Hypertriglyceridemia induced pancreatitis is relatively uncommon (about 8% of patients with pancreatitis). This is likely to become more of an increasing problem in the future due to growing rates of obesity.
Basic Pathophysiology:
· Insulin promotes storage of triglycerides into adipose if resistance or not enough insulin lipolysis, releasing free fatty acids in circulation.
· Many people have high triglyceride levels and don’t develop pancreatitis from it, so likely the toxicity causing pancreatitis comes from free fatty acids
· It is difficult to measure free fatty acid levels, but we can easily measure triglyceride levels.
Risk Factors:
· DM, Obesity
· Hereditary hyperlipoproteinemia
· Pregnancy
· Hypothyroidism
· Medications
Interesting Clinical Signs:
· Xanthoma Tuberosum
o Nontender, pink-yellow papules or nodules that occur on extensor surfaces, such as the elbows and knees, and on trauma-prone areas
· Lipemia
o White, milky, opaque serum on blood draw
Diagnosis:
· Requires at least two:
o Clinically significant history/physical (epigastric abdominal pain), CT demonstrating inflammation, or lipase >3 times upper limit of normal
o Triglyceride level >1,000 (higher the level the more significant/ higher likelihood to be causing pancreatitis)
o Must exclude other causes – gallstones, meds, etc.
Treatment:
· *****Fluids*****
o BE CAREFUL!!!! Overloading these patients is one of the worst things you can do for them. Don’t exceed >3-4 liters in the first
o Lactated ringers (has been found to reduce inflammation compared to NS)
· Vasopressors
o Use early to prevent fluid overload
· Pain control
o Opioids can promote Ileus, try to avoid this class of medications as best as possible
o Great time to use acetaminophen with pain-dose ketamine infusions (0.1-0.3mg/kg/hr)
· Insulin
o Appropriate dose is variable ranging from 0.1-0.3 U/kg/hr (dosage can vary based on history of diabetes or insulin resistance)
o Monitor for hypokalemia, hypoglycemia
o Likely to be best treatment
· Plasmapheresis
o Unclear if there is a large benefit to this
o Invasive, requires large bore access catheter
o Expensive, resource intensive, and not widely available
o Heparin used during process can cause bleeding
· Antibiotics
o Generally, should be avoided with these exceptions:
§ Unclear diagnosis and have clinical suspicion for infection
§ Concern for coexisting ascending cholangitis
Complications:
ARDS
Infection
Abdominal compartment syndrome
· Increased intra-abdominal pressures
o Pancreatic/peri-pancreatic inflammation
o Ascites
o Ileus (opioids)
o Aggressive fluid resuscitation
o Abdominal wall compliance (pain)
o Pancreatic perfusion, worsens with intraabdominal hypertension increases risk for pancreatic necrosis
Quick Tips:
· Do not give too much fluid
· Control pain with modalities other than opioids if possible
· Insulin therapy is very effective, and plasmapheresis has not been shown to be more advantageous
· Look for alternative causes before focusing solely on hypertriglyceride induced pancreatitis (consider ultrasound imaging and review patient medications)
References:
https://emcrit.org/ibcc/hypertag/
https://wikem.org/wiki/Acute_pancreatitis
https://rebelem.com/acute-pancreatitis/