Plasmapheresis in the management of acute severe hyperlipidemic pancreatitis: report of 5 cases

Evaluating the efficacy and timing of blood purification modalities in early-stage hyperlipidemic acute pancreatitis treatment

Hypertriglyceridemia-induced acute pancreatitis (HTG-AP) is characterized by a violent cytokine storm-driven inflammation and is associated with a predisposition to severe disease. The treatment strategy for HTG-AP consists mainly of conventional symptomatic and lipid-lowering treatments. For early-stage HTG-AP, blood purification (BP) can rapidly and effectively reduce serum triglyceride and inflammatory cytokine levels, block the development of systemic inflammatory response syndrome, and improve patient outcomes. Currently, the primary modalities for BP in patients with HTG-AP include plasma exchange, hemoperfusion, and hemofiltration. When using BP to treat patients with HTG-AP, a comprehensive analysis incorporating the elevated lipid levels and severity of the patient's condition contributes to the selection of different treatment modes. Moreover, the timing of the treatment is also imperative. Early intervention is associated with a better prognosis for patients with HTG-AP requiring lipid-lowering treatment.

Dysregulated SREBP1c/miR-153 signaling induced by hypertriglyceridemia worsens acute pancreatitis and delays tissue repair

Severe acute pancreatitis (AP) is a life-threatening disease with up to 30% mortality. Therefore, prevention of AP aggravation and promotion of pancreatic regeneration are critical during the course and treatment of AP. Hypertriglyceridemia (HTG) is an established aggravating factor for AP that hinders pancreatic regeneration; however, its exact mechanism remains unclear. Using miRNA sequencing and further verification, we found that miRNA-153 (miR-153) was upregulated in the pancreas of HTG animal models and in the plasma of patients with HTG-AP. Increased miR-153 aggravated HTG-AP and delayed pancreatic repair via targeting TRAF3. Furthermore, miR-153 was transcriptionally suppressed by sterol regulatory element-binding transcription factor 1c (SREBP1c), which was suppressed by lipoprotein lipase malfunction-induced HTG. Overexpressing SREBP1c suppressed miR-153 expression, alleviated the severity of AP, and facilitated tissue regeneration in vivo. Finally, therapeutic administration of insulin also protected against HTG-AP via upregulating SREBP1c. Collectively, our results not only provide evidence that HTG leads to the development of more severe AP and hinders pancreatic regeneration via inducing persistent dysregulation of SREBP1c/miR-153 signaling, but also demonstrate that SREBP1c activators, including insulin, might be used to treat HTG-AP in patients.

Evaluation of hypertriglyceridemia-induced acute pancreatitis: A single tertiary care unit experience from Turkey

BACKGROUND/AIMS

This study aimed to determine the frequency of hypertriglyceridemia (HTG)-induced acute pancreatitis (AP) and assess different clinical and prognostic features in these patients.

MATERIALS AND METHODS

The patients who were hospitalized with AP due to HTG (HTG-AP) between January 2005 and December 2014 were retrospectively evaluated in the clinic. The patients with AP due to non-HTG (non-HTG-AP) were also investigated during the same period.

RESULTS

Of 635 patients with AP admitted to the clinic, 33 (5.2%) had HTG-related AP. Mean triglyceride levels were 2653 mg/dL (range: 439-13700 mg/dL). Mean Ranson score at the time of admission was 1.5, and the APACHE II score was 4.63. The mean duration of hospitalization was 4.4 days (range: 2-14 days). One of these patients died on the sixth day of hospitalization due to multiple-organ failure. Patients with a triglyceride level of >1000 mg/dL were younger, had a longer hospital stay, and had a higher recurrence rate. Compared with non-HTG-AP, HTG-AP was observed at a younger age (57.4±17.3 vs. 37.6±14.8, p<0.05, respectively) and more frequently in males (45.2% vs. 57.6%, p<0.05, respectively). The frequency of multiple AP in patients with HTG-AP was higher than non-HTG-AP (63.4% vs. 7.6%, respectively).

CONCLUSION

HTG-AP was observed at a younger age and was responsible for most cases of recurrent pancreatitis. The duration of hospitalization was long, and the risk of recurrence and mortality were high in patients with HTG-AP having a triglyceride level >1000 mg/dL.

