Multiple Concomitant Episodes of Diabetic Ketoacidosis and Acute Pancreatitis in a Pediatric Patient With Type 1 Diabetes

Introduction: Abdominal pain is a common presenting symptom in diabetic ketoacidosis (DKA). Correction of the acidosis usually leads to resolution of the abdominal pain. In some instances, the pain may persist due to additional etiologies presenting alongside DKA. Though uncommon, there has been shown to be an association between DKA and acute pancreatitis (AP). In these rare cases, AP was secondary to the hypertriglyceridemia (HTG) state induced by DKA. We report a 13-year-old female known with type 1 diabetes (T1D) who presented with multiple concomitant episodes of DKA and AP and normal triglyceride levels. Case Presentation: The patient is a 13-year-old female with T1D who presented with two days of hyperglycemia, nausea, and diffuse abdominal pain. Initial laboratory evaluation was remarkable for point-of-care glucose of >500 mg/dL (60-99), venous pH of 7.006 (7.330-7.430), bicarbonate of < 5 mmol/L (20-28), beta-hydroxybutyrate of 5.6 mmol/L (0.0-0.8); consistent with severe DKA. She received normal saline bolus fluids and then started on the DKA protocol with improvement of acidosis, though with the persistence of abdominal pain. Due to concern for other causes of her abdominal pain, additional workup was done, notable for elevated lipase of 624 U/L (10-52), amylase of 434 U/L (25-100), and triglyceride of 121 mg/dL (30-149). An abdominal ultrasound showed findings consistent with AP, lipase levels peaked at 1753 U/L before down-trending to 959 U/L, and amylase decreased to 389 U/L. After several days abdominal pain resolved, and the patient was discharged home. The patient was readmitted six weeks and again one year later for laboratory and symptoms, including abdominal pain consistent with DKA. Both lipase and amylase were elevated during both admissions with normal triglyceride levels. Magnetic resonance cholangiopancreatography was significant for findings compatible with acute pancreatitis with no evidence of cholelithiasis or choledocholithiasis. The patient underwent genetic testing, including normal PRSS1, SPINK1, CFTR, CPA1, and CTRC. A variant of unknown clinical significance was identified in the CTRC gene (c.550G>A), which was not thought to be the cause of her recurrent pancreatitis. Interestingly, since her hemoglobin A1c has been in a better range for the past year, she did not have any recurrent episodes of pancreatitis. Conclusion: The insulin-deficient state associated with DKA can lead to moderate to severe HTG, which in turn can cause AP. Even though abdominal pain is a common symptom in patients presenting in DKA, one should think about other causes when the abdominal discomfort is out of proportion or not improving as acidosis resolves. Our patient had recurrent pancreatitis for unknown etiology; however, she has not had any pancreatitis episodes in the last year since her diabetes has been under better control.

Relationship between fatty pancreas and hypertriglyceridemic waist phenotype: a cross-sectional study

Hypertriglyceridemic waist phenotype (HTWP) and its quantitative indicator, waist circumference-triglyceride index (WTI), are common quantitative indices of visceral obesity and are closely related to metabolic diseases. The purpose of this study was to investigate the relationship between fatty pancreas (FP) and HTWP in China. FP was diagnosed using trans-abdominal ultrasonography in all participants. According to the waist circumference and serum triglyceride levels, the participants were divided into four phenotype groups: normal waist circumference-normal triglyceride, normal waist circumference-elevated triglyceride, elevated waist circumference-normal triglyceride, and elevated waist circumference-elevated triglyceride (indicating HTWP). Clinical characteristics and biochemical indices were compared among the groups. Receiver operating characteristic (ROC) curves were used to evaluate the utility of WTI as a reference factor for FP screening. The HTWP group had a higher prevalence of metabolic syndrome (84.2%), FP (10.4%), fatty liver (64.5%), and hypertension (15.8%) than the other three phenotype groups. The occurrence rate of HTWP and the median WTI were significantly higher in participants with FP than in those without FP (54.7% vs 21.0%, 222 ± 135 vs 142 ± 141, p < 0.001). In the ROC curve analysis, when the maximum area under the curve was 0.746, the WTI was 107.09 and the corresponding sensitivity and specificity were 90.6% and 51.9%, respectively. HTWP is closely associated with FP and can be used as a reference factor for FP screening.

