Long-term follow-up of patients with acute hypertriglyceridemia-induced pancreatitis

Dyslipidaemic pancreatitis clinical assessment and analysis of disease severity and outcomes

INTRODUCTION

The relationship between pancreatitis and dyslipidaemia is unclear.

PATIENTS AND METHODS

Admissions with acute pancreatitis were prospectively evaluated. A comparison of the demographic profile, aetiology, disease severity scores, complications and deaths was made in relationship to the lipid profiles.

RESULTS

From June 2001 to May 2005, there were 230 admissions. The pancreatitis was associated with alcohol (63%), gallstones (18%), idiopathic (9%) and isolated dyslipidaemia (10%). Dyslipidaemia was significantly different between the two predominant race groups: Indian 50.5% and African 17.9% (p < 0.000017). Seventy-eight (34%) had associated dyslipidaemia and 152 (66%) were normolipaemic at admission. The average body mass index was higher in the dyslipidaemic group (27 +/- 6) than in the normolipaemic group (24.5 +/- 6.20; p = 0.004). The mortality rate was similar between the dyslipidaemic and normolipaemic patients (10 and 8%, respectively) and unrelated to race (p = 0.58). The 9 deaths in the dyslipidaemic group occurred in those with persistent hypertriglyceridaemia irrespective of its level (p = 0.003).

CONCLUSION

Dyslipidaemic pancreatitis was more common in the Indian ethnic group. Adverse outcomes in those with dyslipidaemia were predominantly associated with hypertriglyceridaemia.

Hypertriglyceridemic pancreatitis: presentation and management

Hypertriglyceridemia (HTG) is reported to cause 1-4% of acute pancreatitis (AP) episodes. HTG is also implicated in more than half of gestational pancreatitis cases. Disorders of lipoprotein metabolism are conventionally divided into primary (genetic) and secondary causes, including diabetes, hypothyroidism, and obesity. Serum triglyceride (TG) levels above 1,000 mg/dl are usually considered necessary to ascribe causation for AP. The mechanism for hypertriglyceridemic pancreatitis (HTGP) is postulated to involve hydrolysis of TG by pancreatic lipase and release of free fatty acids that induce free radical damage. Multiple small studies on HTGP management have evaluated the use of insulin, heparin, or both. Many series have also reported use of apheresis to reduce TG levels. Subsequent control of HTG with dietary restrictions, antihyperlipidemic agents, and even regular apheresis has been shown anecdotally in case series to prevent future episodes of AP. However, large multicenter studies are needed to optimize future management guidelines for patients with HTGP.

Spectrum and management of hypertriglyceridemia among children in clinical practice

OBJECTIVES

The prevalence and identification of hypertriglyceridemia in youths will likely will increase in the future as a consequence of childhood obesity and increased screening for dyslipidemias. We sought to review our clinical experience with hypertriglyceridemia, evaluate factors associated with increased triglyceride levels, and review treatment options to provide guidance for management.

METHODS

Clinical review of data for all patients who had > or =1 elevated triglyceride level (>4 mmol/L [>350 mg/dL]) while being monitored in a specialized lipid disorders clinic was performed.

RESULTS

The study population consisted of 76 patients with 761 clinic visits. Hypertriglyceridemia was secondary to lifestyle factors for 13 patients. The rest had primary hypertriglyceridemia, with 32 patients having familial combined hypertriglyceridemia and hypercholesterolemia (type II), 25 patients having primary hypertriglyceridemia (type IV), 4 patients having familial lipase deficiency (type I), and 2 patients having hyperlipoproteinemia E2/E2 phenotype (type III). Triglyceride levels were highest in type I and III hypertriglyceridemia (>10 mmol/L [>900 mg/dL]), followed by type IV and adiposity-related hypertriglyceridemia (>4 mmol/L [>350 mg/dL]) and finally type II familial combined hypertriglyceridemia and hypercholesterolemia (>2 mmol/L [>180 mg/dL]). A total of 34 patients received 37 trials of drug therapy as part of triglyceride level management (bile acid-binding resins, n = 12; fibrates, n = 19; statins, n = 6). Triglyceride levels were found to decrease over time with the use of fibrates, to increase with the use of bile acid-binding resins, and not to change with the use of statins.

