Diferencia entre revisiones de «Hypertriglyceridemia»
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==Background==
==Background==
*~5% of acute [[pancreatitis]] caused by high triglycerides<ref>Yadav D, Pitchumoni CS. Issues in hyperlipidemic pancreatitis. J Clin Gastroenterology 2003;36:54-62.</ref>
 
*~5% of acute [[Special:MyLanguage/pancreatitis|pancreatitis]] caused by high triglycerides<ref>Yadav D, Pitchumoni CS. Issues in hyperlipidemic pancreatitis. J Clin Gastroenterology 2003;36:54-62.</ref>
*Etiologies
*Etiologies
**Familial hypertriglyceridemia, autosomal dominant with variable penetrance
**Familial hypertriglyceridemia, autosomal dominant with variable penetrance
**Secondary forms
**Secondary forms
***[[DM]], obesity, [[EtOH]], estrogen therapy
***[[Special:MyLanguage/DM|DM]], obesity, [[Special:MyLanguage/EtOH|EtOH]], estrogen therapy
***[[Hypothyroidism]], ESRD, nephrotic syndrome, [[HIV]], anti-HIV meds
***[[Special:MyLanguage/Hypothyroidism|Hypothyroidism]], ESRD, nephrotic syndrome, [[Special:MyLanguage/HIV|HIV]], anti-HIV meds
*TG levels > 2000mg/dL almost always have both secondary and genetic form<ref>Yuan et al. Hypertriglyceridemia: its etiology, effects and treatment. CMAJ 2007;176:1113-1120.</ref>
*TG levels > 2000mg/dL almost always have both secondary and genetic form<ref>Yuan et al. Hypertriglyceridemia: its etiology, effects and treatment. CMAJ 2007;176:1113-1120.</ref>
*1.7% of US estimated to have [TG] between 500-2000<ref>Brown, Virgil W. Et al. “Clinical Lipidology Roundtable Discussion: Severe Hypertriglyceridemia.” Journal of Clinical Lipidology 2012; 6:397-408</ref>
*1.7% of US estimated to have [TG] between 500-2000<ref>Brown, Virgil W. Et al. “Clinical Lipidology Roundtable Discussion: Severe Hypertriglyceridemia.” Journal of Clinical Lipidology 2012; 6:397-408</ref>
*May present with normal serum lipase levels
*May present with normal serum lipase levels


===Pathophysiology===
===Pathophysiology===
*Excess TG hydrolyzed by increased concentration of pancreatic lipase
*Excess TG hydrolyzed by increased concentration of pancreatic lipase
*Produces increased concentration of free fatty acids that exceeds binding capacity of albumin
*Produces increased concentration of free fatty acids that exceeds binding capacity of albumin
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*Ischemia and pancreatic injury result
*Ischemia and pancreatic injury result
*An acidic environment potentiates free fatty acid toxicity
*An acidic environment potentiates free fatty acid toxicity


==Clinical Features==
==Clinical Features==
===General===
===General===
[[File:Xanthoma.jpg|thumb|A pediatric patient's knee showing multiple xanthoma tuberosum (i.e. xanthoma located over a joint).]]
[[File:Xanthoma.jpg|thumb|A pediatric patient's knee showing multiple xanthoma tuberosum (i.e. xanthoma located over a joint).]]
*Most are generally asymptomatic until sequelae present
*Most are generally asymptomatic until sequelae present
*Eruptive xanthoma may be found on dermatologic exam
*Eruptive xanthoma may be found on dermatologic exam


