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.