CONCLUSIONS

Lifestyle modifications remain the primary therapeutic avenue for the management of pediatric hypertriglyceridemia. We propose an algorithm for the management of this heterogeneous population to guide clinicians in their treatment decisions.

Effects of hormonal treatment on lipids in patients with cancer

Patients with malignant disease may need hormonal therapy as primary or adjuvant treatment or for palliation. Oestrogens usually decrease serum levels of total cholesterol (TC) and low density lipoprotein cholesterol (LDL-C), increase high density lipoprotein cholesterol (HDL-C) concentration, but induce an elevation in serum triglyceride (TG) levels. Progestogens in the short-term decrease TC, LDL-C and HDL-C concentrations, and increase TG levels. In long-term treatment, progestogens usually have a small impact on lipid profile. Tamoxifen induces a decrease in TC and LDL-C levels, an increase in TG concentration, whereas either an increase, decrease or no change has been reported for HDL-C levels. Aromatase inhibitors induce an elevation, reduction or no change in lipid variables. These results depend mainly on the trial design, i.e. whether patients received prior treatment with tamoxifen or not and the duration of therapy. Gonadorelin analogues increase all lipid variables, but LDL-C alterations are usually non-significant. Anti-androgens usually decrease TC, LDL-C and HDL-C levels, whereas TG alterations vary. Information regarding the effects on lipid profile of somatostatin analogues is available almost exclusively in patients with acromegaly. In these patients somatostatin analogues usually induce no change or a decrease in TC and LDL-C levels, whereas they increase HDL-C and decrease TG serum concentrations. Oncologists should consider the lifestyle changes, and if needed hypolipidemic treatment, used to lower cardiovascular risk in non-cancer patients. Tamoxifen may rarely cause serious TG-related side effects, like acute pancreatitis.

Effect of admission hypertriglyceridemia on the episodes of severe acute pancreatitis

AIM: To investigate the effect of admission hypertriglyceridemia (HTG) on the episodes of severe acute pancreatitis (SAP).

METHODS: One hundred and seventy-six patients with SAP were divided into HTG group (n = 45) and control group (n = 131) according to admission triglyceride (TG) ≥ 5.65 mmol/L and < 5.65 mmol/L, respectively. Demographics, etiology, underlying diseases, biochemical parameters, Ranson’ s score, acute physiology and chronic heath evaluation II (APACHE II) score, Balthazar’s computed tomography (CT) score, complications and mortality were compared. Correlation between admission TG and 24-h APACHE II score was analyzed.

RESULTS: SAP patients with HTG were younger (40.8 ± 9.3 years vs 52.6 ± 13.4 years, P < 0.05) with higher etiology rate of overeating, high-fat diet (40.0% vs 14.5%, P < 0.05) and alcohol abuse (46.7% vs 23.7%, P < 0.01), incidence rate of hypocalcemia (86.7% vs 63.4%, P < 0.01) and hypoalbuminemia (84.4% vs 60.3%, P < 0.01), 24-h APACHE II score (13.6 ± 5.7 vs 10.7 ± 4.6, P < 0.01) and admission serum glucose (17.7 ± 7.7 vs 13.4 ± 6.1, P < 0.01), complication rate of renal failure (51.1% vs 16.8%, P < 0.01), shock (37.9% vs 14.5%, P < 0.01) and infection (37.4% vs 18.3%, P < 0.01) and mortality (13.1% vs 9.1%, P < 0.01). Logistic regression analysis showed a positive correlation between admission TG and 24-h APACHE II score (r = 0 .509, P = 0.004).

CONCLUSION: The clinical features of SAP patients with HTG are largely consistent with previous studies. HTG aggravates the episodes of SAP.

Therapeutic plasma exchange for acute hyperlipidemic pancreatitis: a case series

Therapeutic plasma exchange (TPE) has been used for the treatment of hyperlipidemic pancreatitis (HLP) with variable results. Eight patients with acute HLP were studied and treated with TPE, in addition to dietary fat restriction and lipid lowering agents. TPE lowered plasma levels of amylase (723.63 +/- 391.70-189.25 +/- 71.26 IU/L, P = 0.002), triglycerides (110.28 +/- 146.39-38.47 +/- 48.79 mmol/L, P = 0.048) and cholesterol (13.37 +/- 7.97-3.84 +/- 1.34 mmol/L, P < 0.001). Clinical symptoms improved in all patients with no resultant complications, and follow up of the patients for 12 months revealed no recurrence of pancreatitis. Thus, TPE is effective in lowering amylase, triglycerides and cholesterol levels, improves the acute attack of hyperlipidemic pancreatitis, and aids in preventing recurrent attacks.

