Acute Pancreatitis Induced by Diabetic Ketoacidosis with Major Hypertriglyceridemia: Report of Four Cases

Acute Pancreatitis, Hypertriglyceridemia, and Diabetic Ketoacidosis: A Life-Threatening Triad

Hypertriglyceridemia (HTG)-induced pancreatitis is a known complication of uncontrolled diabetes mellitus (DM). However, the coexistence of diabetic ketoacidosis (DKA) and acute pancreatitis in the presence of HTG is rare and presents diagnostic and therapeutic challenges. We present the case of a 42-year-old female with poorly controlled type 2 DM who developed severe HTG-induced pancreatitis complicated by DKA. She initially presented with abdominal pain, metabolic acidosis, and marked hyperglycemia. Subsequent investigations revealed significantly elevated serum triglyceride and lipase levels and characteristic findings of acute pancreatitis on imaging. This case report highlights the complex interplay of metabolic disturbances in diabetes and the importance of timely recognition and tailored management to achieve a successful outcome.

Risks associated with acute pancreatitis (AP) with diabetic ketoacidosis (DKA) in COVID-19 patients: a literature review

Background

SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) has become a global pandemic, and medical experts are scrambling to understand the wide range of symptoms and consequences of the virus. Although acute pancreatitis (AP) and pancreatic damage have been associated with SARS-CoV-2, the mechanism behind this is still unclear. The current article explores whether COVID-19 is an additional cause of AP and diabetic ketoacidosis (DKA). The article illustrates the conditions associated with AP and DKA among COVID-19 patients and diabetes mellitus (DM). Another critical condition is acute kidney injury (AKI), often associated with DKA.

Methods

A search strategy for the article was assigned and retrieved from PubMed, Web of Science, and Scopus databases from 2020 to June 2022. The articles which discussed case studies on AP, DKA, and AKI were included in the study.

Results

The present review of 24 reported case studies represented conditions of AP (12), DKA (5), AP and DKA (5), AP and AKI (1), and DKA and AKI (1) among COVID-19 participants, and showed a potential relationship between the complications.

Conclusion

Healthcare during the COVID-19 pandemic plays a major role among AP, DKA, and AKI-associated COVID-19 patients. A compilation of case studies suggests effective management of COVID-19 infection-related complications such as AP, DKA, and AKI.

Diabetic Ketoacidosis With Acute Pancreatitis in Patients With Type 2 Diabetes in the Emergency Department: A Retrospective Study

Objective

This study aims to explore the incidence and clinical features of acute pancreatitis (AP) in patients with type 2 diabetes diabetic ketoacidosis (DKA) in the emergency department and discuss the predictive value of some pathological indicators for AP in DKA.

Methods

Inpatient medical data of DKA patients hospitalized to our hospital's emergency department between January 2017 and January 2021 were evaluated retrospectively. These DKA patients were split into two groups based on whether they had AP or not. We examined the two groups' epidemiologic features, baseline laboratory results, and clinical outcomes. The Bedside Index for Sequential Organ Failure Assessment (SOFA), Acute Physiology and Chronic Health Evaluation II (APACHE II), and Logistic Organ Failure System (LODS) scores were computed and compared across groups.

