"Rule out SBO"

Answers

1. Lipemic Serum
2. Hypertriglyceridemia-induced acute pancreatitis (HTGP)

Discussion

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.

Pearls

1. Consider alternate etiologies for pancreatitis, such as triglyceridemia, diuretics or ischemia.
2. HTGP requires adjunctive treatment to reduce triglycerides.

References