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Samarasinghe S, Avari P, Meeran K, Cegla J. Management of hypertriglyceridaemic pancreatitis in the acute setting and review of literature. BMJ Case Rep 2018; 11:11/1/e227594. [PMID: 30567142 DOI: 10.1136/bcr-2018-227594] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Acute pancreatitis (AP) is a potentially life-threatening complication of severe hypertriglyceridaemia, which is the third most common cause of AP after gallstone disease and alcohol excess. Standard therapy involves the use of lipid-lowering agents, low-molecular-weight heparin and insulin infusion. In some cases, when standard medical therapies fail, non-pharmacological methods based on the removal of triglycerides with therapeutic plasma exchange can provide positive results in the acute phase. There are currently no guidelines covering management in the acute phase, however, these approaches should be considered in severe or very severe hypertriglyceridaemia. Here, we report the case of a 37-year-old man with recurrent AP due to hypertriglyceridaemia and review the literature.
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Affiliation(s)
| | - Parizad Avari
- Division of Diabetes Endocrinology and Metabolism, Faculty of Medicine, Imperial College London, London, UK
| | - Karim Meeran
- Division of Diabetes Endocrinology and Metabolism, Faculty of Medicine, Imperial College London, London, UK
| | - Jaimini Cegla
- Division of Diabetes Endocrinology and Metabolism, Faculty of Medicine, Imperial College London, London, UK
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Kuchay MS, Farooqui KJ, Bano T, Khandelwal M, Gill H, Mithal A. Heparin and insulin in the management of hypertriglyceridemia-associated pancreatitis: case series and literature review. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2017; 61:198-201. [PMID: 28225998 PMCID: PMC10118862 DOI: 10.1590/2359-3997000000244] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 10/18/2016] [Indexed: 11/22/2022]
Abstract
Severe hypertriglyceridemia accounts for up to 7% of all cases of acute pancreatitis. Heparin and insulin activate lipoprotein lipase (LPL), thereby reducing plasma triglyceride levels. However, the safety and efficacy of heparin and insulin in the treatment of hypertriglyceridemia-associated acute pancreatitis have not been well established yet. We successfully used heparin and insulin as first-line therapy in four consecutive patients with acute pancreatitis secondary to hypertriglyceridemia. In a literature search, we revised almost all reports published to date of patients managed successfully with this combination. Heparin and insulin appear to be a safe, effective, and inexpensive first-line therapy for hypertriglyceridemia-associated acute pancreatitis.
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Affiliation(s)
| | | | - Tarannum Bano
- Division of Endocrinology and Diabetes, Medanta, India
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Curd R, Crook MA. Causes of hypoamylasaemia in a hospital population. Scandinavian Journal of Clinical and Laboratory Investigation 2015. [PMID: 26203959 DOI: 10.3109/00365513.2015.1060520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AIMS We noted serum amylase activity results in our laboratory that fell below the lower reference limit, although there was no obvious explanation for this and the literature on this topic is relatively sparse. METHODS We studied hospital laboratory requests and reports of individuals showing hypoamylasaemia over a one-year period. RESULTS We report one of the few studies to look at hypoamylasaemia in a hospital population. We found that 5.4% of the hospital serum amylase activity results were below the reference range quoted by our laboratory. CONCLUSIONS Some of the associations we observed with hypoamylasaemia were diabetes mellitus, cystic fibrosis, hypertriglyceridaemia and use of the antibiotic gentamicin. We suggest that clinicians and laboratories should be aware of the causes of hypoamylasaemia to aid interpretation of abnormally low amylase activity in their patients.
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Affiliation(s)
- Rachel Curd
- a Department of Clinical Biochemistry , Lewisham Hospital NHS Trust , SE London, UK and St Thomas' Hospitals, London SE1 9RT UK
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Hypertriglyceridemia induced pancreatitis (chylomicronemia syndrome) treated with supportive care. Case Rep Crit Care 2014; 2014:767831. [PMID: 25506434 PMCID: PMC4259136 DOI: 10.1155/2014/767831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 11/09/2014] [Accepted: 11/09/2014] [Indexed: 02/07/2023] Open
Abstract
Hypertriglyceridemia is a rare cause of pancreatitis. In treatment pancreatic rest, lifestyle changes, medications (fibrates, n-3 polyunsaturated fatty acids, and nicotinic acid) are essential. Many experimental treatment modalities have been reported as insulin and heparin infusion and plasmapheresis. In this study we present the hypertriglyceridemia-induced pancreatitis treated with supportive care.
