Hypertriglyceridemia-induced acute pancreatitis

Plasmapheresis vs Conventional Insulin Therapy in Hypertriglyceridemia-Induced Acute Pancreatitis

Hypertriglyceridemia is a rare yet firm etiology of pancreatitis, with an incidence of 2-4% in the general population. The etiology of hypertriglyceridemia itself consists of both primary and secondary causes. We discuss the case of a 37-year-old female with a strong family history of hypertriglyceridemia (primary cause) along with daily alcohol consumption (secondary cause) who initially presented to the emergency department with tingling and numbness of her bilateral upper extremities, bilateral lower extremity cramping and spasm and pins, and needles sensation in all extremities. She was found to have acute pancreatitis (AP) as a cause of hypocalcemia with elevated triglycerides of 5,823 mg/dl responsive to plasmapheresis combined with insulin drip. We explore the pathophysiology of hypertriglyceridemia-induced acute pancreatitis and the different modalities used to treat it which are still largely debated. The choice of therapy has been influenced by the cost, perceived effectiveness, and availability.

Jaundice on Presentation Is Associated with Higher In-Patient Mortality and Complications in Patients Admitted for Acute Pancreatitis: A Retrospective Study Based on National Inpatient Sample Database

Pancreatitis usually presents with characteristic abdominal pain, radiological findings, and elevated lipase. The presence of jaundice may hint at a biliary etiology; however, it is not always present. We hypothesized that the presence of jaundice is associated with worse outcomes in patients admitted with pancreatitis. We conducted a retrospective analysis using the National Inpatient Sample, inquiring about patients admitted with pancreatitis with and without jaundice between October 2015 and December 2017. The primary outcome was in-hospital mortality in patients admitted for pancreatitis with and without jaundice. Secondary outcomes were the median length of stay, hospitalization cost, the incidence of ventilator-dependent respiratory failure (VDRF), acute respiratory distress syndrome (ARDS), sepsis, septic shock, dehydration and electrolyte disturbances, and ascites. A total of 1,267,744 patients were admitted with pancreatitis from October 2015 to December 2017. Among them, 8855 (0.7%) had concomitant jaundice on presentation. In-hospital mortality in this group was 4.3%. The patients with pancreatitis and jaundice had higher odds of in-hospital mortality (adjusted odds ratio [aOR]: 1.51, 99% CI 1.35–1.68, p < 0.0001) as compared to those without jaundice. Patients with jaundice showed a significantly higher incidence of sepsis (15.2% vs. 9.6%, p < 0.0001), septic shock (4.1% vs. 2.9%, p < 0.0001), ascites (6.5% vs. 3.1%, p < 0.0001), and dehydration and electrolyte disorders (47.6% vs. 43.8%, p < 0.0001). Patients with jaundice also had higher total hospital costs ($11,412 vs. $7893, p < 0.0001). There was no statistical difference in ARDS, VDRF, and median length of stay. In conclusion, patients admitted for pancreatitis with jaundice had worse outcomes, including in-hospital mortality and complications, compared to those without jaundice.

Recurrent seasonal severe hypertriglyceridemia-induced acute pancreatitis; a case report

Introduction

Acute pancreatitis (AP) is a serious inflammatory condition of the pancreas. Hypertriglyceridemia (HTG) is considered an uncommon cause of AP. The current study aims to present a unique case of recurrent seasonal severe HTG-induced AP (HTG-AP); treated with insulin and heparin.

Case report

A 36-year-old male presented with recurrent attacks of severe upper abdominal pain that was radiating to the back and associated with repeated vomiting. The condition has being occurring every autumn-winter for the last three years. He had thalassemia minor and had a history of HTG-AP. His TG levels were relatively normal from February to August; however, from September to February, his TG levels highly elevated which has resulted in HTG-AP every year for the past three years. The condition was confirmed via a contrast-enhanced computerized tomography scan of the abdomen. To prevent the next HTG-AP, his TG level was monitored monthly. When TG levels spiked again, the patient was put on an insulin infusion with heparin, glucose, and potassium to rapidly reduce TG level. After two days, serum TG was dramatically reduced (<500 mg/dL).

Discussion

Despite multiple theories being proposed, the pathogenesis of HTG-AP is yet to be understood. Usually, HTG-AP is a single episodic, and recurrent HTG-AP is considered uncommon finding. Previous reports are contradictory regarding TG level and seasonal variation. There is currently no standard management approach to treat HTG-AP cases.

Conclusion

HTG-AP rarely reoccurs on an annual basis, and seasonal variation seems to play a major role in its onset. The condition can be managed with insulin, heparin, and glucose infusions.

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Hypertriglyceridemia is an uncommon cause of acute pancreatitis.

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Seasonal variation seems to play a role in the onset of recurrent hypertriglyceridemia-induced acute pancreatitis.

