St. Luke's University Health Network Bethlehem, PA, United States
Brittney Shupp, DO1, Hammad Liaquat, MD2, Gurshawn Singh, MD2, Ronak Modi, MD3 1St. Luke's University Health Network, Bethlehem, PA; 2St. Luke's University Health Network, Fountain Hill, PA; 3St. Luke's University Hospital, Bethlehem, PA
Introduction: Acute pancreatitis (AP) is a common diagnosis with 275,000 yearly admissions, but only 1-7% of cases are due to hypertriglyceridemia. In these cases, it is imperative that elevated triglycerides (TG) are rapidly corrected. Plasmapheresis is known to be the most effective treatment, but there is question whether insulin can be utilized. We present a case of hypertriglyceridemic pancreatitis (HTGP) successfully treated with insulin.
Case Description/Methods: 29-year-old obese female with history of hyperlipidemia and diabetes mellitus type II presented with epigastric pain radiating to her back, nausea, and vomiting. The patient had no surgical history and denied history of alcohol use. Vital signs were stable, but the patient was in visible discomfort. Abdominal exam displayed tenderness in the epigastric area with absent rebound and guarding and negative Murphy's. Due to the presence of characteristic pain and a lipase level of 1,159 U/L, the diagnosis of AP was made. Additional labs were significant for a hemoglobin A1c of 10.1 and a TG level of 7,951 mg/dL suggesting the etiology of AP. CBC, CMP, and lactic acid were within normal limits. CT abdomen/pelvis demonstrated an unremarkable pancreas and no calcified gallstones or pericholecystic inflammatory changes but an enlarged liver with diffuse fatty changes. The patient was started on aggressive intravenous fluids. Insulin drip (Regular Insulin 1 Units/mL in NS 100 mL infusion) was initiated to correct TG levels along with fenofibrate 145 mg and omega-3 fatty acid 2,000 mg. The patient's TG levels were trended every 12 hours. Within 48 hours, the patient's TG improved to 371 mg/dL allowing the transition to subcutaneous insulin. Two days following admission, the patient was discharged on an insulin regimen in addition to fenofibrate 145 mg and Vascepa 2g BID for outpatient management and recurrence prevention.
Discussion: In cases where TGs are over 5000 mg/dL, plasmapheresis is often used while there are only a few documented cases of insulin use in this setting. However, plasmapheresis has multiple drawbacks including cost, invasiveness, and limited availability. Rapid correction of TGs leads to better clinical outcomes in this uncommon etiology of pancreatitis. Our case demonstrates the effectiveness of insulin in rapidly correcting TG levels within 48 hours and decreasing length of hospitalization. Therefore, our case supports the evolving role of insulin as a safe, readily available, and effective alternative for treatment of HTGP.
Brittney Shupp indicated no relevant financial relationships.
Hammad Liaquat indicated no relevant financial relationships.
Gurshawn Singh indicated no relevant financial relationships.
Ronak Modi indicated no relevant financial relationships.
Brittney Shupp, DO1, Hammad Liaquat, MD2, Gurshawn Singh, MD2, Ronak Modi, MD3. P2159 - Successful and Rapid Correction of Severe Hypertriglyceridemia With Insulin in a Case of Hypertriglyceridemic Pancreatitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.