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Parker VER, Semple RK. Genetics in endocrinology: genetic forms of severe insulin resistance: what endocrinologists should know. Eur J Endocrinol 2013; 169:R71-80. [PMID: 23857978 PMCID: PMC4359904 DOI: 10.1530/eje-13-0327] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
'Insulin resistance' (IR) is a widely used clinical term. It is usually defined as a state characterised by reduced glucose-lowering activity of insulin, but it is also sometimes used as a shorthand label for a clinical syndrome encompassing major pathologies such as type 2 diabetes, polycystic ovary syndrome, fatty liver disease and atherosclerosis. Nevertheless, the precise cellular origins of IR, the causal links among these phenomena and the mechanisms underlying them remain poorly understood or contentious. Prevalent IR usually results from a genetic predisposition interacting with acquired obesity; however, even in some lean individuals, very severe degrees of IR can be observed. It is important to identify these people as they often harbour identifiable single-gene defects and they may benefit from molecular diagnosis, genetic counselling and sometimes tailored therapies. Observation of people with known single-gene defects also offers the opportunity to make inferences about the mechanistic links between IR and common pathologies. Herein, we summarise the currently known monogenic forms of severe IR, with an emphasis on the practical aspects of their recognition, diagnosis and management. In particular, we draw distinctions among the biochemical subphenotypes of IR that arise from primary adipose tissue dysfunction or from primary insulin signalling defects and discuss the implications of this dichotomy for management.
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Affiliation(s)
- Victoria E. R. Parker
- The University of Cambridge Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, UK
| | - Robert K. Semple
- The University of Cambridge Metabolic Research Laboratories, Institute of Metabolic Science, Cambridge, UK
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Henderson SR, Maitland R, Mustafa OG, Miell J, Crook MA, Kottegoda SR. Severe hypertriglyceridaemia in Type 2 diabetes mellitus: beneficial effect of continuous insulin infusion. QJM 2013; 106:355-9. [PMID: 23417910 DOI: 10.1093/qjmed/hcs238] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Severe hypertriglyceridaemia is a recognized complication of Type 2 diabetes mellitus (T2DM); however, there is no consensus on acute management despite the significant risk of developing associated complications such as acute pancreatitis and hyperviscosity syndrome. AIM To identify the association between hyperglycaemia and severe hypertriglyceridaemia in patients with T2DM and assess the effect of continuous insulin infusion therapy on serum triglyceride (TG) concentrations and report any adverse events associated with this therapeutic approach. DESIGN Retrospective review of case records. METHODS Patients with uncontrolled hyperglycaemia and severe hypertriglyceridaemia (serum TG > 15 mmol/l) treated with continuous intravenous insulin infusion between October 2008 and September 2009 were retrospectively evaluated (n = 15). Details recorded included demographics, admission details, lipid profiles, glycaemic control, serum amylase and adverse events. Patients receiving treatment-dose unfractionated heparin infusion were excluded. RESULTS Severe hypertriglyceridaemia is associated with hyperglycaemia in our heterogeneous group of patients with T2DM presenting with new-onset diabetes or established disease on pre-existing insulin or oral hypoglycaemic agents. Administration of continuous exogenous insulin not only achieved normoglycaemia but also dramatically corrected severe hypertriglyceridaemia in all patients (P = 0.001). CONCLUSION The administration of continuous insulin in patients with T2DM with severe hypertriglyceridaemia is a simple and safe method of significantly reducing the immediate risk associated with this metabolic complication and should be considered in any T2DM patient presenting with severe hypertriglyceridaemia and hyperglycaemia.
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8
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Walker P, Crook M. Lipaemia: Causes, consequences and solutions. Clin Chim Acta 2013; 418:30-2. [DOI: 10.1016/j.cca.2012.12.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 12/20/2012] [Accepted: 12/29/2012] [Indexed: 10/27/2022]
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Argula RG, Strange C, Budisavljevic MN. Multiorgan system dysfunction in the chylomicronemia syndrome. J Intensive Care Med 2013; 29:175-8. [PMID: 23753228 DOI: 10.1177/0885066613475425] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe an extreme presentation of the chylomicronemia syndrome resulting in multiorgan system dysfunction. PATIENT A 40-year-old African American male with no past medical history presented with multiorgan system dysfunction manifested by acute respiratory failure and acute kidney injury. He was noted to have very-high triglyceride levels (>5000 mg/dL) at admission. INTERVENTIONS An echocardiogram showed normal cardiac function. Amylase and lipase were normal. We confirmed the chylomicronemia syndrome with a triglyceride assay. The associated hyperviscosity was treated with plasmapheresis to reduce the plasma triglyceride level. RESULTS After 3 sessions of plasmapheresis, his triglyceride levels were significantly reduced, his oxygenation improved, and his acute kidney injury resolved. He was successfully extubated on day 7 of the intensive care unit stay. His diabetes and hypertriglyceridemia were newly diagnosed and drug therapy was instituted with home discharge on day 14. CONCLUSIONS Severe chylomicronemia can cause multiorgan system dysfunction related to hyperviscosity. Early institution of plasmapheresis to reduce the triglyceride-rich lipoproteins can improve tissue perfusion and prevent further organ damage.