===Hypertriglyceridemic Pancreatitis===
===Hypertriglyceridemic Pancreatitis===
''Signs/symptoms of pancreatitis''
''Signs/symptoms of pancreatitis''
*[[Epigastric pain|Pain]] is the most common symptom and is often characterized by:
*[[Special:MyLanguage/Epigastric pain|Pain]] is the most common symptom and is often characterized by:
**Persistent
**Persistent
**Localizes to epigastric area, around waist, RUQ, or occasionally LUQ
**Localizes to epigastric area, around waist, RUQ, or occasionally LUQ
**Radiates to back
**Radiates to back
**The onset may be less abrupt and the pain poorly localized
**The onset may be less abrupt and the pain poorly localized
*[[Nausea/vomiting]] noted in most
*[[Special:MyLanguage/Nausea/vomiting|Nausea/vomiting]] noted in most
*Abdominal distention is frequent complaint
*Abdominal distention is frequent complaint
*[[Eponyms_(C-E)#Cullen.27s_sign|Cullen sign]] (ecchymosis of periumbilical region) - intrabdominal hemorrhage
*[[Special:MyLanguage/Eponyms_(C-E)#Cullen.27s_sign|Cullen sign]] (ecchymosis of periumbilical region) - intrabdominal hemorrhage
*Turner sign (ecchymosis of flanks) - retroperitoneal hemorrhage
*Turner sign (ecchymosis of flanks) - retroperitoneal hemorrhage
*Pulmonary Findings
*Pulmonary Findings
**[[Hypoxemia]], [[ARDS]], tachypnea
**[[Special:MyLanguage/Hypoxemia|Hypoxemia]], [[Special:MyLanguage/ARDS|ARDS]], tachypnea
**Indicates severe pancreatitis
**Indicates severe pancreatitis
***Diaphragmatic inflammation, pancreatico-pleural fistula
***Diaphragmatic inflammation, pancreatico-pleural fistula


==Differential Diagnosis==
==Differential Diagnosis==
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{{Abdominal Pain DDX Epigastric}}
{{Abdominal Pain DDX Epigastric}}
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==Evaluation==
==Evaluation==
[[File:hypertriglyceridemia_green_top.jpg|thumbnail]]
[[File:hypertriglyceridemia_green_top.jpg|thumbnail]]
*Triglycerides; Severely elevated (at least >500 mg/dL, generally >1,000 mg/dL)
*Triglycerides; Severely elevated (at least >500 mg/dL, generally >1,000 mg/dL)
**Lipids in serum may interfere with other lab tests
**Lipids in serum may interfere with other lab tests
***Falsely low Na+, amylase
***Falsely low Na+, amylase


===Pancreatitis workup===
===Pancreatitis workup===
*Rule out other causes of pancreatitis (e.g. [[gallstone pancreatitis]])
 
*Rule out other causes of pancreatitis (e.g. [[Special:MyLanguage/gallstone pancreatitis|gallstone pancreatitis]])
*In general, if triglycerides >1000, can assume this is cause of pancreatitis
*In general, if triglycerides >1000, can assume this is cause of pancreatitis
*Lipase level >3x upper limit of normal
*Lipase level >3x upper limit of normal
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**Negative lipase does not exclude pancreatitis in chronic/recurrent disease
**Negative lipase does not exclude pancreatitis in chronic/recurrent disease
**Absolute value not associated with prognosis or severity
**Absolute value not associated with prognosis or severity
*Characteristic findings on [[ultrasound]] or CT
*Characteristic findings on [[Special:MyLanguage/ultrasound|ultrasound]] or CT
 




==Management==
==Management==


===Management of [[acute pancreatitis]] in the setting of hypertriglyceridemia===
 
===Management of [[Special:MyLanguage/acute pancreatitis|acute pancreatitis]] in the setting of hypertriglyceridemia===
 
