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Resident PGY 1
Henry Ford Hospital
Hypertriglyceridemia (HTG) induced pancreatitis causes up to 15% of cases of acute pancreatitis, typically occurring in patients with triglyceride levels >1,000 mg/dL. HTG occurs in primary(genetic) and secondary disorders of lipoprotein metabolism. Secondary causes include diabetes, pregnancy, medication, alcoholism, and thyroid disorders. Our case involves a 45-year old male former alcohol user who presented with acute epigastric abdominal pain and bilious emesis. On exam, he severe epigastric tenderness with guarding, normoactive bowel sounds. When obtaining labs, his blood was turbid. Labs were significant for elevated Lipase (1,534IU/L), total cholesterol (915mg/dL), triglycerides (>5,250mg/dL),and incalculable LDL and HDL. He was hypocalcemic(7.7 mg/dL) with low 25-hydroxy vitamin D (16 ng/mL). TSH was normal (1.23uIU/mL).CT abdomen pelvis revealed peripancreatic fluid. He was diagnosed with acute hypertriglyceridemia induced pancreatitis. After assessing cost-benefit therapies, decision was made to treat with Insulin infusion along with D5 for blood sugar support over apheresis. Triglyceride levels were monitored every 12 hours until /dL, after which insulin infusion was discontinued. He was concomitantly started on Atorvastatin 80mg daily and Fenofibrate 48mg daily. Early recognition of HTG-induced pancreatitis is important in providing appropriate therapy and preventing future episodes because HTG induced pancreatitis has a presentation similar to that of acute pancreatitis of other etiologies, although it is related to more complications and higher severity. At this time there is no approved treatment guideline, but treatment is focused on reducing triglycerides early on in the clinical course. In addition to insulin infusion and apheresis, other treatment options include heparin, omega 3 fatty acids, and fibric acids. We believe it is important to educate physicians on the cost-benefit of insulin infusion therapy for HTG-induced pancreatitis with recent studies (Bi-TPA Itrial) showing insulin infusion being non-inferior to apheresis in the critical care setting. These studies have treatment implications because insulin therapy offers a safer and effective option. It is also important to recognize the worrisome features of HTG pancreatitis and how to appropriately monitor.
Gill, Sonika, "Hypertriglyceridemia induced pancreatitis: a cost-effective management approach" (2020). Case Reports. 91.