Acute pancreatitis in a cohort of 129 patients referred for severe hypertriglyceridemia

OBJECTIVES

The aim of this study was to assess retrospectively the prevalence and the predictive factors of acute pancreatitis (AP) in a population of patients referred in our endocrinology department for evaluation of very high triglyceride (TG) levels.

METHODS

One hundred twenty-nine patients (119 with type IV phenotypes and 10 with type V phenotypes according to Fredrickson's classification) were referred to our hospital between 2000 and 2005.

RESULTS

Twenty-six subjects (20.2% of the population) presented with AP. This population was significantly younger at diagnosis of hyperlipidemia (32 vs 40 years, P < 0.001) and at age of investigation (43 vs 48 years, P = 0.05) and had maximum TG levels greater than the population without AP (44.7 vs 24.5, P < 0.001). Subjects of the third tertile of TG levels had a 4.0-fold increased risk (95% confidence interval, 1.3-12.3) of AP compared with the first tertile. Severe pancreatitis (need for intensive care, C-reactive protein >150 mg/L, or Balthazar score >C) was observed in 71.5% of the patients.

CONCLUSIONS

Twenty percent of patients with severe hypertriglyceridemia experience at least 1 attack of AP. Pancreatitis seems to occur in young patients at higher levels of TG than previously thought (85% of patients >30 g/L) and is associated with a severe clinical course.

The value of a specialist lipid clinic

AIMS

To establish the value of the first 3 years of a cardiovascular risk factor clinic in tackling the major risk factors for cardiovascular disease (CVD).

METHODS

A database review of all 339 patients referred to the clinic.

RESULTS

Blood pressure levels in the hypertensive patients were significantly reduced and 9% of the smokers managed to quit for 12 months, half of them subsequently relapsing. Ninety-eight oral glucose tolerance tests were performed and 40% were abnormal yielding 10 patients with hitherto unsuspected diabetes and 29 with impaired glucose tolerance. Sixty-four of the 97 referrals of patients in the primary prevention group (no evidence of CVD) were found to have calculated Framingham coronary heart disease risk estimates of < 15% per decade, the lowest being 0.3%. Lipid levels were significantly reduced in both the hypercholesterolaemic (n = 290) and hypertriglyceridaemic (n = 49) patient groups through the use of more potent statins, extensive use of combination therapy and appropriate use of fibrates and omega-3 fish oil supplements. The annual drug cost per patient treated only increased from 310.72 pounds sterling to 398.08 pounds sterling, yet there was a 3.5-fold increase in the number of patients achieving the General Medical Services 2 target of a total cholesterol < 5 mmol/l and a 4.5-fold increase in patients achieving the Joint British Societies 2 target of a low-density lipoprotein (LDL) cholesterol < 2 mmol/l.

CONCLUSION

The need for a specialist clinic was demonstrated by the 66% of primary prevention referrals who did not meet the current NICE treatment threshold. Additionally, the clinic was able to diagnose and treat 39 patients with undiagnosed diabetes mellitus/impaired glucose tolerance and 12 with hypothyroidism. LDL cholesterol was reduced overall by 36% implying a greater than one-third reduction in future cardiovascular events before the improvements in blood pressure control and smoking cessation are included and this was achieved at marginal extra cost to the mean drug bill at referral.

Clinical characteristics of acute pancreatitis in middle and late pregnancy stage and its treatment: an analysis of 23 cases

AIM: To discuss the clinical characteristics of acute pancreatitis in middle and late pregnancy stage and its treatment.

METHODS: Twenty-three patients with acute pancreatitis in middle and late pregnancy stage were conservatively treated with drugs under close observation. Operation was performed for those with their conditions worsened to eliminate the necrotic tissues and terminate their pregnancy.

RESULTS: Two mothers with their fetus died, 21 mothers were discharged from the hospital after their entire recovery and 13 fetuses were successfully saved.

