Gastro Case Challenge: Pain, Vomiting in a 48-Year-Old on Levothyroxine, Metformin

Bashar Sharma, MD; John W. Birk, MD


September 23, 2022

Plasmapheresis has also been used in patients with severe triglyceride-induced pancreatitis because it can lead to a rapid decline in serum triglycerides by about 66% after one session and 83% after two sessions.[12] In addition, it has the potential benefit of removing proteases that can further damage the pancreas. However, studies have not shown improved outcomes or mortality benefit.[5] If plasmapheresis is used, it should be initiated early, and serum triglycerides should be measured after every session. It should be stopped when the serum triglyceride level is < 500 mg/dL.

Once the patient is able to tolerate oral intake, a fat-restricted diet is recommended. In addition, triglyceride-lowering agents should be started; fibrates are the most effective.[6] A reasonable second choice is high-dose omega-3 fatty acids. Niacin and statins can be added to the regimen; however, the risk for adverse events, including rhabdomyolysis and myopathy, is higher with combination therapy, especially fibrates and statins.[6] Long-term management should involve lifestyle modifications, including a low-fat diet, aerobic exercise, weight loss in patients with obesity, strict glycemic control in patients with diabetes, and alcohol cessation in patients with alcohol use disorder.

In the patient in this case, the SIRS criteria score was 2 and the Modified Marshall Score was 2. These scores indicate severe pancreatitis. He was admitted to the ICU, and IV fluids and analgesics were started. Given his hyperglycemia and severe pancreatitis with evidence of end-organ damage (hypotension, tachycardia, and leukocytosis), insulin infusions were initiated, with monitoring of his serum glucose. Dextrose infusion was also started once his glucose level was < 180 mg/dL. His serum triglyceride level was measured daily while he was receiving insulin.

After 48 hours, his triglyceride level dropped to < 500 mg/dL, and the insulin was discontinued. His symptoms also started to improve. He was transitioned to a clear-liquid diet, then to a low-fat diet, which he tolerated well. Fenofibrate was started, and the patient was discharged home in stable condition, with a short follow-up.


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