Tripler Army Medical Center Honolulu, HI, United States
Michael S. Abdo, MD1, Lindsay Clough, MD1, Katherine Park, DO1, Arjun Patel, MD, MS2, Rachel Villacorta Lyew, MD1, Brian Foster, DO1 1Tripler Army Medical Center, Honolulu, HI; 2Tripler Army Medical Center, Tripler Army Medical Center, HI
Introduction: Hypertriglyceridemia (HTG), defined as serum triglycerides >150mg/dL, can cause pathology including eruptive xanthomas and ~10% of all cases of acute pancreatitis. Severely and very severely elevated triglyceride (TG) levels, defined as >1000mg/dL or >2000mg/dL, respectively, are an independent risk factor for acute pancreatitis. In cases of HTG-induced pancreatitis, both HTG and pancreatitis should be treated concurrently, but standard protocols can result in complications from the treatment itself. We present a case of acute pancreatitis in a patient with very severe HTG ( >8000mg/dL).
Case Description/Methods: A 38-year-old female with a history of familial HTG (including an episode of acute pancreatitis 4 years prior) presented to the ED for acute abdominal pain and nausea over one week. Her labs were notable for an elevated lipase, hyponatremia, and an estimated TG level >8000mg/dL. This constellation of findings supported a diagnosis of acute pancreatitis in the setting of her very severe HTG and was confirmed with CT imaging. She was hemodynamically stable, so an IV insulin protocol was started for the HTG with pain control and aggressive fluid support (with lactated ringer's solution) for pancreatitis. D5W was titrated to maintain euglycemia, and within the first 24 hours her TGs had decreased to < 1000mg/dL. However, despite this improvement in her TG levels, she developed abdominal distension and tachypnea (40-50/min) the following evening. Given the amount of IV fluids that were administered, there was a concern for possible abdominal compartment syndrome. This was excluded with normal bladder abdominal pressures, but as she did not tolerate an oral diet TPN was initiated with fibrate therapy for her HTG. She was then discharged safely from the hospital.
Discussion: Our patient responded well to IV insulin management of her very severe triglyceride levels. An alternative option that was considered includes plasma exchange. The decision to pursue other therapies - such as PLEX or heparin infusion - was deferred due to her initial mild presentation and limited evidence for these alternative therapies, especially in patients with TGs >2000.
More research is needed into the optimal management of patients with pancreatitis due to very severely elevated TG levels, as current aggressive treatment protocols may lead to complications. However, this case illustrates that even profoundly elevated TGs can be rapidly corrected to a target of < 1000mg/dL in 24 hours with IV insulin therapy alone.
Disclosures: Michael Abdo indicated no relevant financial relationships. Lindsay Clough indicated no relevant financial relationships. Katherine Park indicated no relevant financial relationships. Arjun Patel indicated no relevant financial relationships. Rachel Villacorta Lyew indicated no relevant financial relationships. Brian Foster indicated no relevant financial relationships.
Michael S. Abdo, MD1, Lindsay Clough, MD1, Katherine Park, DO1, Arjun Patel, MD, MS2, Rachel Villacorta Lyew, MD1, Brian Foster, DO1. P0052 - Greasy Blood: A Case of Profound Hypertriglyceridemia and Ensuing Complications, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