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It can be prevented and treated with insulin, heparin, and glucose infusions.

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This report aims to present a unique case of recurrent seasonal severe HTG-AP treated with insulin and heparin.

Integrated omics analysis revealed the Tinospora cordifolia intervention modulated multiple signaling pathways in hypertriglyceridemia patients-a pilot clinical trial

Purpose

Hypertriglyceridemia (HTG) is strongly associated with the various types of disease conditions and evolving as epidemics. Hence, it is important to identify molecules that lower the triglyceride and chylomicron levels. Tinospora cordifolia is an illustrious Ayurveda drug, has proved juvenile and immunomodulatory properties.

Methods

Twenty four (24) patients having >499 mg/dL TG and 130-230 mg/dL of cholesterol were randomized and given 100 mL/day (~3.0 g) water extract of T. cordifolia (TCE) for 14 days. Basal parameters were analyzed before and after TC intervention to analyzed primary outcomes. Further, unbiased metabolomics and proteomics profiling was explored to assess the efficacy of TCE in HTG patients.

Results

TCE intervention decreased the levels of triglycerides, and VLDL to 380.45 ± 17.44, and 31.85 ± 5.88, and increased the HDL levels to 47.50 ± 9.05 mg/dL significantly (p < 0.05). Metabolomics analysis identified the significant alteration in 69 metabolites and 72 proteins in plasma of HTG patients. TCE intervention reduced the level of isoprostanes, ROS, BCAA, and fatty acid derivatives, significantly. The annotation databases, Metboanalyst predicted Akt and Rap1 signaling, and ECM-receptor interaction is the most affected in HTG patients. TCE intervention normalized these events by increasing the peroxisome biogenesis and modulating Akt and Rap1 signaling pathway.

Conclusion

T. cordifolia intervention suppresses the baseline in HTG patients. Omics analysis showed that TCE intervention modulates the Akt and Rap signaling, and peroxisome biogenesis to control the cellular switches and signaling pathways. Hence, TCE can be used as a supplement or alternate of standard drugs being used in the management of HTG.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-022-00985-6.

Assessment of the course of acute pancreatitis in the light of aetiology: a systematic review and meta-analysis

The main causes of acute pancreatitis (AP) are biliary disease, alcohol consumption, hypertriglyceridaemia (HTG) and endoscopic retrograde cholangiopancreatography (ERCP). The aim of this meta-analysis was to evaluate the effects of these aetiological factors on the severity and outcome of AP. Pubmed and Embase were searched between 01/01/2012 and 31/05/2020. Included articles involved adult alcoholic, biliary, HTG- or post-ERCP AP (PAP) patients. Primary outcome was severity, secondary outcomes were organ failures, intensive care unit admission, recurrence rate, pancreatic necrosis, mortality, length of hospital stay, pseudocyst, fluid collection and systematic inflammatory response syndrome. Data were analysed from 127 eligible studies. The risk for non-mild (moderately severe and severe) condition was the highest in HTG-induced AP (HTG-AP) followed by alcoholic AP (AAP), biliary AP (BAP) and PAP. Recurrence rate was significantly lower among BAP vs. HTG-AP or AAP patients (OR = 2.69 and 2.98, 95% CI 1.55-4.65 and 2.22-4.01, respectively). Mortality rate was significantly greater in HTG-AP vs. AAP or BAP (OR = 1.72 and 1.50, 95% CI 1.04-2.84 and 0.96-2.35, respectively), pancreatic necrosis occurred more frequently in AAP than BAP patients (OR = 1.58, 95% CI 1.08-2.30). Overall, there is a potential association between aetiology and the development and course of AP. HTG-AP is associated with the highest number of complications. Furthermore, AAP is likely to be more severe than BAP or PAP. Greater emphasis should be placed on determining aetiology on admission.

Higher Inpatient Morbidity and Mortality in Biliary Pancreatitis Compared to Hypertriglyceridemia-Induced Pancreatitis: A Nationwide Retrospective Study

Introduction

Hypertriglyceridemia (HTG)-induced pancreatitis is the third most common cause of acute pancreatitis after gallstone disease and alcohol. We analyzed data from the National (Nationwide) Inpatient Sample (NIS) with the aim of evaluating the outcomes of patients with HTG-induced pancreatitis when compared to those with biliary-induced pancreatitis.

Methods

The NIS database was sourced for data involving adult hospitalizations for HTG-induced pancreatitis in the United States between January 1, 2016 and December 31, 2017. The main outcome was mortality in patients with biliary pancreatitis vs HTG pancreatitis. Secondary outcomes were the incidence of sepsis, septic shock, non-ST-elevation myocardial infarction (NSTEMI), blood transfusion requirements, acute kidney failure, acute respiratory distress syndrome (ARDS), and length of hospital stay.

