34-year-old female with a history of hypertension, diabetes mellitus, and pancreatitis presents for epigastric and left upper quadrant abdominal pain. Her symptoms started yesterday evening and have been worsening since onset. She reports chronic epigastric pain that waxes and wanes for several years since her first episode of pancreatitis in 2014. Yesterday she had an abrupt onset of nausea that accompanied the pain without emesis. The pain worsened and is now currently 10/10 in severity. She describes it as severe and deep. She has no bloody or dark stool. She denies any heavy alcohol use, changes in medications, or drug use.
Vitals: 97.9 F; BP 121/78; Pulse 96; RR 16; SpO2 99%
General: Appears mildly distressed due to pain, but able to engage in history and physical
Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops
Pulmonary: Lungs clear bilaterally without wheezes or rhonchi
Abdominal: Soft, non-distended, upper abdominal tenderness most pronounced in the epigastric region; no rebound but with mild anticipatory voluntary guarding
Skin: No lesions or rashes
Back: No CVA tenderness
Extremities: Warm and well perfused
CMP: Notable for glucose 191 mg/dL and CO2 19 mEq/L; otherwise unremarkable
Lipase: Mildly elevated
Triglycerides: 9,918 mg/dL
The patient’s blood has this appearance because of the markedly elevated triglycerides. At high triglyceride levels, the serum appears lactescent (milky coloration).
The patient has hypertriglyceridemia (HTG)-induced pancreatitis.
The triglycerides (TG) themselves are not toxic. It is the breakdown of TGs into toxic free fatty acids (FFA) by pancreatic lipases that causes lipotoxicity during acute pancreatitis. Typically serum TG levels >1000 mg/dL are required for HTG to be considered the etiology of acute pancreatitis. HTG is considered very severe when levels are >2000 mg/dL.
The patient was admitted to the ICU and was treated with an insulin infusion. Insulin promotes the synthesis of lipoprotein lipase, which is a crucial enzyme in the hydrolysis of TG. Lipoprotein lipase hydrolyzes triglycerides into fatty acids and glycerol and facilitates the storage of the fatty acids in adipocytes.
Insulin infusions for hypertriglyceridemia (HTG) typically run at 0.1-0.3 units/kg/hr. D5 infusion can be run concurrently to prevent hypoglycemia. The insulin drip can typically be stopped when TG levels are <500 mg/dL.
Another treatment option is apheresis. As with the insulin drip, continue apheresis until the serum triglyceride level is <500 mg/dL.
Common causes of pancreatitis include:
- Gllstones (35-75%)
- Alcohol (25-35%)
- Idiopathic (10-20%)
Uncommon causes include:
- HTG (1-4%)
- ERCP and drugs (1.4-2%)
Take Home Points
- HTG is a less common, but important cause of pancreatitis, and can be considered the etiology when TG levels are >1000 mg/dL.
- Treatment for HTG-induced pancreatitis include either IV insulin drip or apheresis.
- HTG causes a classic milky appearance of the blood.