Hypertriglyceridaemia-induced pancreatitis

A 31-year-old male with a body mass index of 30 kg/m2, a history of alcohol use disorder and hyperglycemia presented to the emergency department with sudden onset of severe left upper quadrant (LUQ) abdominal pain. He had no history of pancreatitis or binge drinking episodes before the onset and denied a family history of hyperlipidemia or diabetes mellitus. On examination, LUQ abdomen was tender to percussion and palpation. Abdominal contrast-enhanced computed tomography showed indistinct pancreatic tail margins owing to inflammation and surrounding retroperitoneal fat stranding without evidence of gallstone disease or pancreatic duct dilation (Figure 1a). Substantial, thick chylous layers in the collected blood were noted (Figure 1b); hence, additional laboratory studies were performed that revealed 10.7% HbA1c, and 74 IU/l serum amylase and 6882 mg/dl serum triglyceride (TG) levels. He was subsequently diagnosed with hypertriglyceridemia-induced pancreatitis (HTGP). Following subcutaneous insulin, fluid, and analgesics administration, his symptoms resolved completely. (a) Indistinct pancreatic tail margins and surrounding retroperitoneal fat stranding. (b) Thick chylous layers in the collected blood. Hypertriglyceridaemia (HTG) is the third leading cause of acute pancreatitis (AP), possibly accounting for 4% of cases.1 HTG can have a primary or secondary etiology, like uncontrolled diabetes mellitus, visceral obesity, alcohol use, pregnancy or oral estrogens.2 The risk of developing AP with serum TG >1000 mg/dl is ∼5%.3 Lipotoxicity, caused by the breakdown of TG into free fatty acids, contributes to the inflammatory response, multisystem organ failure and necrotic acinar cell death in AP.4 Serum TG levels >500 mg/dl may cause falsely normal amylase levels, probably from interference of the calorimetric reading. Serial dilutions of the serum amylase sample can reduce TG interference.5 HTGP should be suspected in patients with AP and risk factors for HTG regardless of normal serum amylase levels. Measuring serum TG and lipase levels can help guide and optimize treatments for patients with AP, HTG or potential HTGP. Kosuke Ishizuka (Supervision [Equal]), Yuya Kitai (Supervision [Equal]), and Tetsuya Inoue (Supervision [Equal]). Conflict of interest: None declared.