CONCLUSION: Women in the middle and late pregnancy stage, especially those with a history of gallbladder and biliary tract diseases are easy to suffer from pancreatitis. Changes in endocrine during this stage can also lead to the development of acute pancreatitis.

Advances in pathogenesis of hyperlipidemic acute pancreatitis and its diagnosis and treatment

Hyperlipidemia is one of the causes for acute pancreatitis. Hyperlipidemic acute pancreatitis often occurs in patients with type Ⅰ, Ⅴ or Ⅳ hyperlipidemia. It results from chemical irritation to the pancreas and disturbance of pancreatic microcirculation due to the toxicity of free fatty acids released from massive triglycerides. When the serum triglyceride level is elevated, the incidence of complications may increase accordingly. However, serum amylase levels may be normal in serum of some patients or lightly e1evated. The diagnosis of hyperlipidemic acute pancreatitis is mainly based on the clinical manifestations of acute pancreatitis and the serum triglyceride level. Therefore, hyperlipidemic acute pancreatitis patients are treated mainly by reducing their serum triglyceride level.

Hypertriglyceridemia and Recurrent Pancreatitis following Splenectomy

Hyperlipoproteinemia represents a constellation of clinical syndromes that frequently includes hypertriglyceridemia. Because of the degree of elevation in the triglyceride levels frequently seen in these syndromes, they are associated with complications not generally observed among those patients with essential hypertriglyceridemia, including as in this case report, recurrent pancreatitis. Here, we present a case of a patient with hyperlipoproteinemia who developed acute worsening of his hypertriglyceridemia and onset of acute panceatitis that became recurrent following elective splenectomy for suspected lymphoma. In particular, we discuss the dietary management of hypertriglyceridemia which significantly reduced the number of episodes of acute pancreatitis in this patient.

Severe acute pancreatitis in China: etiology and mortality in 1976 patients

OBJECTIVES

Many epidemiological studies have recently been published on acute pancreatitis; however, there is no known published report on pancreatitis in China. The present study aims to assess the etiology and mortality of severe acute pancreatitis in China.

METHODS

Fifteen medical centers located throughout mainland China were involved in this retrospective study. The medical records of 1976 patients, who were admitted to these centers with the diagnosis of severe acute pancreatitis from December 1990 to December 2005, were reviewed. Epidemiological, laboratory, radiological, and therapeutic data for each case were collected on a standardized form for analysis. Severity of pancreatitis was graded according to established criteria.

RESULTS

Of the 1976 patients (1028 men, 948 women; mean age, 56.2 +/- 16.5 years; range, 9-94 years). Biliary tract disease (58.7%) was the main etiologic factor, whereas in 25.2%, the cause was identified as idiopathic. Endotherapy was performed in 9.1% of the severe biliary cases, but only in 33%, it was performed within 72 hours. The mean duration of hospitalization was 22.5 +/- 21.4 days, and the overall mortality rate was 11.8%.

CONCLUSIONS

In this retrospective study, biliary tract disease was the main etiologic factor of severe acute pancreatitis in China. The highest mortality occurred in severe idiopathic pancreatitis, and there was no clear relationship between mortality and age.

Role of prescription omega-3 fatty acids in the treatment of hypertriglyceridemia

A prescription form of omega-3 fatty acids has been approved by the United States Food and Drug Administration as an adjunct to diet for the treatment of very high triglyceride levels. The active ingredients of omega-3 fatty acids are eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), which are responsible for the triglyceride lowering. The prescription product contains a total of 0.84 g of these two active ingredients in every 1-g capsule of omega-3 fatty acids. The total EPA and DHA dose recommended for triglyceride lowering is approximately 2-4 g/day. Fish oil products containing EPA and DHA are available without a prescription, but the American Heart Association advises that therapy with EPA and DHA to lower very high triglyceride levels should be used only under a physician's care. In patients with triglyceride levels above 500 mg/dl, approximately 4 g/day of EPA and DHA reduces triglyceride levels 45% and very low-density lipoprotein cholesterol levels by more than 50%. Low-density lipoprotein cholesterol levels may increase depending on the baseline triglyceride level, but the net effect of EPA and DHA therapy is a reduction in non-high-density lipoprotein cholesterol level. Alternatively, patients may receive one of the fibrates (gemfibrozil or fenofibrate) or niacin for triglyceride lowering if their triglyceride levels are higher than 500 mg/dl. In controlled trials, prescription omega-3 fatty acids were well tolerated, with a low rate of both adverse events and treatment-associated discontinuations. The availability of prescription omega-3 fatty acids, which ensures consistent quality and purity, should prove to be valuable for the medical management of hypertriglyceridemia.