HYPERTRIGLYCERID-ASSOCIATED ACUTE PANCREATITIS: CLINICAL CHARACTERISTICS AND TREATMENT RESULTS

The aim of the study is to evaluate the clinical characteristics of patients with hypertriglyceride associated acute pancreatitis. A single-center observational study of a series of cases was performed on the basis of the Kyiv Department of Surgery for Liver, Pancreas and Bile Tracts named after V.S. Zemskov in the period from 2018 to 2019. Investigation includes patients with acute pancreatitis and hypertriglyceridemia (the triglycerides level is more than 1.7 mmol/l). Exclusion criteria: patients with acute pancreatitis with normal triglyceride levels, patients with acute pancreatitis with elevated triglycerides, that have not been treated enough. All patients were evaluated by Charlson index of comorbidity, body mass index, alcohol history, relapses and severity of disease. All patients were monitored throughout inpatient treatment, from hospitalization to discharge to home or death. The end point of the study was the discharge of the patient to home after the elimination of the manifestations and complications of acute pancreatitis or death of the patient. The 234 patients who were hospitalized and treated with a diagnosis of acute pancreatitis, 27 patients had hypertriglyceridemia and 3 of them were excluded from the study. The study involved 24 patients. Therefore, the frequency of acute pancreatitis associated with high triglycerides was 11.5% (27/234), with the average level of triglyceridemia was 10.1 ± 2.4 mmol / l (range 5.8 - 13.6 mmol / l) , 75% of patients (18/24) had moderate hypertriglyceridemia (2.3 - 11.2 mmol / l), 25% (6/24) - severe (11.2 - 22.4 mmol / l) . The median age was 32 years (quarterly interval 31.5 - 35 years). There were 18 men (75%) and 6 women (25%). Alcohol-induced pancreatitis was observed in 17 (70.8%) patients with hypertrtiglyceridemia. The median body mass index is 28.9 kg / m 2. Normal weight was 33% (8/24) patients, excessive - 25% (6/24), obesity I stage - 29% (7/24) obesity II stage - 8% (2/24) obesity III stage - 4% (1/24). The Charlson comorbidity index ranged from 0 to 5 points, in 1 patient it was 5 points, in 3 patients - 2 points, in 3 patients - 1 point. Diabetes mellitus were in 25% of patients (6 /24), two of them was diagnosed at first. Recurrent cases of disease were in 58.3% of patients (14 /24), 10 of 14 had a history of two cases of acute pancreatitis. In 71% (17 /24) observed a light stage of the disease, 25% (6 /24) - pancreatitis medium degree of severity and in 4% (1 /24) of the patient severe pancreatitis. Mortality was 4%. Conclusions. The frequency of hypertriglyceride-associated acute pancreatitis is 11.5%. In light, moderate and severe pancreatitis, the average degree of hypertriglyceridemia (blood triglycerides 2.3 -11.2mmol/l) was prevailed. Hypertriglyceride-associated acute pancreatitis has no specific complications, but has a tendency to recurrence. Patients with hypertriglyceridemia need constant laboratory monitoring (determination of triglycerides), pharmacological therapy and follow-up to prevent the development of acute pancreatitis.

SAT-577 Severe Asymptomatic Hypertriglyceridemia

Background Case reports of patients with severely elevated serum triglyceride levels (&gt;1000 mg/dL) have been documented where Insulin infusions, heparin and plasmapheresis have demonstrated rapid and successful decrease in serum Triglyceride levels. The benefits of one approach versus the other to prevent major complications such as cardiovascular events or acute pancreatitis has not been well investigated. We present the case of a patient with severely elevated serum triglyceride levels without any manifestations. Case Description A 53-year-old male presented from his primary care provider’s office due to elevated Triglycerides levels over 6000 as per outpatient lab work. Inpatient labs were unattainable initially due to hemolysis secondary to the severely high lipid content. Patient was admitted to the medical ICU for closer monitoring and initiated on an insulin drip. Two days after insulin initiation patient’s triglyceride levels returned as 2,887 with a total cholesterol count of 848. His insulin drip was continued until his TAG levels were less than 1000. Upon discharge his levels were less than 600. Discussion Most patients with hypertriglyceridemia are asymptomatic. However, in patients with levels above 1000 mg/dL, the risk of pancreatitis or cardiovascular event is of concern. Hypertriglyceridemia may account for 1 to 14 percent of cases of acute pancreatitis. Treatment is largely based upon symptoms and complications. In the event of pancreatitis or other cardiovascular complication, plasmapheresis is usually recommended. If asymptomatic, Insulin may be used. Insulin promotes synthesis of lipoprotein lipase which functions to hydrolyze triglycerides, and has been shown to be an effective lowering agent in the treatment of such individuals. Case reports of Heparin being used as a lipid lowering agent have also been documented, but was not used in our particular patient. Normal triglyceride plasma levels are defined as less than 150 mg/dL. Mild hypertriglyceridemia typically ranges between 150-499 mg/dL, moderate between 500-866 mg/dL, and severe is defined as levels greater than 886 mg/dL. Plasma triglyceride levels above 1000 mg/dL occur in fewer than 1 in 5000 individuals. It is said that patients with TAG levels above 2000 mg/dL almost always have both a secondary and a genetic form of Hypertriglyceridemia. For this reason it is very important to identify these patients as early as possible to treat appropriately. Our patient was a known alcohol abuser, yet without the presence of some polygenic familial disorder, the likelihood of our patient having TAG levels &gt;6000 mg/dL, is very unlikely.