*Evidence for management based on case series and reports<ref>Santana YR et al. Treatment of severe hypertriglyceridemia with continuous insulin infusion. Case Reports in Critical Care. June 2011.</ref><ref>Poonuru S et al. Rapid Reduction of Severely Elevated Serum Triglycerides with Insulin Infusion, Gemfibrozil and Niacin. Clin Med Res. 2011 Mar; 9(1): 38–41.</ref>
*Evidence for management based on case series and reports<ref>Santana YR et al. Treatment of severe hypertriglyceridemia with continuous insulin infusion. Case Reports in Critical Care. June 2011.</ref><ref>Poonuru S et al. Rapid Reduction of Severely Elevated Serum Triglycerides with Insulin Infusion, Gemfibrozil and Niacin. Clin Med Res. 2011 Mar; 9(1): 38–41.</ref>
*[[Insulin]] drip - most dramatic and rapid intervention, with reduction within 24 hrs
*[[Special:MyLanguage/Insulin|Insulin]] drip - most dramatic and rapid intervention, with reduction within 24 hrs
**Initiate at 0.1 units/kg/hr (similar to treatment for DKA)
**Initiate at 0.1 units/kg/hr (similar to treatment for DKA)
**Goal is to reduce triglycerides to < 500
**Goal is to reduce triglycerides to < 500
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***K > 5 no extra potassium
***K > 5 no extra potassium
*IVF as for standard pancreatitis treatment, add potassium as per above
*IVF as for standard pancreatitis treatment, add potassium as per above
*Treat concurrent [[hypothyroidism]] if present
*Treat concurrent [[Special:MyLanguage/hypothyroidism|hypothyroidism]] if present
*Pain control
*Pain control
*[[Niacin]] 500mg QD
*[[Special:MyLanguage/Niacin|Niacin]] 500mg QD
*[[Gemfibrozil]] or [[fenofibrate]]
*[[Special:MyLanguage/Gemfibrozil|Gemfibrozil]] or [[Special:MyLanguage/fenofibrate|fenofibrate]]
*Max dose statin, 81mg [[ASA]]
*Max dose statin, 81mg [[Special:MyLanguage/ASA|ASA]]
*[[Heparin]] q8 SC, effect short-lived
*[[Special:MyLanguage/Heparin|Heparin]] q8 SC, effect short-lived
*NPO initially
*NPO initially
*May advance diet starting at TG level < 1000mg/dL with resolution of abdominal pain/pancreatitis symptoms
*May advance diet starting at TG level < 1000mg/dL with resolution of abdominal pain/pancreatitis symptoms
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**Low calorie diet
**Low calorie diet


====[[Plasma exchange]]====
 
====[[Special:MyLanguage/Plasma exchange|Plasma exchange]]====
 
*Therapeutic plasma exchange, for 1-3 days (sickest patients)
*Therapeutic plasma exchange, for 1-3 days (sickest patients)
**Generally indicated for hypocalcemia, persistent elevated lactic acidosis, other signs of worsening organ dysfunction  
**Generally indicated for hypocalcemia, persistent elevated lactic acidosis, other signs of worsening organ dysfunction  
*For euglycemic patients, not routine first line
*For euglycemic patients, not routine first line
*Requires central venous access
*Requires central venous access


==Disposition==
==Disposition==
*Asymptomatic hypertriglyceridemia is treated as an outpatient
*Asymptomatic hypertriglyceridemia is treated as an outpatient
*For acute pancreatitis, ICU or step-down for frequent labs, insulin drip
*For acute pancreatitis, ICU or step-down for frequent labs, insulin drip


==See Also==
==See Also==
*[[Acute pancreatitis]]
 
*[[Special:MyLanguage/Acute pancreatitis|Acute pancreatitis]]
 


==External Links==
==External Links==
Línea 101: Línea 131:


==References==
==References==
<references/>
<references/>


[[Category:GI]]
[[Category:GI]]
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Revisión actual - 23:09 4 ene 2026


Background

  • ~5% of acute pancreatitis caused by high triglycerides[1]
  • Etiologies
    • Familial hypertriglyceridemia, autosomal dominant with variable penetrance
    • Secondary forms
  • TG levels > 2000mg/dL almost always have both secondary and genetic form[2]
  • 1.7% of US estimated to have [TG] between 500-2000[3]
  • May present with normal serum lipase levels


Pathophysiology

  • Excess TG hydrolyzed by increased concentration of pancreatic lipase
  • Produces increased concentration of free fatty acids that exceeds binding capacity of albumin
  • Micelles are formed that attack platelets, vascular endothelium and acinar cells
  • Ischemia and pancreatic injury result
  • An acidic environment potentiates free fatty acid toxicity


Clinical Features

General

A pediatric patient's knee showing multiple xanthoma tuberosum (i.e. xanthoma located over a joint).
  • Most are generally asymptomatic until sequelae present
  • Eruptive xanthoma may be found on dermatologic exam