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Affiliation(s)
- Rahul G Argula
- Division of Pulmonary & Critical Care Medicine, Medical University of South Carolina, Charleston, SC, USA
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Schaefer EW, Leung A, Kravarusic J, Stone NJ. Management of severe hypertriglyceridemia in the hospital: a review. J Hosp Med 2012; 7:431-8. [PMID: 22128096 DOI: 10.1002/jhm.995] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Revised: 09/14/2011] [Accepted: 09/29/2011] [Indexed: 01/08/2023]
Abstract
For hospitalists, hypertriglyceridemia (HTG) is more than cardiovascular risk. Severe HTG occurs when serum triglycerides rise above 1000 mg/dL, and it carries a risk of abdominal pain and pancreatitis. The etiology of severe HTG is usually a combination of genetic and secondary factors. A detailed history with attention to family history, medications, and alcohol consumption can often lead to the cause. Physical examination findings may stretch across multiple organ systems. Patients with severe HTG should be admitted to the hospital for aggressive medical therapy if they develop symptoms such as abdominal pain or pancreatitis. Asymptomatic patients with severe HTG who have significant short-term risk for developing symptoms require urgent consultation that may lead to a brief hospitalization to address exacerbating factors. Treatment of severe HTG includes a combination of pharmacologic agents and a restriction on dietary triglyceride intake. If oral medications fail to adequately lower triglyceride levels, intravenous insulin and in rare cases therapeutic plasma exchange may be required. To prevent recurrent severe HTG, the patient should be counseled about adherence to long-term medications and lifestyle changes.
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Affiliation(s)
- Eric W Schaefer
- Division of Hospital Medicine, Northwestern University, Chicago, Illinois, USA.
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Lashkari HP, Lancaster D, Atra A, Champion MP, Taj MM. Symptomatic severe hypertriglyceridaemia with asparaginase therapy in acute lymphoblastic leukaemia (ALL) and lymphoblastic lymphoma: is rechallenging safe? Int J Hematol 2011; 94:571-5. [DOI: 10.1007/s12185-011-0966-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Revised: 10/17/2011] [Accepted: 10/20/2011] [Indexed: 01/19/2023]
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Munigoti SP, Rees A. Hypertriglyceridaemia, LPL deficiency and pancreatitis -pathogenesis and therapeutic options. ACTA ACUST UNITED AC 2011. [DOI: 10.1177/1474651411413192] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Severe hypertriglyceridaemia (HTG) is recognised as the third most common cause of acute pancreatitis. While secondary causes of HTG such as excess alcohol, obesity and diabetes are well recognised, identification and treatment of primary genetic disorders such as lipoprotein lipase (LPL) deficiency remain a challenge. HTG secondary to such genetic disorders does not respond to established medical therapy, resulting in recurrent episodes of acute pancreatitis. A very low fat diet remains first-line therapy in the treatment of severe HTG secondary to LPL deficiency, and in resistant cases insulin, heparin and plasma apheresis are used with some success. Viral vector-delivered gene therapy is a novel treatment option that is currently being tested in patients with LPL deficiency with promising results.
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Affiliation(s)
| | - Alan Rees
- University Hospital of Wales, Cardiff, UK,
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Tsuang W, Navaneethan U, Ruiz L, Palascak JB, Gelrud A. Hypertriglyceridemic pancreatitis: presentation and management. Am J Gastroenterol 2009; 104:984-91. [PMID: 19293788 DOI: 10.1038/ajg.2009.27] [Citation(s) in RCA: 266] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Wayne Tsuang
- Department of Internal Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
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Lerch MM, Zenker M, Turi S, Mayerle J. Developmental and metabolic disorders of the pancreas. Endocrinol Metab Clin North Am 2006; 35:219-41, vii. [PMID: 16632089 DOI: 10.1016/j.ecl.2006.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The pancreas is an important exocrine and endocrine organ that develops from the dorsal and ventral anlagen during embryogenesis and arises from the endodermal lining of the duodenum within the first month of human embryonic life. A number of developmental disorders can either lead to anatomic abnormalities of the pancreas and its ducts, or can be part of complex disorders that affect multiorgan systems. Other genetic changes can lead to metabolic abnormalities that affect the pancreas exclusively or increase the lifetime risk for developing pancreatitis or pancreatic diabetes. This article reviews some of the developmental and metabolic disorders that can affect the endocrine and exocrine pancreas.
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Affiliation(s)
- Markus M Lerch
- Department of Gastroenterology, Endocrinology and Nutrition, Ernst-Moritz-Arndt-University, Friedrich-Loeffler-Strasse 23A, Greifswald 17485, Germany.