Results

The prevalence of AP in DKA patients was 15.53%. The difference in Abdominal pain between the two groups of patients was statistically significant (p < 0.001), and there was no statistical difference in age, gender, and BMI. The DKA and AP group LOS (P < 0.001), ICU admission rate (P = 0.046), anion gap (P < 0.001), red blood cell (P = 0.002), hemoglobin (P < 0.001), hematocrit (P = 0.002), serum triglyceride (P < 0.001), serum cholesterol (P < 0.001), serum amylase (P = 0.004), random glucose (P = 0.028), plasma fibrinogen (P < 0.001), glycosylated hemoglobin [HbA1c (%); P = 0.008] higher than the DKA group, pH (P < 0.001), carbon dioxide combining power (CO2CP; P < 0.001), ionized calcium (Ca2+; P = 0.022), ionized sodium (Na+; P = 0.001), and correction Na (P = 0.034) lower than the DKA group. Multivariate analysis showed that low pH (P < 0.05), hypertriglyceridemia (P = 0.001), and hypercholesterolemia (P = 0.01) were risk factors for DKA combined with AP. ROC curve analysis showed that the three cut-off value: serum triglycerides of 10.52 mmol/L, serum cholesterol of 9.03 mmol/L, and pH of 7.214. Serum triglyceride has the largest area under the curve (0.93). Under this cut-off value, the sensitivity (80%) and specificity of serum triglyceride, the degree (93.7%) is the highest, while the positive predictive value (62.0%) and negative predictive value (94.7%) of serum cholesterol are the highest.

Conclusions

A severe episode of DKA with significant acidosis and hyperlipidemia is more likely to be linked with AP. The frequently used critical illness score is ineffective in determining the severity of the condition. When the serum triglyceride cut-off value is 10.52mmol/L, it has a higher predicted value for AP in DKA.

Dapagliflozin-Associated Euglycemic Diabetic Ketoacidosis in a Patient Who Underwent Surgery for Pancreatic Carcinoma: A Case Report

Diabetic ketoacidosis (DKA), an acute and life-threatening complication of diabetes, is a metabolic disorder caused by insulin deficiency and an increase in counter-regulatory hormones. Several cases of DKA without marked hyperglycemia have been reported and are defined as euglycemic DKA (eu-DKA). The use of sodium-glucose cotransporter 2 inhibitors (SGLT2is) is associated with the occurrence of eu-DKA, of which, dapagliflozin is one of the agents. In this study, we report a case of dapagliflozin-associated eu-DKA following surgery for pancreatic carcinoma. A 57-year-old woman presented with acute abdominal pain after surgery for pancreatic carcinoma. Emergency exploratory laparotomy was performed because of suspicion of gastrointestinal perforation based on a CT scan. The surgeons observed that the stomach was significantly dilated but not perforated. Meanwhile, the patient developed shock and severe acidosis. A further examination confirmed the diagnosis of dapagliflozin-associated eu-DKA. We reviewed the precipitating factors and mechanisms of SGLT2i-associated eu-DKA and discussed the treatment and prevention of this condition. Clinicians need to be alert of the occurrence of SGLT2i-associated eu-DKA in patients treated with this drug in the perioperative period.

[Prediction and diagnosis of pancreatogenic encephalopathy in patients with destructive pancreatitis]

OBJECTIVE

To study the literature data on pancreatogenic encephalopathy in patients with destructive pancreatitis.

MATERIAL AND METHODS

Searching for Russian- and English-language literature data was carried out in electronic databases: elibrary, PubMed, the Cochrane Library. We planned a systematic review if studies with evidence level 1 and 2 were available. If these trials were absent, descriptive review was considered.

RESULTS

No studies with evidence level 1 and 2 were found in available literature. Therefore, a descriptive review was carried out. Analysis of primary sources showed that the incidence of pancreatogenic encephalopathy is 9-35% and has no direct correlation with etiology of destructive pancreatitis. Major factors of pathogenesis are high serum enzymes, activation of proinflammatory cytokines and hypoxemia, which are accompanied by damage to myelin sheath of the white matter and cytotoxic brain edema. Clinical manifestation of pancreatogenic encephalopathy occurs within two weeks. Acute onset and various symptoms are typical. Possible laboratory predictors of encephalopathy are persistent hyperglycemia, increased hematocrit, fibrinogen-like protein 2 (FPB-2), proinflammatory cytokines TNF-αand interleukin-1-beta. Pancreatogenic encephalopathy is a factor of unfavorable prognosis of treatment. Mortality in patients with pancreatogenic encephalopathy is 57-70%. Favorable course of pancreatic necrosis is followed by regression of cerebral disorders in most cases while residual cognitive disorders are possible in elderly patients.

