp, and severe in the epigastric region The patient rated her pain as severe in intensity, occasionally radiating to her back, and worsening in intensity while laying flat. Gemfibrozil and omega-3 fatty acid capsules were added to the regimen Her ICU course was complicated by the development of bilateral pleural effusions that responded to diuresis (Figure 3). She was transferred to the general medical floor and was eventually discharged home and advised to take atorvastatin 40 mg daily, gemfibrozil 600 mg PO BID, and omega 3 fatty acid capsules. She is scheduled to follow up with an endocrinologist and primary care provider for further outpatient management

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