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Mikhail N, Trivedi K, Page C, Wali S, Cope D. Treatment of severe hypertriglyceridemia in nondiabetic patients with insulin. Am J Emerg Med 2005; 23:415-7. [PMID: 15915436 DOI: 10.1016/j.ajem.2005.02.036] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Birlik M, Demir T, Zeybel M, Akar S, Onen F, Comlekci A, Tunca M, Akkoc N. A case of recurrent pancreatitis due to hyperlipidemia misdiagnosed as familial Mediterranean fever. Clin Rheumatol 2005; 23:559-61. [PMID: 15801080 DOI: 10.1007/s10067-004-0922-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Familial Mediterranean fever (FMF) is prevalent among Arabic, Turkish, Armenian, and Jewish people and it must always be considered in the differential diagnosis of patients from these ethnic groups presenting with recurrent abdominal pain with fever. In cases of fever and recurrent abdominal pain, acute pancreatitis is an important clinical condition, which should be considered in the differential diagnosis. Serum amylase concentration in acute pancreatitis is usually more than three times the upper limit of normal. However, in recurrent pancreatitis secondary to hypertriglyceridemia, serum amylase levels, for reasons that are not well understood, may be normal or mildly elevated. Recurrent pancreatitis secondary to hypertriglyceridemia may thus pose a problem in the differential diagnosis and may lead to an erroneous diagnosis of FMF. Measurement of serum triglyceride along with amylase levels should be required for a suspected diagnosis. Computerized examination of the abdomen may need to be undertaken to exclude acute pancreatitis in the presence of hypertriglyceridemia since serum amylase levels may be normal or slightly elevated.
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Wager E. Experiences of the BMJ ethics committee. BMJ 2004; 329:510-2. [PMID: 15612090 PMCID: PMC515212 DOI: 10.1136/bmj.329.7464.510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2004] [Indexed: 11/04/2022]
Abstract
The BMJ established its ethics committee nearly four years ago. What has it achieved and has it changed the journal's practice?
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van Walraven LA, de Klerk JBC, Postema RR. Severe acute necrotizing pancreatitis associated with lipoprotein lipase deficiency in childhood. J Pediatr Surg 2003; 38:1407-8. [PMID: 14523833 DOI: 10.1016/s0022-3468(03)00409-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
An 11-year-old girl with lipoprotein lipase deficiency experienced recurring episodes of abdominal pain. She initially underwent appendectomy for suspected appendicitis; however, the appendix was normal. Pancreatitis was subsequently identified as the cause of her pain.
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Affiliation(s)
- L A van Walraven
- Department of General Surgery, Academic Hospital Dijkzigt, Rotterdam, The Netherlands
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Simon P, Weiss FU, Zimmer KP, Koch HG, Lerch MM. Acute and chronic pancreatitis in patients with inborn errors of metabolism. Pancreatology 2002; 1:448-56. [PMID: 12120223 DOI: 10.1159/000055846] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Acute and chronic recurrent pancreatitis have been reported in patients with a variety of inborn errors of metabolism. Among these are hyperlipidaemias, various disorders of branched-chain amino acid degradation, homocystinuria, haemolytic disorders, acute intermittent porphyria and several amino acid transporter defects. Some of these disease entities are exceedingly rare. In most of these disorders, pancreatitis is not very common and, with the exception of lipoprotein lipase and apolipoprotein C-II deficiency, is neither the leading nor the clinically most distressing manifestation of the underlying metabolic defect. The majority of these syndromes are, however, inherited, and often entire kindreds are carriers of well-defined germline mutations that can, to varying degrees, be associated with pancreatitis. We have reviewed the clinical, biochemical and genetic characteristics of those inborn errors of metabolism because interesting information can be gained from the in regard to the pathophysiology of pancreatitis and because they need to be distinguished from other hereditary causes of the disease.
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Affiliation(s)
- P Simon
- Departments of Medicine B and Pediatrics, Westfälische Wilhelms-Universität, Münster, Albert-Schweitzer-Strasse 33, D-48129 Münster, Germany
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20
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Raza MN, Tikkisetty B, Lagattolla N, Taylor JE. Rash, abdominal pain and hyponatraemia. Scott Med J 2001; 46:184-5. [PMID: 11852634 DOI: 10.1177/003693300104600610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Hypertriglyceridaemia is a rare precipitant of acute pancreatitis. We present a patient with acute pancreatitis and hyponatraemia in association with severe hyperlipidaemia, predominantly hypertriglyceridaemia. The patient was successfully treated with plasma exchange therapy.
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Affiliation(s)
- M N Raza
- Renal Unit and Department of Surgery, Dorset County Hospital, Dorchester
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