Drug-induced acute pancreatitis: an evidence-based review

The diagnosis of drug-induced acute pancreatitis often is difficult to establish. Although some medications have been shown to cause acute pancreatitis with a large body of evidence, including rechallenge, some medications have been attributed as a cause of acute pancreatitis merely by a single published case report in which the investigators found no other cause. In addition, some medications reported to have caused acute pancreatitis have obvious patterns of presentation, including the time from initiation to the development of disease (latency). There also appear to be patterns in the severity of disease. After reviewing the literature, we have classified drugs that have been reported to cause acute pancreatitis based on the published weight of evidence for each agent and the pattern of clinical presentation. Based on our analysis of the level of evidence, 4 classes of drugs could be identified. Class I drugs include medications in which at least 1 case report described a recurrence of acute pancreatitis with a rechallenge with the drug. Class II drugs include drugs in which there is a consistent latency in 75% or more of the reported cases. Class III drugs include drugs that had 2 or more case reports published, but neither a rechallenge nor a consistent latency period. Class IV drugs were similar to class III drugs, but only 1 case report had been published. Our analysis allows an evidence-based approach when suspecting a drug as causing acute pancreatitis.

Hypertriglyceridemia: its etiology, effects and treatment

Elevated plasma triglyceride concentration is a common biochemical finding, but the evidence for the benefit of treating this lipid disturbance remains less robust than that for treating elevated low-density lipoprotein-cholesterol. Part of the difficulty in the provision of specific recommendations has been the frequent coexistence of elevated triglycerides with other conditions that affect cardiovascular disease risk, such as depressed high-density lipoprotein-cholesterol, obesity, metabolic syndrome, proinflammatory and prothrombotic biomarkers, and type 2 diabetes. Recent investigations of outcomes of cardiovascular disease when medications are used to reduce triglyceride levels suggest that, although a net benefit probably exists, both relative and absolute risk reductions seem underwhelming when compared with the benefit of reducing low-density lipoprotein-cholesterol levels with treatment. However, the totality of evidence suggests that elevated triglyceride levels likely contribute independently to increased risk of cardiovascular disease, although there is no consensus about appropriate target levels. Furthermore, severe hypertriglyceridemia is associated with an increased risk of acute pancreatitis, irrespective of its effect on risk of cardiovascular disease. We review the causes and classification of elevated triglyceride levels, the clinical manifestations of primary hypertriglyceridemia and the management of patients with elevated triglyceride levels.

Clomiphene-Induced Acute Pancreatitis without Hypertriglyceridemia

Acute pancreatitis may be caused by drugs. In the literature, there are more than 260 different drugs that have been blamed for causing pancreatitis. Among these drugs, only 1 case has been reported as clomiphene-induced acute pancreatitis. However, in this single case, there was concomitant hypertriglyceridemia. We report the case of a woman who developed 2 attacks of acute pancreatitis without hypertriglyceridemia while receiving treatment with clomiphene.

Etiology, severity and recurrence of acute pancreatitis in southern taiwan

BACKGROUND/PURPOSE

Changes in lifestyle have led to variation in the etiologies of acute pancreatitis indifferent areas of Taiwan. This study investigated the etiologies and factors associated with severity and recurrence of acute pancreatitis in southern Taiwan.

METHODS

Eighty acute pancreatitis patients (M/F: 64/16), including 53 (66.2%) with alcohol abuse, 16 (20%) with biliary disease, five (6.3%) with hyperlipidemia, and six (7.5%) with other risk factors, etiologies or idiopathic disease, were included. The mean follow-up period was 20 months. Contrast-enhanced computed tomography (CT) was used to assess the severity of acute pancreatitis.

