Endocrine Abstracts

Objective: We present a case of hypertriglyceridemia induced acute pancreatitis (HTG-AP) and concurrent diabetic ketoacidosis (DKA) as a first presentation of Diabetes Mellitus in an adult patient. This uncommon triad has been previously described in the literature, however, it is rare to be observed in a previously undiagnosed patient with diabetes. The purpose of this poster is to describe the potential mechanisms for this and discuss management strategies.

Case Presentation: A previously fit and well 30-year-old South Asian man presented to the emergency department with a 3-day history of vomiting and abdominal pain. He had a BMI of 36 kg/m² and there was a maternal history of Type 2 Diabetes Mellitus. His initial panel of investigations demonstrated severe metabolic acidosis with ketonaemia. Admission venous blood gas showed a pH of 7.152, glucose 20.4 mmol/l, lactate 1.3 mmol/l, bicarbonate (HCO₃^-) 5.8 mmol/l as well as blood ketones of 6 mmol/l. A subsequent CT scan showed acalculous acute pancreatitis (severity = Glasgow Score 2, Balthazar Score 2). Diabetic antibodies (GAD65, IA-2, ZnT8) were negative for Latent Autoimmune Diabetes of Adulthood (LADA). Triglycerides were 44.22 mmol/l and Haemoglobin A1C (HbA1C) was 118 mmoll/mol. He was treated in a high dependency unit with aggressive fluid resuscitation, intravenous and subcutaneous insulin as well as fibrates.

Conclusion: While acute pancreatitis (AP) and DKA are common presentations in the Emergency Department, it was unusual as a de novo diabetic presentation and required Multidisciplinary Team discussion with the Diabetology team as well as the Intensive Care team. AP is a complication in around 11% of patients with DKA and hypertriglyceridaemia (HTG) commonly occurs as a result of inhibition of lipoprotein lipase. It has been hypothesised that DKA could be the inciting event leading to HTG and ultimately AP. The correction of DKA is the crux of management, involving aggressive fluid repletion, intravenous insulin infusion and diligent monitoring of glucose, ketones and electrolytes. In the case of severe hypertriglyceridemia, clinicians should be aware of interventions such as fibrates or therapeutic plasma exchange.