A 43-year-old woman comes to the emergency department due to a 2-day history of nausea, vomiting, and epigastric pain. The pain is stabbing in character and radiates to her back. She also feels dizzy and weak but has not experienced shortness of breath, skin rash, constipation, abdominal trauma, headache, or fever. The patient's medical history is notable for hyperlipidemia and hypothyroidism, but she has not seen a physician in the past year. Current medications include levothyroxine, hydrochlorothiazide, and metoprolol. The patient has smoked a pack of cigarettes daily for 20 years and usually drinks 1 or 2 cans of beer a day, but she has been drinking more during the last few weeks due to a stressful relationship with her boyfriend.
Temperature is 37.2 C (99 F) , blood pressure is 90/60 mm Hg, pulse is 112/min, and respirations are 20/min. Oxygen saturation is 97% on room air. BMI is 30 kg/m². On examination, the patient appears to be in moderate distress due to pain. Mucous membranes are dry. Abdominal examination shows epigastric tenderness with mild guarding. The liver is palpable 2 cm below the costal margin. There is no splenomegaly. The remainder of the physical examination is unremarkable.
Laboratory results are as follows:
Abdominal radiograph is unremarkable. Abdominal ultrasound shows an enlarged, hypoechoic pancreas and a normal gallbladder. The common bile duct size is normal. The liver is enlarged and diffusely hyperechoic.
The patient's pain and blood pressure improve with intravenous fentanyl and a 1-L normal saline bolus.
Which of the following is the best additional therapy for this patient at this time?

Question

A 43-year-old woman comes to the emergency department due to a 2-day history of nausea, vomiting, and epigastric pain. The pain is stabbing in character and radiates to her back. She also feels dizzy and weak but has not experienced shortness of breath, skin rash, constipation, abdominal trauma, headache, or fever. The patient's medical history is notable for hyperlipidemia and hypothyroidism, but she has not seen a physician in the past year. Current medications include levothyroxine, hydrochlorothiazide, and metoprolol. The patient has smoked a pack of cigarettes daily for 20 years and usually drinks 1 or 2 cans of beer a day, but she has been drinking more during the last few weeks due to a stressful relationship with her boyfriend.
Temperature is 37.2 C (99 F) , blood pressure is 90/60 mm Hg, pulse is 112/min, and respirations are 20/min. Oxygen saturation is 97% on room air. BMI is 30 kg/m². On examination, the patient appears to be in moderate distress due to pain. Mucous membranes are dry. Abdominal examination shows epigastric tenderness with mild guarding. The liver is palpable 2 cm below the costal margin. There is no splenomegaly. The remainder of the physical examination is unremarkable.
Laboratory results are as follows:

Abdominal radiograph is unremarkable. Abdominal ultrasound shows an enlarged, hypoechoic pancreas and a normal gallbladder. The common bile duct size is normal. The liver is enlarged and diffusely hyperechoic.
The patient's pain and blood pressure improve with intravenous fentanyl and a 1-L normal saline bolus.
Which of the following is the best additional therapy for this patient at this time?

Quizplus · Accepted Answer

11ec193a_97b0_b303_853d_ed037b4ac9ce_MD0002_00 This patient has acute pancreatitis, likely due to hypertriglyceridemia. Pancreatitis can occur in primary (inherited) or acquired hypertriglyceridemia, and the risk increases with pregnancy, alcohol intake, obesity, and uncontrolled diabetes. The risk increases across all levels of hypertriglyceridemia, but most cases occur in patients with visibly lipemic serum and triglyceride levels >1000 mg/dL. Initial management is similar to pancreatitis of other causes, and includes nothing by mouth, aggressive hydration, and pain control. In addition, moderate to severe hypertriglyceridemia-induced pancreatitis (eg, triglycerides >1000 mg/dL, lipase ≥3 times the upper limit of normal, evidence of organ dysfunction) requires rapid lowering of serum triglyceride levels. If blood glucose levels are very high (≥500 mg/dL), an insulin infusion (with intravenous glucose to prevent hypoglycemia when glucose falls below 200 mg/dL) can correct triglyceride levels within 3-4 days (by enhancing lipoprotein lipase activity). However, if glucose is <500 mg/dL or pancreatitis is severe (eg, lactic acidosis, acute kidney injury, hypocalcemia) as in this patient, therapeutic plasma exchange apheresis should be considered to quickly lower triglyceride levels. If blood glucose levels are very high (≥500 mg/dL), an insulin infusion (with intravenous glucose to prevent hypoglycemia when glucose falls below 200 mg/dL) can correct triglyceride levels within 3-4 days (by enhancing lipoprotein lipase activity). However, if glucose is <500 mg/dL or pancreatitis is severe (eg, lactic acidosis, acute kidney injury, hypocalcemia) as in this patient, therapeutic plasma exchange apheresis should be considered to quickly lower triglyceride levels. (Choice A) Once the patient has been stabilized, long-term management should include dietary fat restriction and triglyceride-lowering medication (eg, gemfibrozil). However, these medications would not lower lipids rapidly enough to avoid further pancreatic injury. (Choice B) Heparin lowers serum triglyceride levels by stimulating release of lipoprotein lipase by endothelial cells. However, the effect is small and transient, and there is concern that the increased production of free fatty acids may worsen the inflammatory injury. (Choice C) Mild triglyceride-induced pancreatitis (ie, triglycerides <1000 mg/dL, lipase <3 times the upper limit of normal, normal calcium level, no evidence of end-organ damage) can sometimes be managed conservatively, and triglyceride levels will fall gradually while the patient is fasting. However, this patient has clinical features (eg, hypocalcemia, acute kidney injury) that warrant more aggressive management. (Choice E) Ultrafiltration and hemodialysis will not remove larger molecules and lipoproteins and therefore will not be useful in this patient. Educational objective: Moderate to severe hypertriglyceridemia-induced pancreatitis requires rapid lowering of serum triglyceride levels. If blood glucose is very high (≥500 mg/dL), an insulin infusion can correct triglyceride levels within 3-4 days. However, if glucose is <500 mg/dL or pancreatitis is severe (eg, lactic acidosis, hypocalcemia), therapeutic plasma exchange apheresis should be considered. __________ References: Acute pancreatitis secondary to severe hypertriglyceridemia: management of severe hypertriglyceridemia in emergency setting. (http://www.ncbi.nlm.nih.gov/pubmed/28725307)

A 43-Year-Old Woman Comes to the Emergency Department Due to a 2-Day