"Rule out SBO"
- Jun 6th, 2014
- Adaira Landry
Chief Complaint: “Rule out SBO”
History of Present Illness: A 52-year-old male was sent from his correctional facility for evaluation of small bowel obstruction after complaining of one day of acute onset severe abdominal pain. He endorsed nausea, vomiting, anorexia, polyuria and polydipsia but denied fevers, diarrhea, recent travel, sick contacts or unusual foods. His last bowel movement was two days prior to presentation but he was still passing flatus.
- Medical Hx: denies
- Surgical Hx: appendectomy
- Review of Systems: otherwise negative
- Social history: denies alcohol or drug use
- Vital Signs: T 99.5F BP 107/57 P 109 RR 18 O2 Sat 98-100% Pain 10/10
- Gen: Apparent discomfort while clutching stomach
- HEENT: EOMI, dry mucous membranes, full ROM neck
- Lung: CTAB, symmetric chest rise, no respiratory distress
- Cardiac: RRR, nl S1/S2, no m/r/g
- Abdomen: Nondistended with healed surgical scar in right lower quadrant, + BS, diffuse mild tenderness to palpation, no organomegaly
|WBC 13.8||Hematocrit 30.2||Platelet count 229|
|INR 1.3||PT 13||APTT 32|
|Sodium 114||Potassium 3.8||Chloride 78|
|Bicarbonate 24||BUN 14||Cr 0.3|
|Glucose 280||Calcium 10.2||Serum Osm 290|
|AST 22||ALT 49||AlkP 68|
|Total protein 3.0||Albumin 5.3||Lipase 208|
Peripheral serum studies were visually suggestive of the diagnosis (Figures 1 and 2).
RUQ Ultrasound: Unremarkable
- Lipemic Serum
- Hypertriglyceridemia-induced acute pancreatitis (HTGP)
Hypertriglyceridemia (HTG) is an uncommon cause of acute pancreatitis (AP). The greatest risk for hypertriglyceridemia-induced acute pancreatitis (HTGP) occurs with triglyceride levels above 1000 mg/dL or 10 mmol/L; however, pancreatitis can occur at lower levels. (1,2) HTGP often causes a more severe clinical course, when compared to other etiologies of AP. (3) Serum triglycerides are nontoxic, but their metabolites lead to a profound inflammatory response. (4)
HTGP presents with abdominal pain, nausea, and vomiting; unique are xanthomas, hepatosplenomegaly, or lipemia retinalis (creamy white appearance to the retinal arteries and veins). Treatment includes conventional management of AP (bowel rest, hydration, pain medication) as well as decreasing serum triglyceride levels with options of apheresis, insulin or heparin. (5-7) While total plasma exchange apheresis has been shown to be effective, no evidence is available comparing it to insulin or heparin therapies. Patients should be started on oral antihyperlipidemic therapy as well to help further prevent pancreatic organ failure or necrosis. (8,9)
Our patient had a computed tomography of the abdomen and pelvis that showed acute pancreatitis congruent with the grossly lipemic samples. The labs revealed a triglyceride level of 17,155mg/dL, lipase 208U/L, glucose 280mg/dL and hemogobin A1C 7.0%. The hyponatremia found on labs is secondary to the HTG and is not physiologically significant. (10) While admitted, he received apheresis, oral gemfibrozil and insulin for goal triglyceride level of <1000mg/dL.
- Consider alternate etiologies for pancreatitis, such as triglyceridemia, diuretics or ischemia.
- HTGP requires adjunctive treatment to reduce triglycerides.