A Rare Case of Acute Pancreatitis Due to Very Severe Hypertriglyceridemia (>10 000 mg/dL) Successfully Resolved With Insulin Therapy Alone: A Case Report and Literature Review

Abstract

A 48-year-old male presented to the psychiatric emergency room for dysmorphic mood. He was admitted to medical service for the management of hyponatremia, which was discovered in his initial laboratory workup. After the first day of admission, he developed abdominal pain and fever, and subsequent laboratory work revealed a triglyceride level of 10 612 mg/dL (reference range = 0-194 mg/dL). Computed tomography scan of the abdomen and pelvis revealed a hypodense lesion in the pancreas surrounded by a moderate amount of peripancreatic fluid suggestive of hemorrhagic pancreatitis. Based on the laboratory findings and imaging, we diagnosed acute pancreatitis (AP) secondary to hypertriglyceridemia. The patient was initiated on intravenous fluids and insulin to help decrease the triglyceride level with the plan to initiate apheresis. However, the patient improved on insulin therapy alone, which negated the need for apheresis, and the patient was discharged with fenofibrate with no further complications. While elevated triglycerides are a well-known cause of AP, we sought to assess various treatment options in management, especially considering a severely elevated triglyceride level of >10 000 mg/dL. Along with supportive care in AP, there are additional options in hypertriglyceridemia AP, including heparin, insulin, apheresis, antioxidants, and fibrates. Currently, there are no clear guidelines favoring one therapeutic option over the other.

Triad of Diabetic Ketoacidosis, Hypertriglyceridemia, and Acute Pancreatitis: Severity of Acute Pancreatitis May Correlate with the Level of Hypertriglyceridemia

“…Our patient presented with mild acute pancreatitis. Upon reviewing other similar case reports on this triad, we noticed a milder presentation in patients with lower level of TG and severe presentation in patients with very high TG level [6-9]. There has also been a retrospective study on a large number of patients who depicted a more severe form of pancreatitis in the higher TG groups than that in the lower TG groups implying that an elevated TG level may be associated with a poor prognosis [10].…”

The Efficacy of Intravenous Insulin Infusion in the Management of Hypertriglyceridemia-Induced Pancreatitis in a Rural Community Hospital

“… 1 The severity of acute pancreatitis in patients with hypertriglyceridemia is dependent on both the inflammatory response caused by pancreatitis itself, and the injury caused by lipotoxicity from triglyceride hydrolysis. 3 …”

“…1 The severity of acute pancreatitis in patients with hypertriglyceridemia is dependent on both the inflammatory response caused by pancreatitis itself, and the injury caused by lipotoxicity from triglyceride hydrolysis. 3 There are no current established guidelines for the treatment of very severe HTG-AP, although insulin, heparin, and plasmapheresis have all been used in the literature. Being in a rural hospital with no timely access to other treatment options, insulin drip was started as studies have showed, insulin is noninferior and as effective as plasmapheresis, which tends to be costly with limited access.…”

Hypertriglyceridemia induced acute pancreatitis managed with low dose intravenous Insulin.

“…The duration of Insulin therapy is another variable among reported cases; it ranges between 2-4 days. In non-diabetic patients lower doses of Insulin are usually used [7]. Although we used the lowest reported dose ; however, it was safe and effective to lower hypertriglyceridemia within two days.…”