Abstract
Background: Hypertriglyceridemia (HTG) is a well-established cause of acute pancreatitis (AP) in up to 14% of all cases & up to 56% cases during pregnancy. The triad of HTG, Diabetic ketoacidosis (DKA) and AP is rarely seen posing diagnostic challenges. Early recognition of HTG-induced pancreatitis (HTGP) is important to provide appropriate therapy & prevent recurrence. In this case series, we discuss the diagnostic challenges and clinical features of HTGP. Clinical cases: Our first patient was a 65-year-old male with a history of hypertension who presented to the ER with abdominal pain and new-onset pruritic skin rash after a heavy meal. His exam and labs were notable for a diffuse papular rash on his back, triglycerides (TG) of 7073mg/dL (normal: <150mg/dL). The rash improved with the resolution of HTG. Our second patient was a 29-year-old male with a history of alcohol dependence who was found to have AP complicated by ARDS requiring intubation. Further testing revealed that his TG was 12,862mg/dL & his sodium (Na) was 102mEq/L. Although HTG was known to cause pseudohyponatremia, it was a diagnostic challenge to estimate the true Na level. In a third scenario, a 28-year-old female with a history of T2DM on Insulin presented with nausea & abdominal pain. Labs were suggestive of DKA and lipase was normal. CT abdomen showed changes consistent with AP. The TG level that was later added on was elevated to 4413mg/dL. She was treated with insulin that improved her TG level. Discussion: We present three cases of hypertriglyceridemic pancreatitis. While the presentation can be similar to other causes of acute pancreatitis (AP), there are factors in the diagnosis and management of HTGP that are important to understand. Occasionally, physical exam findings can be suggestive of underlying HTG. In the first scenario, our patient presented with eruptive xanthomas - a sudden eruption of crops of papules that can be pruritic. They are highly suggestive of HTG, often associated with serum TG levels > 1500mg/dL. Our second patient presented with pseudohyponatremia. HTG falsely lowers Na level, by affecting the percentage of water in plasma. Identifying this condition is important to prevent possible complications from aggressive treatment. This can be corrected either by using direct ion-specific electrodes or with the formula: Na change = TG * 0.002. DKA is associated with mild-moderate HTG in 30–50% cases. This is due to insulin deficiency causing activation of lipolysis in adipocytes & decreased activity of lipoprotein lipase (LPL). However, severe HTG is a rare complication of DKA, increasing the risk of AP. Diagnosis of AP in DKA poses many challenges: the common presenting complaint of abdominal pain, non-specific hyperlipasemia in DKA. AP with DKA has also been associated with normal lipase levels. A high clinical index of suspicion is required to diagnose HTGP in patients with DKA.
A rare complication of cholecystolithiasis: perforation of the gallbladder
