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Safety and Efficacy of Insulin and Heparin in the Management of Hypertriglyceridemia-Induced Pancreatitis in a Patient without Diabetes: A Case Report. Case Rep Endocrinol 2022; 2022:7905552. [PMID: 36203643 PMCID: PMC9532158 DOI: 10.1155/2022/7905552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 08/24/2022] [Indexed: 11/30/2022] Open
Abstract
Acute pancreatitis (AP) leads to a variety of complications, such as local or systemic inflammatory responses as well as organ failure. While choledocholithiasis and alcohol abuse are two of the most common causes of AP, hypertriglyceridemia causes AP with an incidence rate between 2 and 5%. The management of hypertriglyceridemia-induced pancreatitis (HTGIP) is focused on the lowering of triglyceride (TG) levels, and the efficacy of therapies for the management of HTGIP may vary based on the hypertriglyceridemia etiology. The aim of this article is to report a case of a 43-year-old female with a history of familial hypertriglyceridemia and without diabetes who was admitted for acute pancreatitis with a TG level elevated to 4,435 mg/dL. The patient was treated with a combination of insulin, heparin, atorvastatin, and omega-3-acid ethyl esters, and her TG level was reduced to 880 mg/dL after 9 days of therapy. Despite the successful treatment of the patient, standardization of the approach for the treatment of HTGIP is needed. Future research should aim to identify the appropriateness of insulin therapy specifically in patients without diabetes presenting with hypertriglyceridemia and the dosing associated with optimal safety.
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2
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Ghizlane EA, Manal M, Salma T, Abderrahim EK, Mohammed M, Ikram Z, Fatem-Zahra A, Sanae EM, Houssam B, Brahim H. Hypertriglyceridemia revealing acute pancreatitis: A case report. Ann Med Surg (Lond) 2021; 70:102914. [PMID: 34691438 PMCID: PMC8519797 DOI: 10.1016/j.amsu.2021.102914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/01/2021] [Accepted: 10/03/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction Acute pancreatitis (AP) is considered one of the potentially rare complications of severe hypertriglyceridemia (HTG). Multiple treatment modalities have been suggested for patients with HTG-AP, such as permanent removal of TG by plasmapheresis, the use of insulin and heparin to enhance lipoprotein lipase activity and fibrate therapy, but the data remains limited. Case management we reported a case of 33-year-old women admitted for HTG-induced PA (HTG-AP). The patient had hypertriglyceridemia for 7 years under fibrate therapy as a medical history. On admission to our intensive care unit, his triglyceride level was 1060 mg/dl and the lipase level was 298 IU/L. An abdominal CT scan revealed stage E AP. The patient was treated with a low dose insulin infusion (0.05 unit/kg/h) with heparin and 5-day course of plasmapheresis, Fibrate therapy was maintained. His triglycerides went down to 130.9 mg/dl and she was discharged. Conclusion Early recognition of severe HTG can prevent progression to multiples diseases such as acute pancreatitis, can facilitate appropriate or even aggressive treatment to minimize complications of this. Hypertriglyceridemia is the third most common cause of acute pancreatitis. It is necessary to have a TG level greater than 1000 mg/dl (or 20 mmol/l) to induce acute pancreatitis. Treatment of this acute pancreatitis due to hypertriglyceridemia involves lowering lipid levels through the use of plasmapheresis, heparin and insulin infusions and/or fibrate therapy.