Conservative management in hypertriglyceridemia-associated pancreatitis

BACKGROUND

Severe hypertriglyceridemia (serum triglyceride >10 mmol L^-1 ) is implicated in ~9% of acute pancreatitis cases. Certain guidelines list severe hypertriglyceridemia as an indication for plasmapheresis.

OBJECTIVE

We assembled the natural trajectory of triglyceride levels in patients with acute pancreatitis due to severe hypertriglyceridemia who were managed conservatively without plasmapheresis to evaluate the effectiveness of this approach.

METHODS

A retrospective chart review was performed on 22 hospital admissions for acute pancreatitis episodes considered to be caused by severe hypertriglyceridemia. Patients were managed supportively, with cessation of oral intake (NPO) and intravenous hydration. Insulin infusion was used in 12 patients to manage concurrent hyperglycaemia.

RESULTS

Triglyceride levels for the group were evaluated using a mixed-effects model. The average triglyceride level fell from 45.4 mmol L^-1 on presentation to 13.3 mmol L^-1 within 48 h, corresponding to a mean 69.8% decrease. Regression analysis showed a triglyceride half-life of 30.6 h. Findings were similar for NPO-only and insulin infusion subgroups.

CONCLUSION

Patients with severe hypertriglyceridemia and acute pancreatitis can be conservatively managed safely and effectively without plasmapheresis.

Total Plasma Exchange in Hypertriglyceridemia-Induced Pancreatitis: Case Report and Literature Review

Objective

To emphasize the role of apheresis in management of pancreatitis.

Methods

The clinical course of a patient admitted for hypertriglyceridemia-induced pancreatitis (HTGP) complicated by multiorgan dysfunction is described, who demonstrated dramatic improvement in his clinical status after total plasma exchange (TPE). In addition, the current guidelines for TPE and the alternative treatment options for HTGP are also presented.

Results

A patient presenting with pancreatitis associated with severe systemic inflammatory response was admitted to our hospital with an initial triglyceride level of 1181 mg/dL. Given the patient's worsening clinical condition, he was started on TPE with a rapid fall in his serum TG levels, in turn leading to early clinical recovery.

Conclusion

Though various therapeutic options for the treatment of HTGP are described in literature, there are no set guidelines available to tackle this difficult clinical situation. TPE, albeit not very well known in this context, is one of the many therapies available. Though it leads to a rapid, precipitous fall in the TG levels and early symptom resolution, the data about the long-term morbidity as well as the effectiveness of this therapy is still lacking.

A Diabetic Patient with Abdominal Pain and Lactescent Serum

We present the case of a poorly controlled diabetic patient suffering from acute onset of abdominal pain and vomiting. A blood sample taken at the bedside revealed lactescent serum and provided an important clue to the patient's status of having severe hypertriglyceridaemia. The clinical diagnosis of hypertriglyceridaemia-induced acute pancreatitis was correctly made in the accident and emergency department. Clinical photos of the lactescent serum are shown. The incidence, risk factors and management of this particular type of acute pancreatitis are discussed.

A Retrospective Research of the Characteristic of Hypertriglyceridemic Pancreatitis in Beijing, China

Aim. To investigate the characteristic of hypertriglyceridemic- (HTG-) induced pancreatitis (HTG pancreatitis). Methods. We reviewed 126 cases of HTG pancreatitis and 168 cases of biliary pancreatitis as control. Results. The HTG group mean age was younger than biliary group. The number of females was a little higher than males in both groups. There were 18 cases that were recurrent in HTG group and 11 in billiary group. The mean hospitalization times were 13.7 ± 2.6 and 11.2 ± 2.3 days in two groups. Six patients received apheresis in HTG group. The proportion of severe AP was 31.0% and 26.2%, mortality 1.6% and 1.2%, comorbidity of diabetes mellitus (DM) 20.6% and 6.5% in two groups. The number of complications of gastrointestinal (GI) bleeding, sepsis, and multiple organ dysfunction syndrome (MODS) in HTG group and biliary group was 1, 1, and 2 versus 4, 12, and 4. Conclusions. The proportion of recurrent and severe AP and comorbidity of DM of HTG group was higher than billiary group. The proportion of the complications of GI bleeding, sepsis, and MODS of HTG group was less than biliary group. Apheresis could effectively reduce serum TG levels soon. There was no significant difference of the mortality between two groups.