RESULTS

Biliary pancreatitis was significantly associated with females while alcoholic pancreatitis occurred predominantly in males. Univariate analysis showed that male gender, alcoholic pancreatitis, and elevated serum triglyceride (>170 mg/dL) were significantly associated with severe acute pancreatitis. Multivariate logistic regression analysis revealed that male gender and abnormal serum triglyceride were independent risk factors for severity. Alcohol abuse was an independent risk factor for recurrent pancreatitis.

CONCLUSION

Alcoholic pancreatitis was the major etiology of acute pancreatitis in southern Taiwan, exhibiting a strong male predominance and higher risk of severe CT grading. Abnormal serum triglyceride was independently associated with the severity of acute pancreatitis. Alcoholic pancreatitis had a higher risk of recurrence than other etiologies.

Plasma exchange in severe hypertriglyceridemia a clinical study

BACKGROUND

Hypercholesterolemia and hypertriglyceridemia are independent risk factors for atherosclerotic heart diseases. Moreover acute pancreatitis may occur in patients with severe hypertriglyceridemia.

AIM OF THE STUDY

To evaluate the effectiveness of plasma exchange (PE) in patients with severe hypertriglyceridemia.

METHODS

Seven patients with severe hypertriglyceridemia (a triglyceride level of more than 1000mg/dl) were treated with PE. After PE, lipid and hematological parameters and side effects were evaluated.

RESULTS

Triglyceride levels decreased below 1000mg/dl in all patients. The levels of triglyceride and very low-density lipoprotein cholesterol (p<0.05 for both), and total cholesterol (p<0.005) decreased significantly. PE was well-tolerated. Liver and renal functions, hematological parameters, except for an increase in white blood cell counts, did not change significantly.

CONCLUSION

PE may be used safely and effectively in severe hyperlipidemic patients at risk of acute coronary events and acute pancreatitis. Further extended studies may provide more detailed information.

Hyperlipidemia intensifies cerulein-induced acute pancreatitis associated with activation of protein kinase C in rats

AIM: To investigate the effects of hyperlipidemia on acute pancreatitis (AP) and the possible mechanisms.

METHODS: Rat models of hyperlipidemia and AP were established by Triton WR1339 and cerulein respectively. Human albumin was used to treat AP complicated by hyperlipidemia. In each group, we compared the histological score, volume of ascites, ratio of pancreatic wet/dry weight, serum amylase (AMY) and pancreatic acinar cell apoptosis. The level of protein kinase C (PKC) membrane translocation in pancreatic tissue was detected by Western blot.

RESULTS: In the hyperlipidemia model established by Triton WR1339, triglyceride (TG) increased remarkably and reached its peak 6 h after injection, and most rats developed mild acute pancreatitis. Histological score, volume of ascites, ratio of wet/dry weight and serum AMY in AP animals with hyperlipidemia were obviously higher than those in AP animals (P < 0.05) and decreased after albumin therapy but not significantly (P > 0.05). Apoptotic cells detected by terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling (TUNEL) increased in AP animals with hyperlipidemia and did not change distinctly after albumin therapy. PKC membrane translocation level increased in AP animals with hyperlipidemia and decreased remarkably after albumin therapy (P < 0.05).

CONCLUSION: Hyperlipidemia may induce AP or intensify pancreatic injury. Albumin therapy can not alleviate pancreatic lesion effectively. PKC activation may be one mechanism by which AP is intensified by hyperlipidemia.

Hypertriglyceridemia—why, when and how should it be treated?

The relationship between serum triglyceride levels and cardiovascular disease has remained enigmatic despite four decades of research. The majority of the available evidence tends to support the role of hypertriglyceridemia as an independent risk factor for cardiovascular disease. However, there are no guidelines recommending a target triglyceride level for prevention of cardiovascular disease. The focus of lipid lowering therapy still remains the reduction of global cardiovascular risk by optimizing LDL cholesterol levels. Therapeutic options for triglyceride-lowering include lifestyle modification and pharmacological agents, such as fibrates, omega 3 fatty acids and niacin. Post-hoc analyses of the Helsinki Heart Study, Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial and Bezafibrate Infarction Prevention Study suggest a beneficial effect of the treatment of hypertriglyceridemia with fibrates, mainly in obese subjects with insulin resistance. However, in order to establish the actual clinical relevance of lowering triglyceride levels, prospective trials need to be conducted with the specific purpose of studying the effects of triglyceride reduction on clinical end points, i. e. coronary events and stroke.

