AN UNUSUAL CASE OF RECURRENT HYPERTRIGLYCERIDEMIC PANCREATITIS

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Hypertriglyceridemia (HTG) induced recurrent acute pancreatitis (RAP) is a rare entity. Its occurrence with normal pancreatic enzyme levels has not been commonly reported. Herein, we report a case of RAP secondary to hypertriglyceridemia with normal blood lipase level. CASE PRESENTATION: A 48-year old male with a history of hypertriglyceridemia presented with a 72-hour history of right upper quadrant (RUQ) and epigastric abdominal pain. He had hypertriglyceridemic pancreatitis 5 years ago, however was not compliant with treatment. On presentation, he was febrile with RUQ and epigastric tenderness. His laboratory investigations revealed: white cell 10.59 x 10^9/L, sodium 133mmol/L, carbon dioxide 18mmol/L, creatinine 0.7 mg/dL, glucose 138 mg/dL calcium 8.8mg/dL; albumin 4.2g/dL, total bilirubin 1.9mg/dL, alanine transferase 37u/L, aspartate transferase 60u/L, alkaline phosphatase 138 u/L. Triglycerides were significantly elevated at >2,625mg/dL with serum lipase 113 u/L (normal 23-300). CT scan of the abdomen and pelvis revealed extensive inflammatory stranding centered at the head and uncinate process of the pancreas, consistent with acute pancreatitis. He received intravenous crystalloids, opioids and continuous insulin infusion which was discontinued on day 4 once triglyceride level was <500. He was started on gemfibrozil and discharged home. DISCUSSION: With an incidence of 13–45/100,000 acute pancreatitis is one of the most common diagnoses for contacting emergency services and for hospitalization in Europe and the USA. Acute pancreatitis (AP) is defined by two of three criteria: typical belt-like abdominal pain, elevated serum lipase level three times above the normal threshold, or radiological imaging signs of pancreatitis. RAP is defined as 2 or more attacks of AP without any evidence of chronic pancreatitis. HTG is the third-most common, possibly underestimated and missed, cause of AP and it accounts for 1%–7% of cases. Serum amylase can be normal hypertriglyceridemia-induced pancreatitis, but lipase is more sensitive and specific than amylase for diagnosis of AP. Normal lipase levels in HTG induced AP, as in this case, is rare. Several studies have reported a negative predictive value of serum lipase in diagnosing acute pancreatitis to be between 94 and 100 percent. CONCLUSIONS: Though uncommon, HTG induced Acute Pancreatitis can present with normal biomarkers, and if suspicion is high, imaging should be pursued to confirm or exclude the diagnosis. REFERENCE #1: Weiss, F. U., Laemmerhirt, F., & Lerch, M. M. (2019). Etiology and Risk Factors of Acute and Chronic Pancreatitis. Visceral medicine, 35(2), 73–81. https://doi.org/10.1159/000499138 REFERENCE #2: Kumar, P., Ghosh, A., Sinha, N., & Tonk, R. S. (2018). Secondary Hypertriglyceridemia Causing Recurrent Acute Pancreatitis with Normal Pancreatic Enzymes. Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine, 22(5), 381–383. https://doi.org/10.4103/ijccm.IJCCM_353_17 REFERENCE #3: Shah, A. M., Eddi, R., Kothari, S. T., Maksoud, C., DiGiacomo, W. S., & Baddoura, W. (2010). Acute pancreatitis with normal serum lipase: a case series. JOP : Journal of the pancreas, 11(4), 369–372 DISCLOSURES: No relevant relationships by Janeen Grant-Sittol, source=Web Response No relevant relationships by Fausto Lisung, source=Web Response No relevant relationships by Anna-Belle Robertson, source=Web Response No relevant relationships by Rani Sittol, source=Web Response