Coagulopathy and the prognostic potential of D-dimer in hyperlipidemia-induced acute pancreatitis

BACKGROUND

Coagulopathy and its association with disease severity in hyperlipidemia (HL)- and non-hyperlipidemia (NHL)-induced acute pancreatitis (AP) are not clear. The present study was to evaluate the relationship between coagulation homeostasis and AP.

METHODS

This study included 106 AP patients admitted to our hospital between October 2011 and January 2013. Stratified by disease severity, the patients were divided into two groups: a mild AP (MAP) group (n=69); and a moderately severe AP (MSAP) group (n=37). Based on disease etiology, there were 31 HL-induced AP (HLP) cases and 75 NHL-induced AP (NHLP) cases. The HLP and NHLP groups were compared for parameters of coagulation homeostasis, lipid metabolism, and disease severity. Correlations between disease severity and levels of D-dimer and protein C were investigated, and the prognostic potential of D-dimer was evaluated.

RESULTS

Compared with MAP patients, MSAP patients showed higher levels of D-dimer and lower levels of protein C. HLP patients had higher protein C levels than NHLP patients. Both D-dimer and protein C levels were significantly associated with the disease severity, not the disease etiology. D-dimer levels correlated positively with low density lipoprotein cholesterol levels and performed well as a sensitive and specific predictor of disease severity in AP patients, especially in HLP patients.

CONCLUSIONS

The coagulation homeostasis is different between HLP and NHLP patients, and HL may be a contributing factor for thrombosis and fibrinolysis in HLP. D-dimer may be a robust marker of disease severity in HLP.

Early plasmapheresis in patients with severe hypertriglyceridemia induced acute pancreatitis

Hypertriglyceridemia can cause severe diseases such as acute pancreatitis (AP) and coronary artery disease. The routine management of hypertriglyceridemia is dietary restriction of fat and lipid-lowering medications to manage the secondary or precipitating causes of hypertriglyceridemia. However, in cases of AP with severe hypertriglyceridemia (SHTG) (triglycerides [TG] >1000 mg/dl) rapid reduction of TG levels to well below 1000 mg/dl can improve outcome and prevent further episodes of pancreatitis. Plasmapheresis is a therapeutic option in such medical emergencies. We discussed 2 cases of severe AP with SHTG where we used early plsmapheresis along with other supportive management.

Early plasmapheresis in patients with severe hypertriglyceridemia induced acute pancreatitis

Hypertriglyceridemia can cause severe diseases such as acute pancreatitis (AP) and coronary artery disease. The routine management of hypertriglyceridemia is dietary restriction of fat and lipid-lowering medications to manage the secondary or precipitating causes of hypertriglyceridemia. However, in cases of AP with severe hypertriglyceridemia (SHTG) (triglycerides [TG] >1000 mg/dl) rapid reduction of TG levels to well below 1000 mg/dl can improve outcome and prevent further episodes of pancreatitis. Plasmapheresis is a therapeutic option in such medical emergencies. We discussed 2 cases of severe AP with SHTG where we used early plsmapheresis along with other supportive management.

Plasmapheresis in the management of severe hypertriglyceridemia

Plasmapheresis can benefit a variety of critically ill patients. A woman with diabetic ketoacidosis and severe hypertriglyceridemia was treated with plasmapheresis when conventional treatments did not markedly reduce her triglyceridemia. The patient was admitted to a medical intensive care unit because of diabetic ketoacidosis with severe lipemia. The lipemia-associated interference in laboratory studies made treatment of electrolyte abnormalities extremely difficult. The hypertriglyceridemia was initially treated with insulin, antilipidemic medications, and heparin, but the levels of triglycerides remained elevated, delaying results of needed laboratory studies for hours. After plasmapheresis, the serum level of triglycerides decreased by 77% in less than 24 hours. Severe lipemia interferes with photometric laboratory studies, yielding an underestimation of serum levels of electrolytes. Plasmapheresis is safe, rapid, and effective for emergent management of severe hypertriglyceridemia in critically ill patients. The impact of the procedure on critical care nursing is growing as nurses become involved in the treatment and follow-up care of patients who have plasmapheresis.