Carboxylester lipase gene polymorphism as a risk of alcohol-induced pancreatitis

OBJECTIVES

Alcohol abuse causes pancreatic damage in humans. However, only 5% of alcoholic patients have a clinical manifestation of pancreatitis, and the genetic predisposition of alcohol-associated pancreatitis remains elusive. Nonoxidative metabolites of ethanol, fatty acid ethyl esters (FAEEs), might play an important role in pancreatic damage. Carboxylester lipase (CEL) has been known to catalyze FAEE synthesis from fatty acids and ethanol.

METHODS

The variable number of tandem repeat (VNTR) polymorphism in the coding region of the CEL gene was studied in patients with alcoholic pancreatitis (n = 100), in alcoholics without pancreatitis (n = 52), in patients with nonalcoholic pancreatitis (n = 50), in hyperlipidemia patients (n = 96), and control subjects (n = 435).

RESULTS

The frequency of the NN-type (wild-type) gene was significantly decreased in patients with alcoholic pancreatitis than in other groups. The frequency of subjects who had the L allele in patients with alcoholic pancreatitis was significantly higher than in other groups. The distribution of the CEL gene polymorphism was not different among the control subjects, alcoholics without pancreatitis, patients with nonalcoholic pancreatitis, and patients with hyperlipidemia.

CONCLUSIONS

The CEL gene polymorphism, especially an increase in the frequency of the L allele, was found to be associated with alcohol-induced pancreatitis.

Therapeutic plasma exchange in patients with hyperlipidemic pancreatitis

AIM: To clarify the effectiveness of plasma exchange by comparing the mortality and morbidity before and after the intervention of plasma exchange.

METHODS: Plasma exchange has been available as an optional therapy for hyperlipidemic pancreatitis since August 1999 in our hospital. The patients were assorted into 2 groups (group I: before August 1999 and group II: after August 1999). Group I consisted of 34 patients (before the availability of plasma exchange). Group II consisted of 60 patients (after the availability of plasma exchange). Twenty patients in group II received plasma exchange after giving their consent. The mortality and morbidity were compared between group I and group II. Furthermore, the patients with severe hyperlipidemic pancreatitis (Ranson’s score ≥ 3) were analyzed separately. The mortality and morbidity were also compared between those receiving plasma exchange (group A) and those who did not receive plasma exchange (group B).

RESULTS: There was no statistical difference in the mortality, systemic and local complications between group I and group II. When the patients with severe hyperlipidemic pancreatitis were analyzed separately, there was no statistical difference between group A and group B.

CONCLUSION: Plasma exchange can not ameliorate the overall mortality or morbidity of hyperlipidemic pancreatitis. The time of plasma exchange might be the critical point. If patients with hyperlipidemic pancreatitis can receive plasma exchange as soon as possible, better result may be predicted. Further study with more cases is needed to clarify the role of plasma exchange in the treatment of hyperlipidemic pancreatitis.

Patient with gemfibrozil-controlled hypertriglyceridemia that developed acute pancreatitis after starting ketogenic diet

OBJECTIVE

To report the case of a patient with gemfibrozil-controlled hypertriglyceridemia (HTG) that developed acute pancreatitis several days after starting a high-fat ketogenic diet.

METHODS

The patient was evaluated and treated by the authors.

RESULTS

The patient denied viral prodrome or previous symptoms, ethanol consumption, or a known history of cholelithiasis. He was compliant with his gemfibrozil regimen. Clinical examination revealed a tachycardic, febrile, moderately distressed man with exquisite tenderness across the left flank and left abdomen. Laboratory studies revealed increased serum amylase (114 U/L), lipase (530 U/L) and triglyceride (>1000 mg/dL) concentrations. There was a borderline leukocytosis (12800 WBC/mm(3)). Computed tomography of the abdomen demonstrated enlargement and marked inflammatory change to the pancreas. Abdominal ultrasonography revealed no evidence of cholelithiasis or pancreatobiliary obstruction. These findings were diagnostic of HTG-induced acute pancreatitis.

CONCLUSION

Ketogenic diets may cause a substantial increase in serum triglycerides and, as a result, may precipitate HTG-induced pancreatitis in those with abnormal lipid metabolism. Patients with a history of HTG should be advised of the potentially deleterious correlation between ketogenic diets and pancreatic function.

