Case Presentation: Our case involves a 45-year-old male with a history of alcohol abuse, who presented with acute epigastric pain and bilious emesis. On exam, he had severe epigastric tenderness with guarding and normoactive bowel sounds. When obtaining labs, his blood was grossly turbid. Labs were significant for elevated lipase (1,534 IU/L), normal TSH (1.23 uIU/mL) total cholesterol (915 mg/dL), and triglycerides (greater than 5,250 mg/dL). He was hypocalcemic (7.7 mg/dL) with low 25-hydroxy vitamin D (16 ng/mL). CT abdomen pelvis revealed peripancreatic fluid. He was diagnosed with acute hypertriglyceridemia-induced pancreatitis. After assessing cost-benefit therapies, the decision was made to treat with an insulin infusion along with dextrose 5% in water for blood sugar support over apheresis. Triglyceride levels were monitored every 12 hours until it became less than 500 mg/dL, after which the insulin infusion was discontinued. He was concomitantly started on atorvastatin 80 mg daily and fenofibrate 48 mg daily.
Discussion: Hypertriglyceridemia (HTG)- induced pancreatitis causes up to 15% of cases of acute pancreatitis, typically occurring in patients with triglyceride levels greater than 1,000 mg/dL. HTG occurs in primary (genetic) and secondary disorders of lipoprotein metabolism. Secondary causes include diabetes, pregnancy, medication, alcoholism, and thyroid disorders. Although HTG- induced pancreatitis has a similar presentation to pancreatitis of other etiologies it is related with more complications and has a higher severity, thus early recognition is imperative to treatment. At this time there is no approved first-line treatment guideline, however reducing triglycerides early on in the clinical course in emphasized. We believe it is important to educate physicians on the cost-benefit of insulin infusion therapy for HTG-induced pancreatitis, with recent studies (Bi-TPAI trial) showing insulin infusion being non-inferior to apheresis in the critical care setting. These studies have treatment implications because insulin therapy offers a safer and effective option.
Conclusions: The early diagnosis of HTG-induced pancreatitis is important to be able to start early treatment focused on reducing triglyceride levels. Based on recent studies, an insulin infusion has shown to be non-inferior, to plasmapheresis in the treatment of HTG-induced pancreatitis. Additionally, it is more cost-effective, safer, and more accessible, allowing patients to be treated in a timely manner.