Key Points
- Treat AP per ACG 2024 (moderate fluids, early feeding).
- Insulin infusion is first‑line for severe HTG‑AP; apheresis for select severe cases.
- Address secondary causes and initiate long‑term lipid control.
Algorithm
- Primary survey and stabilization; focused history and exam.
- Order high‑yield tests first; escalate imaging as indicated.
- Initiate disease‑specific therapy and supportive care.
- Reassess clinical response; arrange consultation and disposition.
Clinical Synopsis & Reasoning
Severe abdominal pain with TG >1000 mg/dL—hypertriglyceridemia‑induced acute pancreatitis (HTG‑AP). After confirming AP diagnosis (two of: pain, lipase >3× ULN, imaging), recognize HTG as an etiology and institute standard AP care (goal‑directed fluids, early enteral nutrition, analgesia). Weigh insulin infusion vs apheresis for rapid TG reduction in severe disease.
Treatment Strategy & Disposition
Start insulin infusion with dextrose to maintain euglycemia; consider therapeutic plasma exchange in severe or refractory cases per ASFA 2023. Avoid heparin drips for TG lowering; address precipitants and start long‑term lipid therapy (fibrates, omega‑3s) at recovery.
Epidemiology / Risk Factors
- Epidemiology varies by setting; see citations for details.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| Serum triglycerides | Confirm etiology | >1000 mg/dL (often) | Trend to <500 |
| Lipase/amylase | AP diagnosis | >3× ULN | — |
| CT A/P (if unclear severity) | Complications assessment | Necrosis, collections | Delay to 72 h unless diagnostic uncertainty |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Regular insulin infusion + dextrose | Activates lipoprotein lipase | Immediate | Rapid TG reduction | Hypoglycemia, K+ shifts |
| Fenofibrate (outpatient) | PPAR‑α agonist | Days | Secondary prevention | Renal dosing |
| Omega‑3 fatty acids | TG lowering | Days | Adjunct outpatient therapy | GI upset |
Prognosis / Complications
- Prognosis depends on timeliness of diagnosis, comorbid disease, and response to therapy.
Patient Education / Counseling
- Explain expected course, warning signs requiring urgent care, and follow‑up testing.
- Review medication use, interactions, and monitoring parameters.