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Affiliation(s)
- El Aidouni Ghizlane
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco.,Mohammed First University Oujda, Faculty of Medicine and Pharmacy, Oujda, Morocco.,Anesthesiology and Intensive Care Unit Department, Mohammed First University, Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - Merbouh Manal
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco.,Mohammed First University Oujda, Faculty of Medicine and Pharmacy, Oujda, Morocco.,Anesthesiology and Intensive Care Unit Department, Mohammed First University, Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - Taouihar Salma
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco.,Mohammed First University Oujda, Faculty of Medicine and Pharmacy, Oujda, Morocco.,Anesthesiology and Intensive Care Unit Department, Mohammed First University, Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - El Kaouini Abderrahim
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco.,Mohammed First University Oujda, Faculty of Medicine and Pharmacy, Oujda, Morocco.,Anesthesiology and Intensive Care Unit Department, Mohammed First University, Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - Maarad Mohammed
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco.,Mohammed First University Oujda, Faculty of Medicine and Pharmacy, Oujda, Morocco.,Anesthesiology and Intensive Care Unit Department, Mohammed First University, Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - Zaid Ikram
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco.,Mohammed First University Oujda, Faculty of Medicine and Pharmacy, Oujda, Morocco.,Anesthesiology and Intensive Care Unit Department, Mohammed First University, Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - Aftiss Fatem-Zahra
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco.,Mohammed First University Oujda, Faculty of Medicine and Pharmacy, Oujda, Morocco.,Anesthesiology and Intensive Care Unit Department, Mohammed First University, Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - El Mezzioui Sanae
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco.,Mohammed First University Oujda, Faculty of Medicine and Pharmacy, Oujda, Morocco.,Anesthesiology and Intensive Care Unit Department, Mohammed First University, Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - Bkiyar Houssam
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco.,Mohammed First University Oujda, Faculty of Medicine and Pharmacy, Oujda, Morocco.,Anesthesiology and Intensive Care Unit Department, Mohammed First University, Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - Housni Brahim
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco.,Mohammed First University Oujda, Faculty of Medicine and Pharmacy, Oujda, Morocco.,Mohammed First University Oujda, FMP Oujda, LAMCESM, Oujda, Morocco.,Anesthesiology and Intensive Care Unit Department, Mohammed First University, Faculty of Medicine and Pharmacy, Oujda, Morocco
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3
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Berberich AJ, Ziada A, Zou GY, Hegele RA. Conservative management in hypertriglyceridemia-associated pancreatitis. J Intern Med 2019; 286:644-650. [PMID: 31077464 DOI: 10.1111/joim.12925] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Severe hypertriglyceridemia (serum triglyceride >10 mmol L-1 ) is implicated in ~9% of acute pancreatitis cases. Certain guidelines list severe hypertriglyceridemia as an indication for plasmapheresis. OBJECTIVE We assembled the natural trajectory of triglyceride levels in patients with acute pancreatitis due to severe hypertriglyceridemia who were managed conservatively without plasmapheresis to evaluate the effectiveness of this approach. METHODS A retrospective chart review was performed on 22 hospital admissions for acute pancreatitis episodes considered to be caused by severe hypertriglyceridemia. Patients were managed supportively, with cessation of oral intake (NPO) and intravenous hydration. Insulin infusion was used in 12 patients to manage concurrent hyperglycaemia. RESULTS Triglyceride levels for the group were evaluated using a mixed-effects model. The average triglyceride level fell from 45.4 mmol L-1 on presentation to 13.3 mmol L-1 within 48 h, corresponding to a mean 69.8% decrease. Regression analysis showed a triglyceride half-life of 30.6 h. Findings were similar for NPO-only and insulin infusion subgroups. CONCLUSION Patients with severe hypertriglyceridemia and acute pancreatitis can be conservatively managed safely and effectively without plasmapheresis.
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Affiliation(s)
- A J Berberich
- From the, Department of Medicine and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - A Ziada
- From the, Department of Medicine and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - G Y Zou
- From the, Department of Medicine and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - R A Hegele
- From the, Department of Medicine and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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Mathuram Thiyagarajan U, Ponnuswamy A, Chung A. An enigmatic triad of acute pancreatitis, diabetic ketoacidosis and hypertriglyceridaemia: who is the culprit? BMJ Case Rep 2019; 12:12/7/e217272. [PMID: 31296632 DOI: 10.1136/bcr-2016-217272] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Acute pancreatitis(AP) is one of the common causes of acute abdomen and known to be associated with high morbidity and mortality in severe cases. Though most common causes of AP are cholelithiasis and alcoholism, it has also been reported in association with diabetic ketoacidosis (DKA). Triad of AP, hypertriglyceridaemia (HTG) and DKA is rare co-association and here the causal factor of AP is still not fully established. We report a case of AP in a DKA patient with recent diagnosis of hyperlipidaemia and diabetes. Usually AP has been associated with severe HTG; interestingly, our patient showed only moderate raise in triglycerides but still suffered AP during DKA. Hence, it raises question about the real culprit in this enigmatic triad.
