Hypertriglyceride Induced Acute Pancreatitis

Abstract

Pancreatitis is a common clinical entitiy with multiple contributing etiologies1. Triglyceride (TG) levels greater than 1000 mg/dL are seen in a small but significant number of cases of acute pancreatitis (AP), with estimates ranging between 1-7% of all cases and perhaps slightly higher in patients who present during pregnancy2-4. The clinical presentation of hypertriglyceridemic pancreatitis (HTGP) is similar to other causes of acute pancreatitis, but some evidence suggests that there may be an increased severity and risk of complications5,6. Multiple etiologies of highly elevated TG levels have been implicated, including congenital disorders, metabolic perturbations and certain medications but a definitive treatment regimen for profoundly elevated serum TG in association with acute, and often severe, pancreatitis has yet to be demonstrated7-10. Dietary restriction is the cornerstone of therapy. Additional treatment modalities have included insulin and heparin to stimulate the synthesis, release and activation of lipoprotein lipase (LPL) from capillary endothelial cells to promote TG degradation into free fatty acids for further metabolism or storage11. We present a case of HGTP managed with insulin, heparin and octreotide with dramatic results; a logarithmic decrease in serum TGL magnitude and a significant reduction in the time to resolution as compared with previous reports of treatment with insulin and heparin alone. Recent advances in the management of HGTP, including proposed mechanisms, will be reviewed. Adjunctive therapies, including plasmapheresis and more chronic therapy with lipid lowering agents and dietary modification will be discussed.