Hypertriglyceridaemia-Induced Acute Pancreatitis: Is Plasmapheresis Really Indicated? 3C00

A 47-year-old man presented with severe acute pancreatitis, thought to be hypertriglyceridaemia-induced. Serum triglyceride concentration fell from 42.4 mmol/L to 5.9 mmol/L by day three with fasting alone. Hypertriglyceridaemia precipitates a small but significant proportion of acute pancreatitis episodes, especially during pregnancy. Treatment strategies are discussed, with special focus on plasmapheresis. The reduction in serum triglyceride concentration achieved by plasmapheresis is similar to that achieved by fasting alone, or in conjunction with insulin or heparin therapy. It is possible that plasmapheresis may offer the patient more harm than benefit. Currently, there is insufficient evidence to either recommend or reject plasmapheresis in triglyceride-induced acute pancreatitis.

[Multiple organ failure complicating a severe acute necrotising pancreatitis secondary of a severe hypertriglyceridemia: a case report]

We report the case of a 42-year-old man admitted for a multi-organ failure with a coma, a hemodynamic instability, a respiratory distress syndrome, an acute renal failure and a thrombocytopenia. The blood samples highlighted a milky serum and allowed to diagnose an acute pancreatitis associated with a major dyslipidemia: hypertriglyceridemia 11,800 mg/dL and hypercholesterolemia 1195 mg/dL. The CT-scans do not reveal any cerebral abnormalities but highlighted pancreatic lesions without biliary obstruction. A multi-organ failure complicating a severe acute pancreatitis secondary of a major hypertriglyceridemia was mentioned. Despite the absence of clear guidelines, a session of plasma exchange was started in emergency. Symptomatic treatment with protective ventilation, vasopressors, continuous heparin and insulin was continued. The clinical and biological course was good in parallel of the normalization of lipid abnormalities. The patient was discharged at day 17 with a lipid-lowering therapy. We discuss the various treatments available for the management of acute pancreatitis complicating a severe hypertriglyceridemia and their actual relevance in the absence of clear recommendations.

Treatment options for severe hypertriglyceridemia (SHTG): the role of apheresis

Hypertriglyceridemia is associated with a number of severe diseases such as acute pancreatitis and coronary artery disease. In severe hypertriglyceridemia (SHTG, triglycerides > 1,000 mg/dL), rapid lowering of plasma triglycerides (TG) has to be achieved. Treatment regimes include nutritional intervention, the use of antihyperlipidemic drugs, and therapeutic apheresis. Apheretic treatment is indicated in medical emergencies such as hypertriglyceridemic pancreatitis.

Reviewing the current literature, plasmapheresis appears to be a safe and useful therapeutic tool in patients suffering from SHTG. Apheretic treatment is able to remove the causative agent for pancreatic inflammation. Data suggests that the use of apheresis should be performed as early as possible in order to achieve best results. The use of plasmapheresis, however, is limited due to the rather high costs and the limited availability of the procedure.

Triglyceride levels and apolipoprotein E polymorphism in patients with acute pancreatitis

BACKGROUND

Hypertriglyceridemia is an unusual cause of acute pancreatitis and sometimes considered to be an epiphenomenon. This study aimed to investigate the clinical and analytical features and the APOE genotypes in patients with acute pancreatitis and severe hypertriglyceridemia.

METHODS

We undertook a one-year, prospective study of patients with acute pancreatitis whose first laboratory analysis on admission to the emergency department included measurement of serum triglycerides. The APOE genotype was determined and the patients answered an established questionnaire within the first 24 hours concerning their alcohol consumption, the presence of co-morbidities and any medications being taken. The patients' progression, etiological diagnosis, hospital stay and clinical and radiological severity were all recorded.

RESULTS

Hypertriglyceridemia was responsible for 7 of 133 cases of pancreatitis (5%); the remaining cases were of biliary (53%), idiopathic (26%), alcoholic (11%) or other (5%) origin. Compared with these remaining cases, the patients with hypertriglyceridemia were significantly younger, had more relapses, and more often had diabetes mellitus. They usually consumed alcohol or consumed it excessively on the days before admission. Also, the ε4 allele of the APOE gene was more common in this group (P<0.05).

