(10.08) A Rare Case of Acute Pancreatitis due to Alcohol-Induced Hypertriglyceridemia

Acute pancreatitis is an acute inflammatory condition that can be potentially fatal. About 70-80% of cases are caused by alcohol misuse or gallstones. A lesser common cause is hypertriglyceridemia (HTG), which can be attributed to about 2-4% of cases of acute pancreatitis. HTG can either be from a primary cause such as familial dyslipidemia or it could be from a secondary cause such as obesity, excessive alcohol consumption, uncontrolled diabetes, or medications. We present this rare case report of acute pancreatitis likely triggered by HTG in a patient with heavy alcohol use.

Case(s) Description :

A 27-year-old male presented with 5 days of worsening abdominal pain associated with nausea, vomiting, and poor intake. He reported daily consumption of beer and whiskey, averaging about 49 standard drinks weekly. He admitted to overindulgence the few days prior, due to external stressors. He denied any current medication use or family history of hyperlipidemia. Blood work showed WBC 13,200 cells/μL, ALT 241 U/L, AST 356 U/L, lipase 463 U/L, and triglycerides (TG) 5900 mg/dL. CT imaging of the abdomen showed diffuse infiltration of the pancreas as well as the right anterior pararenal fat plane, ventral mesentery, and transverse colon. No gallstones were seen and the common bile duct was normal. He was admitted with acute pancreatitis. He was treated with Lactated Ringers infusion at 150cc/hr and an insulin infusion at 0.1 units/kg/hr. Once the TG levels were below 500 mg/dL, he was transitioned from insulin infusion to oral fenofibrate. On discharge, blood work showed TG 422 mg/dL, and the patient was pain free and tolerating food.

Discussion :

About 11.3% of adults in the US have alcohol use disorder. The detrimental effects of alcohol on health are widely known, including hypertension, cardiomyopathies, arrhythmias, cirrhosis, malignancy, and pancreatitis. The lesser-known consequence is HTG. Alcohol is thought to cause HTG by increasing chylomicron secretion from the small intestine, upregulating hepatic delivery of free fatty acids, and increasing VLDL secretion. The free fatty acids and chylomicrons in HTG are believed to increase plasma viscosity, therefore induce ischemia in pancreatic tissue, and thus trigger organ inflammation leading to pancreatitis.

Patients with HTG-induced pancreatitis are treated with insulin and fluids. While on the insulin infusion, frequent blood checks should be performed to avoid hypoglycemia and dextrose infusions should be started to maintain euglycemia. If the TG levels are not lowering, plasmapheresis should be considered. Once the acute pancreatitis attack has resolved and TG levels have decreased, lipid-lowering medications such as fibrates should be initiated to achieve chronic TG control below 500 mg/dL.

Both elevated triglyceride levels and excessive alcohol consumption can lead to negative health outcomes. Therefore, it is imperative that alcohol cessation and low-fat diets are encouraged in patients with alcohol use disorder. Lipid levels should also be closely monitored in these patients to initiate early treatment and to avoid severe complications of hypertriglyceridemia such as acute pancreatitis.