CONCLUSION

Pancreatogenic encephalopathy accompanies severe destructive pancreatitis. It is an unfavorable factor for treatment outcomes requiring further research.

Comparison of the Development and Prognosis in Patients of Hypertriglyceridemic Pancreatitis with and without Diabetes

Aim

To investigate the clinical features and prognosis in patients of hyperlipidemic acute pancreatitis with or without diabetes.

Methods

157 patients with hypertriglyceridemic pancreatitis (HTGP) were included in this study. Patients with a previous history of diabetes were identified in the group of HTGP with diabetes (HTGPD), while patients without a history of diabetes were identified in the group of HTGP. The clinical characteristics and prognosis data of these patients in the two groups were analyzed.

Results

Multivariate Cox regression analysis showed that age, body mass index, glycated serum protein (GSP), and Acute Physiology and Chronic Health Evaluation (APACHE) II score were significantly associated with mortality in patients with HTGP. The mortality was significantly higher in the HTGPD group than in the HTGP group (p < 0.001). Compared to patients of HTGP, those of HTGPD had older age of onset, higher blood glucose levels, and higher GSP levels on admission. Electrocardiograms showed that patients of HTGPD had a significantly higher risk of heart ischemia than those of HTGP (p < 0.05). Patients of HTGPD had higher APACHE II scores than those of HTGP (p < 0.001). Single-factor analysis showed that higher triglyceride levels, GSP, LDL, and previous history of diabetes were associated with HTGP recurrence.

Conclusions

Clinicians should be alert to patients of HTGP with diabetes. Diabetes is an important risk factor for HTGP and hyperglycemia may affect the development and prognosis of HTGP.

Plasmapheresis as an Early Treatment for Severe Hypertriglyceridemia, Acute Pancreatitis, and Diabetic Ketoacidosis

Objective

Severe hypertriglyceridemia (SHTG; plasma triglycerides >1000 mg/dL) is a rare but serious complication in children who develop diabetic ketoacidosis (DKA) from uncontrolled or new-onset type 1 diabetes.

Methods

We present the case of a severely malnourished 16-year-old with a 10-month history of presumed type 2 diabetes managed with lifestyle modifications and metformin, who presented with SHTG, acute pancreatitis, and DKA. On examination, there was no evidence of lipemia retinalis, cutaneous xanthomas, or xanthelasma. He was initially treated with an insulin infusion and intravenous fluids. Despite this treatment, his pancreatitis symptoms worseneed and lipase level increased, necessitating 2 courses of plasmapheresis that immediately resolved his symptoms and dramatically improved his clinical status. He was discharged on hospital day 5. During his hospital admission, islet cell antigen 512, insulin, glutamic acid decarboxylase 65, and zinc transporter 8 autoantibodies were positive in the presence of insulinopenia, consistent with type 1 diabetes.

Results

Hypertriglyceridemia and hypercholesterolemia did not recur during follow-up, suggesting that the underlying mechanism for SHTG was insulin deficiency.

Conclusion

This report of SHTG, DKA, and pancreatitis in an adolescent highlights the safe, early initiation of plasmapheresis as an effective treatment. To our knowledge, plasmapheresis has rarely been used so early in the course of treatment for an adolescent with SHTG, DKA, and acute pancreatitis.

A Fatal Case of Hypertriglyceridemia-Induced Acute Pancreatitis in a Patient With Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) with coexisting hypertriglyceridemia-induced acute pancreatitis is a rare yet potentially life-threatening condition. This report describes a patient with no history of diabetes who presented with DKA and coexisting acute pancreatitis secondary to severe hypertriglyceridemia. The patient did not respond to standard DKA management or plasmapheresis, developed acute respiratory distress syndrome (ARDS), and eventually expired.