Introduction: Acute pancreatitis is an inflammatory disease that can be associated with significant morbidity and mortality. Common causes include gallstones, significant alcohol use, and hypertriglyceridemia. Many medications have been known to cause hypertriglyceridemia including tamoxifen, a selective estrogen receptor modulator. We present a rare case of acute pancreatitis caused by tamoxifen-induced hypertriglyceridemia.
Case Description/Methods: A 53-year-old female presented to the ED with sharp abdominal pain with radiation to her chest. Lab workup revealed an elevated lipase at 169 U/L. CT of the abdomen and pelvis showed acute inflammatory changes at the head of the pancreas. A triglyceride level was obtained showing a level >1000 mg/dL. The patient was then started on an insulin drip and admitted to the ICU for further monitoring. The patient had been diagnosed with breast cancer about 5 years prior to admission and had been taking tamoxifen during that time. Chart review revealed a triglyceride level performed in the outpatient setting a year prior with a result greater than 4000 mg/dL. The patient reported that this was determined to be a lab error and was left untreated. Her pain and triglycerides decreased after IV fluids and insulin drip. Tamoxifen was discontinued and the patient was started on fenofibrate and atorvastatin.
Discussion: Diagnosis of acute pancreatitis is based on the Revised Atlanta Criteria which should include 2 or more of the following symptoms: epigastric pain, serum lipase >3 times the upper limit of normal, and/or characteristic findings on abdominal imaging. Further testing should be done if no clear etiology. Treatment includes aggressive IV fluids, analgesia, and directed therapy based on etiology. Hypertriglyceridemia causing acute pancreatitis accounts for about 1%-4% of cases. Elevation in triglycerides can cause sludging of pancreatic vasculature and increasing activity of pancreas lipases leading to cytotoxic injuries. Tamoxifen is a selective estrogen receptor modulator and is thought to increase the synthesis of triglycerides and very low-density lipoproteins. It is also proposed to decrease the activity of lipoprotein and triglyceride lipase. Treatment of hypertriglyceridemia includes discontinuing the offending agent with insulin drip or plasmapheresis. This case suggests that those on tamoxifen should have regular monitoring of serum lipids and treat any abnormal lab value as significant until proven otherwise.