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Affiliation(s)
| | | | - Alex Chung
- General Surgery, St Georges Hospital NHS Trust, London, UK
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Inayat F, Zafar F, Baig AS, Chaudhry NA, Aslam A, Khan ZH, Iqbal MJ. Hypertriglyceridemic Pancreatitis Treated with Insulin Therapy: A Comparative Review of 34 Cases. Cureus 2018; 10:e3501. [PMID: 30648042 PMCID: PMC6318129 DOI: 10.7759/cureus.3501] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Although the clinical presentation of hypertriglyceridemic pancreatitis is usually similar to other forms of acute pancreatitis, it is frequently associated with increased clinical severity and rate of complications. Therefore, appropriate and timely management is of paramount importance in these patients. We performed a structured literature search of the medical databases PubMed and Google Scholar, using the terms “hypertriglyceridemia,” “acute pancreatitis,” “insulin,” and “treatment.” In this search, we identified 34 cases of hypertriglyceridemia-related pancreatitis available in the full-text form in English. The data on patients’ characteristics, epidemiology, clinical features, comorbid conditions, and diagnostic modalities were collected and summarized. This review illustrates that the use of insulin therapy with close monitoring of blood glucose levels is safe. It can be considered as an important component of management in patients with hypertriglyceridemia-related pancreatitis, especially in a clinical setting without the availability of plasmapheresis. Randomized clinical trials are warranted to outline a generalized and efficient treatment regimen for hypertriglyceridemic pancreatitis.
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Affiliation(s)
- Faisal Inayat
- Internal Medicine, Allama Iqbal Medical College, Lahore, PAK
| | - Fahad Zafar
- Internal Medicine, King Edward Medical University, Lahore, PAK
| | - Asad S Baig
- Internal Medicine, Nawaz Sharif Medical College, Gujrat, PAK
| | - Najaf A Chaudhry
- Internal Medicine, Lahore Medical and Dental College, Lahore, PAK
| | - Aysha Aslam
- Internal Medicine, Beth Israel Deaconess Medical Center, Boston, USA
| | - Zarak H Khan
- Internal Medicine, St. Mary Mercy Hospital, Livonia, USA
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Wadood A, Chesner R, Mirza M, Zaman S. Tamoxifen precipitation of familial hypertriglyceridaemia: a rare cause of acute pancreatitis. BMJ Case Rep 2016; 2016:bcr-2016-214837. [PMID: 27489062 DOI: 10.1136/bcr-2016-214837] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Drug-induced pancreatitis is uncommon, and is estimated to account for between 0.1% and 5% of cases. Tamoxifen is commonly used in the management of oestrogen receptor-positive breast cancer. We present a rare case of tamoxifen-related hyperlipidaemia resulting in repeated episodes of pancreatitis, which, to the best of our knowledge, has only been documented a few times in the literature. A 36-year-old woman with familial hypertriglyceridaemia presented with recurrent episodes of abdominal pain, modest increases in serum amylase levels and normal liver function tests. The patient had recently been diagnosed with breast carcinoma and was managed with wide local excision (WLE), adjuvant radiotherapy and tamoxifen. On each admission, the patient's symptoms were confirmed either biochemically and/or radiologically. Analysis of the case led to a diagnosis of precipitation of familial hypertriglyceridaemia from tamoxifen use resulting in pancreatitis. Management was altered with tamoxifen cessation and initiation of second-line hormonal therapy. Tamoxifen use needs consideration, especially in those with familial hyperlipidaemia.
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Affiliation(s)
- Ali Wadood
- Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, Birmingham, UK
| | - Robert Chesner
- Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, Birmingham, UK
| | - Mehboob Mirza
- Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, Birmingham, UK
| | - Shafquat Zaman
- Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, Birmingham, UK
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Charlesworth A, Steger A, Crook MA. Acute pancreatitis associated with severe hypertriglyceridaemia; A retrospective cohort study. Int J Surg 2015; 23:23-7. [PMID: 26391596 DOI: 10.1016/j.ijsu.2015.08.080] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 08/07/2015] [Accepted: 08/19/2015] [Indexed: 01/22/2023]
Abstract
AIM Acute Pancreatitis (AP) secondary to hypertriglyceridaemia (HTG) is a rare association of which little is known in the literature. This study investigates patient characteristics and outcomes (reoccurrence and mortality) in those presenting with AP secondary to HTG in one of the largest reported British cohorts. METHODS A retrospective observational case note review of all patients treated at our institution between 2004 and 2012. Data are expressed as mean and standard deviation if parametric and as median and range if non-parametric. Full fasting lipid profiles and patient demographics were recorded to elucidate further the cause of the severe hypertriglyceridaemia (>10 mmol/L fasting). RESULTS There were 784 patients admitted with AP admitted to our institution within the study period. APHTG was present in 18 patients (2.3%). Peak serum triglyceride concentration was 43.9 mmol/L, SD 18.9 mmol/L. Serum amylase activity was 'falsely' low (with raised urine amylase) in about 10% of the patients with acute pancreatitis and hypertriglyceridaemia. 67% of our patients had type 2 diabetes mellitus or impaired glucose tolerance, 28% had a fatty liver and 50% displayed alcohol excess all these conditions are known to be associated with HTG There was a 94.5% reduction in serum triglyceride between presentation and last follow-up visit. There were also no deaths or recurrent episodes of AP during the study period. CONCLUSIONS APHTG was present in 2.3% of patients presenting with AP. The reoccurrence and mortality rates were zero in this cohort. This may in part be due to aggressive serum triglyceride lowering by a multi-disciplinary team. Early clinical recognition is vital to provide targeted treatment and to try and reduce further episodes of AP.
