Table 2. Lab results on admission
In the Emergency Department, she received 1L of Normal saline and 4mg of IV morphine for pain control. Her chest X-ray did not show any acute cardiopulmonary process. Her low troponin and absence of EKG changes rendered Acute coronary syndrome unlikely. Her urinalysis was negative for an infection. A CT Angiogram of the chest and abdomen was performed: This ruled out any aortic pathology and PE and was positive foracute pancreatitis.The patient met all three criteriaof acute pancreatitis with elevated lipase levels, epigastric pain and imaging findings of pancreatitis with elevated triglycerides confirming the diagnosis of acute pancreatitis secondary to hypertriglyceridemia. She was admitted for further management. She was kept nil per oral, and we managed her pain with oxycodone and morphine. She was able to consume a clear liquid diet a day after her presentation and was easily transitioned to a regular diet.
We started an insulin drip at a rate of 5 units/ hour intending to lower her triglycerides below 500mg/dL. Dextrose 5% half-normal saline with 40 mEq/L of Potassium was initiated at 250 ml/hr;insulin and glucose checks every 1 hour were requested for monitoring. Her electrolytes and triglycerides were monitored every four hours. After one day of being on an infusion insulin, she was transitioned tosubcutaneous glargine insulin 20 units daily.
However,8 hoursafter transitioning to subcutaneous insulin, hertriglycerides started to rise again requiring re-initiation of IV insulinand the need for an endocrinology consult. They recommended starting 20 units of subcutaneous glargine with 8 units of lispro. In addition, we restarted her fenofibrate 160 mg daily and increased her statin to 80 mg daily. Her triglycerides eventually dropped below 1000in a daybut fluctuated at levels over 500. Subsequently, she was discharged on glargine, Fenofibrate, atorvastatin, and fish oil with her triglyceride levels in the 500s with close outpatient endocrinology follow up. A further decline in triglycerides was not pursued due to concerns for hypoglycemia and reduced incidence of hypertriglyceridemia induced pancreatitis at levels in the 500s.
Her Leflunomide for Rheumatoid, Pilocarpine for Sjogren, PPI for GERDand Dicyclomine for Irritable Bowel Syndrome were resumed at discharge.