Diagnosis and management:
Based on the clinical findings, such as abdominal pain radiating to the
back, elevated triglyceride, serum amylase, and lipase levels, along
with positive CT findings, a diagnosis of acute pancreatitis was made.
However, challenges arose while looking for the cause of pancreatitis
and its severity.
Although the high triglyceride levels were not significant enough to
directly cause the symptoms of pancreatitis, considering the absence of
various other potential causes like alcohol or drug use, infections, and
trauma, we had to explore moderately elevated triglycerides as a
possible reason behind the symptoms and went ahead with its targeted
treatment. We excluded various potential reasons for the elevated
triglyceride levels.
Beginning with secondary factors, she showed no signs of endocrine
disorders (treated or untreated thyroid disorder or diabetes), was not
under any medication, abstained from alcohol, was not pregnant, and had
an unremarkable family history. Additionally, we eliminated
possibilities of renal disease, liver disease, and autoimmune disorders.
Apart from a high BMI, there were no other identifiable factors
contributing to the elevated triglyceride levels. The severity was 2
according to the Bedside Index of Severity in Acute Pancreatitis (BISAP)
score and 6 according to the CT severity index (CTSI) score, indicating
acute moderate pancreatitis. However, the Ranson score was 1 at the time
of admission, indicating acute mild pancreatitis and creating a dilemma
in grading the severity of the disease.
The patient was transferred to an intensive care unit and initially
managed with aggressive intravenous fluid resuscitation, Fentanyl, and
Ondansetron. After collecting samples for blood cultures, empirical
antibiotics such as Piperacillin-Tazobactam and Metronidazole were
started for high clinical suspicion of infection. Continuous Insulin
infusion decreased triglyceride levels to 367 mg/dl on the third day and
223 mg/dl on the seventh day. Fenofibrate 160 mg once daily was started
to lower the triglyceride level further and prevent further episodes of
pancreatitis. After 48 hours, blood investigations were repeated, which
revealed improvement. Empirical antibiotics were stopped as the blood
culture reports were insignificant, and the patient was transferred from
the ICU to the medical ward. She was discharged on the seventh day of
admission, and her vital signs were within normal limits at discharge.