Pancreas in Trouble… Plasmapheresis to the Rescue

Abstract

Hypertriglyceridemia (HTG) can cause diseases like Acute Pancreatitis (AP) and is associated with Coronary Artery Disease (CAD). Severe HTG, triglycerides (TG) >1000 mg/dl, is the third most common cause of AP in the United States [HTG-induced pancreatitis (HTGP)]. A rapid reduction of TG to less than 1000 mg/dl is known to improve outcome and prevent recurrence. Current management includes resting the pancreas, fluid resuscitation, pain control, insulin, and heparin drip but their slower mode of action makes them less desirable in medical emergencies. Plasmapheresis (PP) can be used as a therapeutic option in such circumstances. A 47-year-old female, with a past medical history of CAD, IDDM and familial HTG, presented to the hospital with acute-onset, progressively worsening epigastric pain which started in the right upper quadrant, migrated to the epigastrium, radiating to the back, 9/10 in severity, exacerbated with movement and improved with rest. On examination, she was afebrile, HR- 115/min, BP- 194/100 mm Hg, SpO2- 91%. Labs—glucose- 455 mg/dl, serum lipase— 1603 U/L and TG-8464 mg/dl. CT abdomen and pelvis showed AP without definite pancreatic necrosis. With a diagnosis of HTGP complicated by a hyperosmolar hyperglycemic state, she was managed with an insulin drip and aggressive fluid resuscitation which reduced her TG levels to 5268 mg/dl. PP was initiated which improved her TG levels further. On day two her respiratory status began to deteriorate, and she was sent to the ICU. She was managed with fluid restriction, ventilatory and vasopressor support over the next five days, and sent to the floors after being extubated, where the rest of her stay was uncomplicated. The use of PP within 48 hours of diagnosing HTGP improved our patient's condition. PP should be used early, within 24-48 hour intervals, until TG levels are < 500 mg/dl. Previous studies showed shorter hospital stay and decreased hospital readmissions in patients with HTGP (TG > 5000 mg/dl) receiving PP. It is an effective treatment for patients with severe HTGP who are at increased risk of developing complications. Due to lack of standardization of protocol, an optimum number of PP treatments required in addition to standard therapy needs to be worked out in future studies. Randomized controlled studies are warranted to assess the efficacy, timing, cost-benefit ratio, and necessity of PP as a treatment modality for HTGP.1240_A.tif Figure 1: CT Abdomen- AP Without Definite Pancreatic Necrosis And A 1.4 X 0.8 cm Pseudoaneurysm1240_B.tif Figure 2: Change in Triglyceride Levels with Subsequent Plasmapheresis