Yazan Abboud, MD1, Meet Shah, DO2, Benjamin Simmons, MD1, John Esli Medina Morales, MD1, Mohamed Ismail, DO1, Fouad Jaber, MD3, Saqr Alsakarneh, MD3, Kaveh Hajifathalian, MD, MPH1 1Rutgers New Jersey Medical School, Newark, NJ; 2Rutgers New Jersey Medical School, Jersey City, NJ; 3University of Missouri-Kansas City, Kansas City, MO
Introduction: Hypertriglyceridemia-induced pancreatitis (HTGP) is a less common but well-documented cause of acute pancreatitis. IV insulin and plasmapheresis are treatment modalities for HTGP; however, definitive guidelines for the management of HTGP complicated by necrotizing pancreatitis are not clearly established. We report a case of HGTP-induced pancreatitis that was complicated by necrotizing pancreatitis and did not improve with treatment.
Case Description/Methods: A 42-year-old male with no known medical history presented with severe epigastric pain, nausea, and vomiting for a few hours. On presentation, the patient was tachycardic HR 118 and tachypneic RR 34 with labs showing WBC 14.9, Na 128, lactic acid 3.3, Lipase 1,850, and Triglycerides 3,350. CT of the abdomen and pelvis was consistent with acute interstitial pancreatitis (Figure A). The patient denied any alcohol use, medications, or supplements. His pancreatitis was attributed to HTGP and he was started on IV fluids and was admitted to the ICU on continuous IV insulin and underwent plasmapheresis. Triglycerides level improved from 3,350 to 383 and lipase levels improved to normal limits over the course of eight days. The hospital course was complicated by acute hypoxic respiratory failure due to aspiration pneumonia requiring broad-spectrum antibiotics and intubation. Subsequent CT of the abdomen and pelvis was suggestive of necrotizing pancreatitis with peripancreatic fluid collection (Figure B) complicated by abdominal compartment syndrome, requiring CT-guided drainage. He also developed acute renal failure requiring hemodialysis with triglycerides increasing to 1,131 requiring another session of plasmapheresis. His condition deteriorated requiring the need to perform urgent exploratory laparotomy with necrosectomy. The patient then passed away from a cardiopulmonary arrest attributed to multi-organ failure.
Discussion: IV insulin and plasmapheresis are guideline-recommended treatment options for HTGP with worrisome features. Our patient demonstrated tachypnea, leukocytosis, and lactic acidosis, which are worrisome features of this condition. Despite early initiation of plasmapheresis, IV insulin, and the downtrending triglycerides, he developed necrotizing pancreatitis that did not respond to treatment, with subsequent multi-organ failure prompting necrosectomy. Poor clinical outcomes in this scenario warrant revisiting current management modalities for HTGP-induced necrotizing pancreatitis.
Figure: Figure A: Computed tomography (CT) of the abdomen and pelvis with IV contrast consistent with acute interstitial pancreatitis with severe hepatic steatosis and hepatomegaly. Figure B: Computed tomography (CT) of the abdomen and pelvis with IV contrast consistent with necrotizing pancreatitis with peripancreatic fluid collection, partially loculated fluid within the left anterior pararenal space. increased acute necrotic collection exerting increased mass effect on the adjacent stomach, increasing loculation and peripheral enhancement of the collection, interval increase in the amount of intra-abdominal ascites, specifically in the perihepatic space.
Disclosures:
Yazan Abboud indicated no relevant financial relationships.
Meet Shah indicated no relevant financial relationships.
Benjamin Simmons indicated no relevant financial relationships.
John Esli Medina Morales indicated no relevant financial relationships.
Mohamed Ismail indicated no relevant financial relationships.
Fouad Jaber indicated no relevant financial relationships.
Saqr Alsakarneh indicated no relevant financial relationships.
Kaveh Hajifathalian indicated no relevant financial relationships.
Yazan Abboud, MD1, Meet Shah, DO2, Benjamin Simmons, MD1, John Esli Medina Morales, MD1, Mohamed Ismail, DO1, Fouad Jaber, MD3, Saqr Alsakarneh, MD3, Kaveh Hajifathalian, MD, MPH1. P0086 - Hypertriglyceridemia-Induced Necrotizing Pancreatitis: Poor Clinical Outcomes Requiring Revisiting Current Management Options, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.