Hypertriglyceridemic Pancreatitis

Signs/symptoms of pancreatitis

  • Pain is the most common symptom and is often characterized by:
    • Persistent
    • Localizes to epigastric area, around waist, RUQ, or occasionally LUQ
    • Radiates to back
    • The onset may be less abrupt and the pain poorly localized
  • Nausea/vomiting noted in most
  • Abdominal distention is frequent complaint
  • Cullen sign (ecchymosis of periumbilical region) - intrabdominal hemorrhage
  • Turner sign (ecchymosis of flanks) - retroperitoneal hemorrhage
  • Pulmonary Findings
    • Hypoxemia, ARDS, tachypnea
    • Indicates severe pancreatitis
      • Diaphragmatic inflammation, pancreatico-pleural fistula


Differential Diagnosis

Epigastric Pain


Evaluation

Hypertriglyceridemia green top.jpg
  • Triglycerides; Severely elevated (at least >500 mg/dL, generally >1,000 mg/dL)
    • Lipids in serum may interfere with other lab tests
      • Falsely low Na+, amylase


Pancreatitis workup

  • Rule out other causes of pancreatitis (e.g. gallstone pancreatitis)
  • In general, if triglycerides >1000, can assume this is cause of pancreatitis
  • Lipase level >3x upper limit of normal
    • Sensitivity 82-100%, specificity 82-100%[4]
    • Negative lipase does not exclude pancreatitis in chronic/recurrent disease
    • Absolute value not associated with prognosis or severity
  • Characteristic findings on ultrasound or CT


Management

Management of acute pancreatitis in the setting of hypertriglyceridemia

  • Evidence for management based on case series and reports[5][6]
  • Insulin drip - most dramatic and rapid intervention, with reduction within 24 hrs
    • Initiate at 0.1 units/kg/hr (similar to treatment for DKA)
    • Goal is to reduce triglycerides to < 500
    • Add D5NS if glucose drops < 200 [7]
    • Monitor BMP q2 hr
    • Manage potassium
      • K < 3.2 stop insulin and replete K
      • K 3.3 to 5 add 20 mEq K/Lto IVF
      • K > 5 no extra potassium
  • IVF as for standard pancreatitis treatment, add potassium as per above
  • Treat concurrent hypothyroidism if present
  • Pain control
  • Niacin 500mg QD
  • Gemfibrozil or fenofibrate
  • Max dose statin, 81mg ASA
  • Heparin q8 SC, effect short-lived
  • NPO initially
  • May advance diet starting at TG level < 1000mg/dL with resolution of abdominal pain/pancreatitis symptoms
    • No fat diet
    • Low calorie diet


Plasma exchange

  • Therapeutic plasma exchange, for 1-3 days (sickest patients)
    • Generally indicated for hypocalcemia, persistent elevated lactic acidosis, other signs of worsening organ dysfunction
  • For euglycemic patients, not routine first line
  • Requires central venous access


Disposition

  • Asymptomatic hypertriglyceridemia is treated as an outpatient
  • For acute pancreatitis, ICU or step-down for frequent labs, insulin drip


See Also


External Links

References

  1. ↑ Yadav D, Pitchumoni CS. Issues in hyperlipidemic pancreatitis. J Clin Gastroenterology 2003;36:54-62.
  2. ↑ Yuan et al. Hypertriglyceridemia: its etiology, effects and treatment. CMAJ 2007;176:1113-1120.
  3. ↑ Brown, Virgil W. Et al. “Clinical Lipidology Roundtable Discussion: Severe Hypertriglyceridemia.” Journal of Clinical Lipidology 2012; 6:397-408
  4. ↑ Yadav D, Agarwal N, Pitchumoni CS. A critical evaluation of laboratory tests in acute pancreatitis. Am J Gastroenterol. 2002 Jun;97(6):1309-18.
  5. ↑ Santana YR et al. Treatment of severe hypertriglyceridemia with continuous insulin infusion. Case Reports in Critical Care. June 2011.
  6. ↑ Poonuru S et al. Rapid Reduction of Severely Elevated Serum Triglycerides with Insulin Infusion, Gemfibrozil and Niacin. Clin Med Res. 2011 Mar; 9(1): 38–41.
  7. ↑ Schaefer EW. Management of Severe Hypertriglyceridemia in the Hospital: A Review. Journal of Hospital Medicine Vol 7|No 5|May/June 2012.
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