Association between atherogenic dyslipidemia and fournier’s gangrene

SUMMARY OBJECTIVE We aimed to determine whether atherogenic dyslipidemia is associated with the disease and morbidity in our patients treated for Fournier’s gangrene (FG). METHODS Sixty-two patients who were treated with the diagnosis of FG at our center between 2012 and 2017 were retrospectively screened. RESULTS The triglyceride values of the patients who required reconstructive surgery were statistically significantly higher than those of the patients for whom wound debridement and primary suturing was sufficient (p:0.001). A total of 65.7% of the patients had normal triglyceride values in the group in which wound debridement and primary suturing was sufficient, while this rate was 22.2% in the group of patients who needed reconstructive surgery; the difference was statistically significant (p: 0.002). The UFGSI score of those with triglyceride values higher than the normal range was statistically significantly higher (p:0.006). The cut-off point for the triglyceride value for which Fournier’s gangrene was more morbid and the probability of reconstructive surgery need was significantly higher, i.e., >233mg. CONCLUSION Our study has demonstrated that atherogenic dyslipidemia, especially hypertriglyceridemia, is an important factor affecting morbidity and associated with high patient care costs after hospitalization and discharge in FG.

Severe hypertriglyceridaemia and pancreatitis in a patient with lipoprotein lipase deficiency based on mutations in lipoprotein lipase (LPL) and apolipoprotein A5 (APOA5) genes

A 44-year-old woman was admitted with pancreatitis caused by hypertriglyceridaemia (fasting triglycerides 28 mmol/L). She used oral contraceptives and ezetimibe 10 mg. She was overweight (body mass index 29.7 kg/m2). Diabetes mellitus was ruled out, as were nephrotic syndrome, alcohol abuse, hypothyroidism and dysbetalipoproteinaemia. Genetic analysis revealed mutations in two genes involved in triglyceride metabolism (apolipoprotein A5 and lipoprotein lipase [LPL]). The LPL activity was 45% compared with pooled healthy controls. The post-heparin triglyceride reduction was 6%, compared with a normal reduction of >20%. The patient was initially treated with gemfibrozil, but this was discontinued due to side effects. Dietary triglyceride restriction and discontinuation of the oral contraceptives lowered the plasma triglycerides within 2 weeks to 3.4 mmol/L. Hypertriglyceridaemia is a risk factor for pancreatitis and cardiovascular disease, and has a broad differential diagnosis including genetic causes. Patients can achieve near-normal triglyceride values with a low-fat diet only.

Association of hyperlipidaemia in preterm delivery

Background: Premature infant is the most important outcome of preterm delivery and is also the cause for infant mortality after congenital abnormality. Around the world, there are 3.6 million per year neonatal deaths, of which in developing countries, 99% deaths are observed. This study was conducted to evaluate the elevated triglycerides and cholesterol relationship on preterm labor risk.Methods: 350 healthy pregnant women were included in the study group in the age group of 18-36 years, their gestational age was confirmed either by last menstrual period or by ultrasound. This study was conducted in Department of Obstetrics and Gynaecology at Osmania University, Hyderabad, Telangana India.Results: The good outcomes were observed in mothers with normal cholesterol values and preterm deliveries were observed in 32.14% of mothers with abnormal cholesterol values. 0.3% of mothers with normal triglyceride values and 75% of mothers with abnormal values had preterm delivery. P value difference was statistically significant (P<0.05).Conclusions: By measuring serum total cholesterol and triglycerides, along with serum screening of α-fetoprotein and inhibin A, it can be used to predict the preterm labour.

Triglyceride Levels on Electronic Cigarette Vapers in Palangka Raya

The electronic cigarette (e-cigarette) is one of the Nicotine Replacement Therapy uses electricity from battery power to deliver nicotine as aerosols. Nicotine can stimulate secretion of catecholamine lead to increase secretion of hepatic triglycerides to the blood vessels. This study aimed to asses the triglyceride levels of electronic cigarette smokers (also known as vapers) on a vaporizer community in Pahandut, Palangka Raya, Central Kalimantan. The cross-sectional design was carried out to asses triglyceride levels on 29 electronic cigarette users. Triglyceride assay was determined by an automated photometric technique using Photometers (5010 V5+ Robert Riele). This study found that mostly e-cigarette user considered normal triglyceride level as 75.9% with average triglyceride level 100.6 mg/dL, 13.8% considered borderline-high triglyceride level with average triglyceride level 180.8 mg/dL, and only 10.3% considered high triglyceride level with average triglyceride level 293.0 mg/dL.

Aortic Dissection Presenting as Acute Pancreatitis: Suspecting the Unexpected

Aortic dissection is a life-threatening condition in which the inner layer of the aorta tears. Blood surges through the tear, causing the inner and middle layers of the aorta to separate (dissect). It is considered a medical emergency. We report a case of a healthy 56-year-old male who presented to the emergency room with sudden onset of epigastric pain radiating to his back. His blood pressure was 167/91 mmHg, equal in both arms. His lipase was elevated at 1258 U/L, and he was clinically diagnosed with acute pancreatitis (AP). He denied any alcohol consumption, had no evidence for gallstones, and had normal triglyceride level. Two days later, he endorsed new suprapubic tenderness radiating to his scrotum, along with worsening epigastric pain. A MRCP demonstrated evidence of an aortic dissection (AD). CT angiography demonstrated a Stanford type B AD extending into the proximal common iliac arteries. His aortic dissection was managed medically with rapid blood pressure control. The patient had excellent recovery and was discharged home without any surgical intervention.