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Affiliation(s)
- Annika Charlesworth
- Dept of Gastroenterology, University Hospital Lewisham, Lewisham, London, SE13 6LH, United Kingdom
| | - Adrian Steger
- Dept of Surgery, University Hospital Lewisham, Lewisham, London, SE13 6LH, United Kingdom
| | - Martin A Crook
- Department of Clinical Biochemistry, University Hospital Lewisham, Lewisham, London, SE13 6LH, United Kingdom.
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Muniraj T, Dang S, Pitchumoni CS. PANCREATITIS OR NOT?--Elevated lipase and amylase in ICU patients. J Crit Care 2015; 30:1370-5. [PMID: 26411523 DOI: 10.1016/j.jcrc.2015.08.020] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 08/21/2015] [Accepted: 08/22/2015] [Indexed: 12/26/2022]
Abstract
Elevation in serum levels of pancreatic enzymes (Hyperamylasemia and/or Hyperlipasemia) can occur in any Intensive Care Unit (ICU) patient either as a result of true acute pancreatitis (AP) or as a reflection of a non-pancreatic disease. Although most patients may not have clinical pancreatitis, identifying true acute pancreatitis in the ICU setting may be critical in the presence of associated co-morbid conditions of the disease for which the patient is being managed. With neither amylase nor lipase being specific for pancreatitis, it is important for the clinician to be aware of different causes of hyperamylasemia and hyperlipasemia, especially when clinical diagnosis of pancreatitis is unclear. This review will focus on understanding different non-pancreatic conditions where there is elevation of pancreatitis enzymes and to identify true acute pancreatitis in critically ill patients without typical symptoms.
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Affiliation(s)
| | - Saurabh Dang
- Department of surgery, Mount Sinai Beth Israel Medical center, New York, NY
| | - Capecomorin S Pitchumoni
- Division of Gastroenterology, Hepatology, and Clinical Nutrition, Saint Peters University Hospital, New Brunswick, NJ, USA
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Otsuki M, Takeda K, Matsuno S, Kihara Y, Koizumi M, Hirota M, Ito T, Kataoka K, Kitagawa M, Inui K, Takeyama Y. Criteria for the diagnosis and severity stratification of acute pancreatitis. World J Gastroenterol 2013; 19:5798-5805. [PMID: 24124324 PMCID: PMC3793134 DOI: 10.3748/wjg.v19.i35.5798] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 06/19/2013] [Indexed: 02/06/2023] Open
Abstract
Recent diagnostic and therapeutic progress for severe acute pancreatitis (SAP) remarkably decreased the case-mortality rate. To further decrease the mortality rate of SAP, it is important to precisely evaluate the severity at an early stage, and initiate appropriate treatment as early as possible. Research Committee of Intractable Diseases of the Pancreas in Japan developed simpler criteria combining routinely available data with clinical signs. Severity can be evaluated by laboratory examinations or by clinical signs, reducing the defect values of the severity factors. Moreover, the severity criteria considered laboratory/clinical severity scores and contrast-enhanced computed tomography (CE-CT) findings as independent risk factors. Thus, CE-CT scans are not necessarily required to evaluate the severity of acute pancreatitis. There was no fatal case in mild AP diagnosed by the CE-CT severity score, whereas case-mortality rate in those with SAP was 14.8%. Case-mortality of SAP that fulfilled both the laboratory/clinical and the CE-CT severity criteria was 30.8%. It is recommended, therefore, to perform CE-CT examination to clarify the prognosis in those patients who were diagnosed as SAP by laboratory/clinical severity criteria. Because the mortality rate of these patients with SAP is high, such patients should be transferred to advanced medical units.
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