Results

A total of 575,230 patients were admitted with a diagnosis of acute pancreatitis, 18.2% of which were classified as having HTG pancreatitis. The in-hospital mortality for pancreatitis was 0.59%. Patients with HTG pancreatitis had lower odds of in-hospital mortality (adjusted odds ratio [aOR]: 0.74, 95% CI 0.582-0.934, p=0.012) compared to those with biliary pancreatitis. Patients with HTG pancreatitis had less odds of developing comorbid sepsis (aOR: 0.52, 95% CI 0.441-0.612, p<0.001), septic shock (aOR: 0.64, 95% CI 0.482-0.851, p<0.001), and NSTEMI (aOR: 0.70, 95% CI 0.535-0.926, p<0.001) and had less odds of requiring transfusion of blood products (aOR: 0.57, 95% CI 0.478-0.678, p<0.001) when compared to those with biliary pancreatitis. Patients with HTG pancreatitis also had a lower average length of hospital stay and lower total hospital charges compared to those with biliary pancreatitis. There was no statistical difference, however, in acute kidney failure and ARDS between the two groups.

Conclusion

Patients with HTG-induced pancreatitis possibly have better inpatient outcomes including mortality when compared to those with biliary-induced pancreatitis.

Hypertriglyceridemia-induced pancreatitis: updated review of current treatment and preventive strategies

Hypertriglyceridemia (HTG) is an uncommon but well-established cause of acute pancreatitis (AP) comprising up to 7% of the cases. The clinical course of HTG-induced pancreatitis (HTGP) is highly similar to that of AP of other etiologies with HTG being the only distinguishing clinical feature. However, HTGP is often correlated with higher severity and elevated complication rate. At present, no approved treatment guideline for the management of HTGP is available, although different treatment modalities such as insulin, heparin, fibric acids, and omega 3 fatty acids have been successfully implemented to reduce serum triglycerides (TG). Plasmapheresis has also been used to counteract elevated TG levels in HTGP patients. However, it has been associated with complications. Following the management of acute phase, lifestyle modifications including dietary adjustments and drug therapy are essential in the long-term management of HTGP and the prevention of its relapse. Results from studies of small patient groups describing treatment and prevention of HTGP are not sufficient to draw solid conclusions resulting in no treatment algorithm being available for effective management of HTGP. Therefore, prospective randomized, active-controlled clinical studies are required to find a better treatment regimen for the management of HTGP. Until date, one randomized clinical trial has been performed to compare clinical outcomes of different treatment approaches for HTGP. However, further studies are required to outline a generalized and efficient treatment regimen for the management of HTGP.

Total Plasma Exchange in Hypertriglyceridemia-Induced Pancreatitis: Case Report and Literature Review

Objective

To emphasize the role of apheresis in management of pancreatitis.

Methods

The clinical course of a patient admitted for hypertriglyceridemia-induced pancreatitis (HTGP) complicated by multiorgan dysfunction is described, who demonstrated dramatic improvement in his clinical status after total plasma exchange (TPE). In addition, the current guidelines for TPE and the alternative treatment options for HTGP are also presented.

Results

A patient presenting with pancreatitis associated with severe systemic inflammatory response was admitted to our hospital with an initial triglyceride level of 1181 mg/dL. Given the patient's worsening clinical condition, he was started on TPE with a rapid fall in his serum TG levels, in turn leading to early clinical recovery.

Conclusion

Though various therapeutic options for the treatment of HTGP are described in literature, there are no set guidelines available to tackle this difficult clinical situation. TPE, albeit not very well known in this context, is one of the many therapies available. Though it leads to a rapid, precipitous fall in the TG levels and early symptom resolution, the data about the long-term morbidity as well as the effectiveness of this therapy is still lacking.

Chronic osteomyelitis correlates with increased risk of acute pancreatitis in a case-control study in Taiwan

OBJECTIVES

The objective of this study was to examine the relationship between chronic osteomyelitis and acute pancreatitis in Taiwan.

METHODS

This was a population-based case-control study utilizing the database of the Taiwan National Health Insurance Program. We identified 7678 cases aged 20-84 with newly diagnosed acute pancreatitis during the period of 1998 to 2011. From the same database, 30,712 subjects without diagnosis of acute pancreatitis were selected as controls. The cases and controls were matched with sex, age and index year of diagnosing acute pancreatitis. The odds ratio with 95% confidence interval of acute pancreatitis associated with chronic osteomyelitis was examined by the multivariable unconditional logistic regression analysis.

RESULTS

After adjustment for multiple confounders, the multivariable analysis showed that the adjusted odds ratio of acute pancreatitis was 1.93 for subjects with chronic osteomyelitis (95% confidence interval 1.01, 3.69), when compared with subjects without chronic osteomyelitis.

CONCLUSIONS

Chronic osteomyelitis correlates with increased risk of acute pancreatitis. Patients with chronic osteomyelitis should be carefully monitored about the risk of acute pancreatitis.