CONCLUSION

One of 20 episodes of acute pancreatitis is caused by hypertriglyceridemia and it is linked to genetic (ε4 allele) and comorbid factors such as diabetes and, especially, alcohol consumption.

Plasma exchange for severe hypertriglyceridemia-induced pancreatitis in an orthotopic heart transplant recipient

We here report a 33-year old male with diabetes, hypertension and history of orthotopic heart transplantation treated by plasma exchange for severe HTG (hypertriglyceridemia) induced pancreatitis. At the time of presentation, his serum TG (triglyceride) level was 10,278 mg/dL. He underwent one of the three planned sessions of plasma exchange, resulting in a decrease in TG level from 4728 mg/dL to 1708 mg/dL. The hospital course was complicated with shock, hemorrhagic transformation of the pancreatitis and acute respiratory distress syndrome. This prevented any further plasma exchange sessions. He was subsequently discharged home in a stable state and TG level of 80 mg/dL. Plasma exchange can be safely used to manage HTG induced pancreatitis in heart transplant recipients.

Plasmapheresis to treat hypertriglyceridemia in a child with diabetic ketoacidosis and pancreatitis

A 10-year-old girl presented with diabetic ketoacidosis, shock, and severe abdominal pain. She was found to have acute pancreatitis and acute kidney injury after shock resuscitation and severe persistent hypertriglyceridemia. The severe hypertriglyceridemia was treated with 1 course of plasmapheresis, which corrected the triglyceride level and was temporally associated with improvement of the abdominal pain and renal dysfunction. Diabetes is known to contribute to an elevated triglyceride level, especially in the setting of an underlying lipid disorder. However, no such disorders were found in this patient. To the best of our knowledge, this is the first report of a pediatric patient presenting with the triad of severe hypertriglyceridemia, diabetic ketoacidosis, and pancreatitis treated successfully with plasmapheresis.

Severe hypertriglyceridemia: an indication for apheresis?

OBJECTIVE

Severe hypertriglyceridemia is associated with a number of severe complications such as acute pancreatitis. Rapid lowering of excessively elevated triglyceride (TG) levels is therefore a primary medical goal in these patients. According to previous reports, immediate apheretic treatment might be an interesting option in order to rapidly lower excessively elevated TG levels.

METHODS

A review of the current available literature was therefore conducted in order to provide an overview of the present data on apheretic treatment for patients with severe hypertriglyceridemia.

RESULTS

A single session of plasmapheresis proofs capable of lowering TG levels by up to 70%, producing clear clinical and laboratory improval. The best clinical benefit concerning reduction in morbitity and mortality can be achieved when apheresis is used as early as possible. Even repetitive use of apheresis is reported. There is controversy on technical details, such as different apheresis techniques (plasma exchange versus double-membrane filtration), slightly favoring plasma exchange.

CONCLUSIONS

In patients with severe hypertriglyceridemia plasmapheresis seems to be a safe and useful tool in rapidly lowering excessively elevated TG levels. Apheresis can be used to rapidly decrease triglyceride levels, and thus remove the causative agent for continuing damage. The indications are medical emergencies such as hypertriglyceridemic pancreatitis with excessively elevated TG levels (TG > 1000 mg/dl). If indicated, it should be used as early as possible.

The clinical outcome of elderly patients with acute pancreatitis is not different in spite of the different etiologies and severity

The aim of this study was to investigate the overall clinical characteristics of elderly patients with acute pancreatitis. We retrospectively evaluated 227 consecutively enrolled patients who were admitted with acute pancreatitis. The clinical features, the radiological and laboratory data and the clinical outcome were analyzed according to the age groups (≥ 65 years vs. <65 years). Among the 227 enrolled patients with acute pancreatitis, there were 85 elderly patients and 142 non-elderly. The mean age of the elderly patients was 72.3 ± 5.5 years and that of the non-elderly was 44.7 ± 11.7 (p<0.001). For the elderly patients, biliary pancreatitis was the most common cause (56.5%), but alcoholic pancreatitis was most common in the non-elderly patients (45.8%). Although the computed tomography (CT) severity index was significantly higher for the non-elderly patients (p<0.001), the acute physiology and chronic health evaluation (APACHE II) score was significantly higher for the elderly than that for the non-elderly (p<0.001). However, the duration of the hospital stay (10.3 ± 9.6 days vs. 11.9 ± 10.1 days, p=0.619) and mortality (3.5% vs. 0.7%, p=0.148) were not different between the age-groups. In our study, chronological age had no significant influence on the clinical outcome in spite of the different etiologies and severity of acute pancreatitis.