Plasmapheresis for hyperlipidemic pancreatitis

Patients with triglyceride levels over 1,000 mg/dl are at high risk of developing acute pancreatitis. This study aimed to determine the effectiveness of plasma exchange (PE) in reducing triglyceride levels during an acute attack of hyperlipidemic pancreatitis (HLP). A total of 17 hypertriglyceridemic patients with the complication of acute pancreatitis received one course of PE treatment for one or two consecutive sessions. The respective mean removal rates during a single PE for triglyceride, cholesterol, amylase, and lipase were 66.3, 62.1, 70.0, and 84.8%, respectively. An additional one exchange increased the removal rate to 83.3, 66.2, 85.5, and 87.0%, respectively. For the two-sessions of treatment, the removal rates were higher for triglyceride (P=0.0015) and amylase with a borderline statistical significance (P=0.0641). Better triglyceride clearance correlated well with lower levels of transmembrane pressure (TMP) at 90 minutes after PE (r2=0.5782, P=0.0010) and shorter plasmapheresis duration (r2=0.2241, P=0.0427). Thirteen of seventeen patients (76.5%) recovered completely, eight patients in a single-session, and five in two-sessions. Two patients developed intra-abdominal abscess, necessitating surgical drainage and two patients died due to both septic shock and multi-organ failure. No significant predictor of clinical outcome was identified. In summary, PE treatment is an effective method to clear lipids and enzymes from plasma in a single session for most HLP patients. A greater extraction of triglyceride would result in a reduced TMP and a shorter duration of PE treatment.

Do high levels of serum triglycerides in pancreas graft recipients before transplantation promote graft pancreatitis?

OBJECTIVE

Graft pancreatitis is a serious complication following pancreas transplantation. The aim of this study was to evaluate the influence of pretransplant serum lipid levels on the development of graft pancreatitis among patients undergoing simultaneous pancreas and kidney transplantation (spkTx).

METHODS

We reviewed data from spkTx patients engrafted between 1999 and 2002. Group 1 consisted of 10 recipients with well-established pancreas and kidney graft function without postoperative pancreatitis; group 2 5 spkTx recipients who developed fatal graft pancreatitis in the first posttransplant month. The lipid parameters evaluated within 1 hour before transplantation and after hemodialysis included total cholesterol, HDL, LDL, VLDL, triglicerides and apoproteins A and B.

RESULTS

Triglycerides, apoprotein B and VLDL were significantly increased just before transplantation among patients who developed fatal pancreatitis compared to those patients with good graft function.

CONCLUSION

Recipient hypertriglyceridemia promotes graft pancreatitis in previously injured pancreatic graft.

Issues in hyperlipidemic pancreatitis

Hypertriglyceridemia (HTG) is a rare cause of pancreatitis. Pancreatitis secondary to HTG, presents typically as an episode of acute pancreatitis (AP) or recurrent AP, rarely as chronic pancreatitis. A serum triglyceride (TG) level of more than 1,000 to 2,000 mg/dL in patients with type I, IV, or V hyperlipidemia (Fredrickson's classification) is an identifiable risk factor. The typical clinical profile of hyperlipidemic pancreatitis (HLP) is a patient with a preexisting lipid abnormality along with the presence of a secondary factor (e.g., poorly controlled diabetes, alcohol use, or a medication) that can induce HTG. Less commonly, a patient with isolated hyperlipidemia (type V or I) without a precipitating factor presents with pancreatitis. Interestingly, serum pancreatic enzymes may be normal or only minimally elevated, even in the presence of severe pancreatitis diagnosed by imaging studies. The clinical course in HLP is not different from that of pancreatitis of other causes. Routine management of AP caused by hyperlipidemia should be similar to that of other causes. A thorough family history of lipid abnormalities should be obtained, and an attempt to identify secondary causes should be made. Reduction of TG levels to well below 1,000 mg/dL effectively prevents further episodes of pancreatitis. The mainstay of treatment includes dietary restriction of fat and lipid-lowering medications (mainly fibric acid derivatives). Experiences with plasmapheresis, lipid pheresis, and extracorporeal lipid elimination are limited.