P2141 - Unlucky Triad: Diabetic Ketoacidosis, Hypertriglyceridemia and Pancreatitis

Sean-Patrick Prince, MD, MPH, Qitan Huang, DO, Andrew Santos, MD, Mollika Hossain, MD, Nelson Mane, MD
Citrus Memorial Hospital, Inverness, FL

Introduction: Hypertriglyceridemia (HTG) is the third most common cause of acute pancreatitis (AP) behind gallstones and alcohol accounting for up to 7% of cases. It can occur in type 1 diabetics due to the lack of insulin’s suppressive effect on glucagon leading to increased lipolysis in peripheral fat stores. This enhanced lipolysis causes elevation serum triglycerides, ketone bodies and toxic free fatty acids that act on the pancreas. Together, these events form an uncommon presentation in the triad of diabetic ketoacidosis, HTG, and AP in our case report.

Case Description/Methods: A 34-year-old Caucasian male with no past medical history presented to our emergency department with a 4-day history of dull epigastric pain radiating to the back. Vitals on admission showed temperature of 100.3°F, heart rate of 125 beats per minute, blood pressure of 122/83 mmHg and respiratory rate of 18 breaths per minute. On physical examination, patient had mild epigastric tenderness with normoactive bowel sounds. Laboratory investigations noted a white blood cell count of 14.3 x 10³/µL, hematocrit 41.5%, sodium 128 mmol/L, bicarbonate 12 mEq/L, BUN 10 mg/dL, glucose 272 mg/dL,lipase 397 unit/L, amylase 103 unit/L, triglycerides 1967 mg/dLand urinalysis showed glycosuria ( >500mg/dL) and ketonuria (80mg/dL). Computer tomography of the abdomen and pelvis showed acute pancreatitis. Patient was given an intravenous fluid bolus of 30ml/kg, started on an insulin infusion rate of 0.15 unit/kg/hr and admitted to the Intensive Care Unit (ICU). After patient’s triglyceride levels decreased below 500mg/dL insulin infusion was transitioned to a sliding-scale insulin regimen and gemfibrozil 600mg twice daily. After clinical improvement, the patient was discharged on basal-bolus regimen and a new diagnosis of type 1 diabetes mellitus.

Discussion: As serum triglycerides increase to levels > 500mg/dL the risk of HTGP steadily increases. When these levels reach > 2000mg/dL, patients are considered to have severe HTG and have a 10%-20% of developing HGTP. When compared to other causes of pancreatitis, patients with HTGP tend to have increased rates of pancreatic necrosis, persistent organ failure (POF), multiple organ failure (MOF), persistent systemic inflammatory response syndrome (SIRS), ICU admission, and mortality. With this association with increased rates of serious outcomes, further studies are vital to provide an evidence-based treatment algorithm.




Disclosures:


Sean-Patrick Prince, MD, MPH, Qitan Huang, DO, Andrew Santos, MD, Mollika Hossain, MD, Nelson Mane, MD. P2141 - Unlucky Triad: Diabetic Ketoacidosis, Hypertriglyceridemia and Pancreatitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.