Therapeutic plasma exchange in patients with severe hypertriglyceridemia: a multicenter study

Extremely high plasma triglyceride (TG) concentration is a recognized risk factor for acute pancreatitis (AP). In order to evaluate the therapeutic efficacy of plasma-exchange plasmapheresis in treating patients with severe hypertriglyceridemia (sHTG), 17 patients who had not responded to conventional medical therapy (fat-free diet plus pharmaceutical interventions) were referred for therapeutic plasma exchange (TPE) in a multicenter frame case series study. Two hundred seventeen TPE sessions were performed, and therapy is ongoing for five (30%) of the patients. After treatment, the mean plasma TG and total cholesterol concentrations were significantly reduced from 1929 and 510 mg/dL, to 762 and 227 mg/dL, respectively (P < or = 0.001 in both cases). In most cases, the interval between treatments was related to the clinical presentation and individual circumstances. The removal of TG-rich lipoproteins prevented relapses of AP. In this case series, TPE is confirmed as a safe and reliable method for treating patients with refractory sHTG when a severe complication, such as AP, is clinically demonstrated or can be actively prevented. Therefore, in cases where standard medical approaches fail to promote the clearance of TGs from plasma and a high risk of first or second hypertriglyceridemic pancreatitis persists, TPE provides a therapeutic option for preventing life-threatening sHTG.

Severe hypertriglyceridemia and pancreatitis: presentation and management

PURPOSE OF REVIEW

Hypertriglyceridemia (HTG) is a well recognized cause of acute pancreatitis accounting for approximately up to 10% of all cases and even up to 50% of all cases in pregnancy. Both primary and secondary disorders of lipoprotein metabolism may be associated with hypertriglyceridemic pancreatitis (HTGP). The purpose of this review is to provide an overview of the current studies on presentation and management of HTGP.

RECENT FINDINGS/CONCLUSION

Hydrolysis of triglycerides by pancreatic lipase and formation of free fatty acids that induce inflammatory changes are postulated to account for the development of HTGP, yet the exact pathophysiology remains unclear. The clinical features of patients with HTGP are generally not different from patients with acute pancreatitis of other causes, and there is some evidence that HTGP is associated with a higher severity or a higher complication rate. There is no clear evidence as to which HTG patients will develop pancreatitis. Several studies have evaluated the effect of apheresis, the benefit of insulin and/or heparin treatment and the use of different antihyperlipidemic agents in HTGP. Dietary modifications resemble the key features in the long-term management of HTG. Whether HTG may cause chronic pancreatitis in the long-term follow-up remains controversial.

Treatment of hyperlipidemic acute pancreatitis with plasma exchange: a single-center experience

Of the cases of acute pancreatitis, 1-7% are caused by severe hypertriglyceridemia and can be treated with plasma exchange (PE). We report on a large series of patients with acute hyperlipidemic pancreatitis (HLP) treated with PE. In the 1992-2008 period, 50 patients (45 +/- 8 years old, 92% male) with acute HLP were treated with PE, during which 1-2 plasma volumes were exchanged. Heparin was used as anticoagulant in 85% of the procedures, and citrate in the rest. Cholesterol and triglycerides were measured before and after PE. In the 2003-2008 cohort of 40 patients, we retrospectively recorded an Acute Physiology and Chronic Health Evaluation II (APACHE II) score at the first PE session, hospital mortality, and length of hospital stay. A total of 79 PE treatments were done, 1-5 per patient. The volume exchanged was 4890 +/- 1300 mL over a duration of 3.5 +/- 2 h. During the first PE, the triglycerides were lowered from 58.9 +/- 40.8 to 10.8 +/- 10.8 mmol/L, and the total cholesterol was lowered from 20.0 +/- 7.6 to 5.7 +/- 4.3 mmol/L. In 10% of the procedures the plasmafilter was replaced, and in 3% the filter was clotted. Hypotension occurred in 3% of PE and there was one case of gastrointestinal bleeding after PE with heparin anticoagulation. In the 2003-2008 cohort, the median APACHE II score was 5 (range 0-15), the median overall hospital stay was 18 days (range 3-142 days) and the hospital mortality was 15%. To conclude, in acute hyperlipidemic pancreatitis, one to two plasma exchanges effectively reduce the serum triglyceride level. There is a low rate of procedure-related complications. A mortality rate of 15% is considerable.

