Recurrent Acute Pancreatitis Due to Hypertriglyceridemia Despite Apheresis

Abstract

Hypertriglyceridemia (HTG) is the third cause of acute pancreatitis (AP) after gall stones and alcohol. HTG is estimated to cause 1-4% of AP cases. Disorders of lipoprotein metabolism are divided into primary and secondary which include diabetes and obesity. Serum triglyceride (TG) levels of 1,000 mg/dl or greater increases the risk of AP. The literature information about the treatment and follow-up of HTG pancreatitis (HTGP) is limited. We report a case of recurrent acute pancreatitis secondary to HTG that responded well to apheresis but the patient still experienced recurrent pancreatitis. A 39 year-old male with history of familial HTG with recurrent pancreatitis, diabetes and BMI of 27.08 kg/m2 presented with left upper quadrant abdominal pain radiating to the back. Review of systems was negative with no nausea, vomiting, fever or diarrhea. On presentation, he was found to have significantly elevated lipase level of 2650 U/L and TG level of 8762 mg/dL. CT abdomen showed AP (images). He underwent urgent apheresis with subsequent lowering of his TG level (table) that was associated with clinical improvement and normalization of his lipase levels. Few months after, he had recurrent AP with markedly elevated TG level that responded well to apheresis. The recognition of HTG as a cause of AP is often delayed or missed. Patients with HTGP commonly have recurrent attacks. The mechanism for HTGP is likely due to hydrolysis of TG by pancreatic lipase and release of free fatty acids that induce free radical damage. The treatment includes conventional treatment of AP, and management of serum TG levels with an initial goal of less than 500 mg/dL, maintenance of which was seen in multiple case series to expedite clinical improvement. Many small studies on HTGP management have evaluated the use of insulin, heparin or both. Multiple series have also recommended use of apheresis to reduce TG levels, but no randomized trials have compared the efficacy of apheresis with that of insulin and heparin with no definitive guidelines. Subsequent control of HTG with dietary restrictions, medications and regular apheresis have been shown to prevent future episodes of AP. The questions remain; what could have prevented our patient from having recurrence of AP, and should we consider regular apheresis in asymptomatic patients to decrease the recurrence risk? Development of a guideline in this area is dearly needed to improve patient care and reduce healthcare costs.Table 1Figure 1Figure 2