2019 Research Forum

Applicant: Tushar Bajaj MD R1 Principal Investigator: Sundeep Grandhe MD R2 Faculty Sponsor: Saman N. Ratnayake MD A Rare Case of Pancreatitis Due to Very Severe Hypertriglyceridemia Treated with Subcutaneous Insulin and Lipid Lowering Drugs Tushar Bajaj MD R1, Sundeep Grandhe MD R2, David Holt MS III, Saman N. Ratnayake MD

INTRODUCTION The diagnosis of acute pancreatitis in a patient requires the presence of two of the following three criteria: acute onset of persistent , severe, epigastric pain often radiating to the back, elevation in serum lipase or amylase to three times or greater than the upper limit of normal , and characteristic radiographic evidence1 • Hypertriglyceridemia is a potential cause of acute pancreatitis when levels are greater than 1000 mg/dL2 • Very severe hypertriglyceridemia is classified as levels above 2000mg/dL. We present a patient with a triglyceride level of 12,234 mg/dL who presented with severe epigastric pain radiating to her back. PURPOSE The patient is a 45-year-old morbidly obese Hispanic female with a past medical history of Hypertension, Diabetes Mellitus Type 2, and Gastroesophageal Reflux Disease presenting to the Emergency Department with complaints of severe 10/ 10 epigastric pain for approximately eight hours. She had a previous laparoscopic cholecystectomy and denied alcohol use. Her significantly elevated lipase was 14, 923 U/L and her triglyceride level was 12, 234. The patient was diagnosed with acute pancreatitis. The patient had a normal calcium level of 8.4 mg/dL and a lactic acid 1.1 mmol/L. The patient was kept nil per os, started on 250 ml/hr of Lactated Ringer ‘s Solution, and pain was controlled with intravenous morphine. Subsequently the patient was started on subcutaneous insulin Glargine I 0 units in the AM and 10 units in the PM along with a high correction scale. After 48 hours the patient was also started on Rosuvastatin 20mg and Fenofibrate 160 milligrams . The patient’s hospital course was complicated by cyclic fevers, persistent abdominal pain, and trouble advancing her diet. After approximately 11 days, the patient was afebrile, tolerating a full diet, and discharged in stable condition. DISCUSSION Hypertriglyceridemia is the third leading cause of acute pancreatitis after gallstones and alcohol use. Hypertriglyceridemia is considered a significant risk for acute pancreatitis when levels are greater than 1000 mg/dL which is the cutoff classified as severe2 • In our case, we present a patient with very severe (>2000 mg/dL) hypertrigl yceridemia; furthermore, we have a rare case in which the triglycerides are even greater than 1O,OOOmg/dL which has been rarely been reported in the literature. Our patient had a triglyceride level of 12,234 mg/dL with acute epigastric pain and a severely elevated lipase level. For acute pancreatitis treatment , we aimed at the three fundamental goals of nil per os, high volume intravenous fluids, and pain control. The standard of care in patients with hypertriglyceridemia-induced acute pancreatitis with worrisome features including but not limited to hypocalcemia , elevated temperature, elevated white blood cell count is plasmapheresis and if not feasible or available, then intravenous insulin is to be administered3, , 4, 5 CONCLUSION We present a rare case in support of the most established treatment guidelines for the management of very severe hypertriglyceridemia causing acute pancreatitis as either plasmapheresis or intravenous insulin. Our patient had normal calcium and lactic acid levels, misleading the necessity of plasmapheresis or intravenous insulin. The patient had a protracted, complicated hospital course that might have otherwise been avoided.

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