Endocrine Abstracts

Introduction: Commonest causes of pancreatitis are alcohol and gallstones but less common causes like hypertriglyceridemia should also be considered as management may differ.

Case history: 47 years old gentleman with history of pancreatitis and hyperlipidaemia type1 taking atorvastatin and bezafibrate, admitted with severe abdominal pain and vomiting. He was non-smoker and non-drinker. No history of cholelithiasis or medications causing pancreatitis. He was haemodynamically stable and systemically well except epigastric tenderness. After excluding diabetic ketoacidosis (DKA), he was initially managed conservatively for acute pancreatitis but bloods showed severe lipaemia therefore insulin/dextrose infusion was started in view of hypertriglyceridemia induced pancreatitis with successful resolution of hypertriglyceridemia without requiring plasmapheresis but required intensive care for active monitoring.

Investigations: Blood sample after hypercentrifugation (due to severe lipaemia) showed: Urea: 9.3 (2.8-7.2 mmol/l), Creatinine: 184(59-104umol/l), Sodium, Potassium and Magnesium were normal but hypocalcaemia 1.91(2.20-2.60 mmol/l) Triglycerides: 103.2 (<1.7 mmol/l), Cholesterol 26.9 (<5 mmol/l) CT Abdomen: Acute severe pancreatitis with severe oedema and extensive peripancreatic fluid but no frank necrosis.

Results and treatment: 1. Conventional management of acute pancreatitis with fluid resuscitation and analgesia. 2. Insulin (0.05units/kg/hour) and 5% dextrose (100-150ml/hour) infusion, given severe hypertriglyceridemia. 3. High dose prophylactic anticoagulation (Enoxaparin 40 mg twice/day) due to hyperviscosity from hypertriglyceridemia. 4. Patient also required calcium infusions for recurrent hypocalcaemia. (Likely because of excessive free fatty acids or saponification). Within 6 days, hypertriglyceridemia improved from 103 mmol/l to 5.4 mmol/l without plasmapheresis and cholesterol dropped to <6.1 mmol/l.

Learning Points: 1. Hypertriglyceridemia should be considered as differential of acute pancreatitis as management varies. 2. Insulin and dextrose infusion should be initiated early if hypertriglyceridemia is the cause as this can reduce complications by effectively lowering triglycerides. 3. Effective thrombo-prophylaxis is essential due to high risk of thromboembolism. 4. Patient may develop severe and recurrent hypocalcaemia therefore active monitoring and management is needed.