A 30-year-old woman comes to the emergency department due to 12 hours of severe abdominal pain, which radiates to her back and is associated with nausea and vomiting. She has no chronic medical conditions. There is no family history of premature coronary artery disease. She does not use tobacco or alcohol. Temperature is 37.7 C (99.9 F), blood pressure is 120/90 mm Hg, pulse is 85/min, and respirations are 18/min. BMI is 34 kg/m². The abdomen is tender to palpation but without rebound or involuntary guarding. Laboratory results are as follows: Ultrasound of the right upper quadrant shows pancreatic edema but is otherwise unrevealing. In addition to an infusion of lactated Ringer solution and pain medication, the patient is treated with intravenous insulin and dextrose solution. Her symptoms and laboratory studies improve after 3 days. Which of the following is recommended to prevent recurrence in this patient?

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Explanation: 11ec2b69_bf1d_e2aa_8f63_17f821ca5e2e_MD0005_00 This patient has acute pancreatitis with characteristic abdominal pain, a serum lipase level ≥3x normal, and pancreatic edema on ultrasound. The most likely etiology is severe hypertriglyceridemia, which is often associated with a genetic predisposition (eg, hereditary dyslipidemia) or uncontrolled diabetes mellitus. Hypertriglyceridemia-associated pancreatitis (HTAP) most commonly occurs in patients who have triglyceride levels >1,000 mg/dL. Insulin can be used to treat HTAP acutely by activating lipoprotein lipase and increasing the movement of triglycerides out of plasma and into tissue, which prevents further pancreatic damage. Apheresis, which directly filters triglycerides out of blood, may also be used in severe cases. lipoprotein lipase In addition, patients with HTAP require chronic lipid-lowering therapy to prevent future recurrence. Fibrates (eg, fenofibrate, gemfibrozil) are the most effective medications available for lowering triglyceride levels and preventing HTAP. Increased exercise, a low-fat diet, and alcohol abstinence are also recommended. (Choice A) Bariatric surgery is indicated for patients with a BMI >40 kg/m² or a BMI >35 kg/m² with certain comorbidities (eg, diabetes, hypertension, obstructive sleep apnea). It is not indicated for HTAP. (Choice B) Cholecystectomy prevents the recurrence of gallstone pancreatitis but is not used for HTAP. Findings suggesting gallstone pancreatitis include hyperbilirubinemia, elevated liver enzymes (eg, alkaline phosphatase, alanine aminotransferase), and specific ultrasound findings (eg, biliary dilation, choledocholithiasis). (Choice D) Metformin is used to treat hyperglycemia in patients with type 2 diabetes mellitus but has only a minor impact on triglycerides and would not be helpful for this individual. (Choice E) Statins (eg, atorvastatin) are potent cholesterol-lowering drugs used to prevent cardiovascular disease in high-risk populations (eg, LDL ≥190 mg/dL, age ≥40 with diabetes mellitus). Although statins weakly lower triglycerides, fibrates are much more effective and are preferred for preventing HTAP recurrence. Educational objective: The acute management of hypertriglyceridemia-associated pancreatitis includes insulin or apheresis for rapidly lowering serum triglyceride levels. Patients should also receive long-term therapy with fibrates (eg, fenofibrate, gemfibrozil) to prevent recurrence. References: Management of hypertriglyceridemia induced acute pancreatitis. (http://www.ncbi.nlm.nih.gov/pubmed/30148167)

A 30-Year-Old Woman Comes to the Emergency Department Due to 12