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.

Is this the worst outcome of metabolic syndrome? Hypophosphatemia and resulting cardiac arrest during the treatment of diabetic ketoacidosis with hypertriglyceridemia

We report a case of diabetic ketoacidosis (DKA) and severe hypertriglyceridemia who developed cardiac arrest due to hypophosphatemia. He was diagnosed with diabetes and hyperlipidemia, indicating metabolic syndrome. Hypophosphatemia was caused by large insulin doses received while treating DKA, which were required because of insulin resistance owing to hypertriglyceridemia. Metabolic syndrome may have accelerated serum phosphate depletion. We suggest frequent monitoring of serum phosphate and phosphate replacement for patients with DKA and severe hypertriglyceridemia. Although such a critical condition has not been reported, it may occur during treatment of patients with poorly controlled type 2 diabetes with DKA.

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.

Severe acute pancreatitis in the elderly: Etiology and clinical characteristics

AIM: To investigate the etiology and clinical characteristics of severe acute pancreatitis (SAP) in elderly patients (≥ 60 years of age).

METHODS: We reviewed retrospectively all the SAP cases treated in Xuanwu Hospital in Beijing between 2000 and 2007.

RESULTS: In 169 patients with SAP, 94 were elderly and 16 died. Biliary and idiopathic etiologies were the first two causes that accounted for over 90% of SAP in the elderly. Biliary, hyperlipemic and alcoholic etiologies were the first three causes in the young. The proportion of co-morbidity of cholelithiasis, biliary infection, hypertension and coronary heart disease in the aged was significantly higher than that in their young partners. The scores of APACHE II and Ranson were also significantly higher in the elderly except the CT score. Organ failures were more common in the elderly, but the local pancreatic complications were not different between the two groups. Mortality of the aged was correlated with the severity of SAP, multiple co-morbidity and incidence of multiple organ dysfunction syndrome (MODS). MODS was the main cause of death.

CONCLUSION: The etiology of SAP in the elderly is quite different from that in the young. Biliary and unknown factors are main causes in the aged. The elderly are subject to major organ failures but there is no difference in the occurrence of local pancreatic complications between the elderly and the young. It is crucial to monitor and improve the functions of major organs so as to prevent MODS in the aged with SAP.

Acute pancreatitis

Acute pancreatitis is an inflammatory disease of the pancreas. Acute abdominal pain is the most common symptom, and increased concentrations of serum amylase and lipase confirm the diagnosis. Pancreatic injury is mild in 80% of patients, who recover without complications. The remaining patients have a severe disease with local and systemic complications. Gallstone migration into the common bile duct and alcohol abuse are the most frequent causes of pancreatitis in adults. About 15-25% of pancreatitis episodes are of unknown origin. Treatment of mild disease is supportive, but severe episodes need management by a multidisciplinary team including gastroenterologists, interventional radiologists, intensivists, and surgeons. Improved understanding of pathophysiology and better assessments of disease severity should ameliorate the management and outcome of this complex disease.

Non-alcoholic etiologies of acute pancreatitis - exclusion of other etiologic factors besides alcohol and gallstones

The etiology of an attack of acute pancreatitis (AP) is highly variable. It is important to identify the causing factor, because it can have an effect on the specific treatment of AP. Furthermore, in some cases relapses of AP can be prevented when the causing factor is eliminated. The most common etiology of AP is alcohol abuse and gallstone disease (>80% of all cases). What diagnostic measures should be undertaken before an attack of AP is considered as idiopathic? Important factor in the etiologic diagnostic work-up is the availability, safety, and cost-effectiveness of suitable methods. Further, the relevance of the findings has to be assessed. In some cases also the age of the patient and number of attacks of AP (first vs. recurring) have effects on efforts to detect the causing factor of AP. This review focuses on the search for other etiologic factors once alcohol and gallstones have been excluded.