Hypertriglyceridemia-induced pancreatitis

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Hypertriglyceridemia-induced pancreatitis is an uncommon form of acute pancreatitis caused by high levels of circulating triglycerides in the blood.

Epidemiology

Hypertriglyceridemia-induced pancreatitis accounts for around 1-4% of cases of acute pancreatitis and is the third most common cause of pancreatitis after gallstones and alcohol . It is responsible for over half of pregnancy-related cases of acute pancreatitis .

Risk factors

Presence of the following may heighten suspicion for hypertriglyceridemia causing acute pancreatitis :

  • poorly controlled diabetes
  • obesity
  • personal history of hypertriglyceridemia
  • familial hypertriglyceridemia
  • personal history of pancreatitis

Clinical presentation

The presentation will be similar to other causes of acute pancreatitis, the cardinal feature being constant, intense abdominal pain which can radiate to the upper back or left shoulder. Peripheral signs of hypertriglyceridemia may be present such as xanthomata and xanthelasma .

Pathology

The exact mechanism of how hypertriglyceridemia causes pancreatitis is unknown . One theory is that hyperviscosity of blood in the pancreatic capillaries caused by hypertriglyceridemia causes ischemia and injury to the pancreas . Generally the level of triglycerides must be significantly elevated to above 11 mmol/L (or 1,000 mg/dL) to be capable of causing pancreatitis.

Etiology

Both primary and secondary causes of hypertriglyceridemia-induced pancreatitis exist :

  • primary
    • inherited defects in proteins involved in fat metabolism (e.g. lipoprotein lipase deficiency or apo C-II protein deficiency)
  • secondary:
    • poorly controlled diabetes (insulin resistance causes increased levels of triglycerides)
    • drugs (e.g. estrogen)
    • pregnancy
    • alcohol use
    • hypothyroidism

Radiographic features

There are no specific findings in hypertriglyceridemia-induced pancreatitis, the main role of imaging is to exclude other causes of pancreatitis (e.g. gallstones) and investigate complications relating to the pancreatitis. Hepatomegaly and steatosis may be present due to fatty infiltration .

Treatment and prognosis

Plasma apheresis or intravenous insulin (in the presence concurrent hyperglycemia) are often used in the treatment of hypertriglyceridemia-induced pancreatitis . Lipid-lowering therapy should also be commenced to lower the risk of future pancreatitis and cardiovascular disease .