SHM Converge Scientific Abstract ePoster Gallery-Pancreatitis in Disguise: False Normalization of Lipase

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This case highlights “pancreatitis in disguise” due to hypertriglyceridemia-induced pancreatitis (HTGP) with a falsely normal lipase. A 54-year-old man with multifactorial chylomicronemia syndrome, cirrhosis, hemochromatosis, and alcohol use disorder presented with two weeks of epigastric/RUQ abdominal pain, malaise, nausea, poor appetite, and jaundice. He had been drinking 3–4 nips daily and last drank two days before presentation.<br /><br />Initial evaluation showed epigastric and RUQ tenderness, tachycardia, marked transaminitis, hyperbilirubinemia, thrombocytopenia, hypocalcemia, and severely elevated triglycerides at 3101 mg/dL. However, lipase was normal at 52 IU/L. CT imaging showed new ascites, severe hepatic steatosis, a small amount of pericholecystic fluid, and a normal pancreas. Because of classic symptoms plus very high triglycerides, he was empirically treated with an insulin drip for suspected HTGP while other causes were evaluated.<br /><br />Further workup was unrevealing, including a negative acute viral hepatitis panel, diagnostic paracentesis without evidence of infection, and RUQ ultrasound showing hepatic steatosis without another clear cause. His symptoms improved on insulin alone, and triglycerides fell substantially. He was restarted on fenofibrate and counseled on alcohol cessation.<br /><br />The report emphasizes that acute pancreatitis is usually diagnosed by meeting 2 of 3 Atlanta criteria: characteristic abdominal pain, lipase/amylase >3 times the upper limit of normal, or supportive imaging. In HTGP, however, lipase may be falsely normal or low because elevated triglycerides can interfere with assays. Clinicians should maintain a high index of suspicion for pancreatitis in patients with classic symptoms and very high triglycerides, even when lipase is not elevated.

Asset Subtitle

Cynthia Zheng

Meta Tag

Author List Atin Jindal, Cynthia Zheng, Ekaterina Skaritanov

Category Clinical Vignettes

Concept Acute Pancreatitis

Concept Hypertriglyceridemia-Induced Acute Pancreatitis

Concept Atlanta Classification Criteria

Concept Hypertriglyceridemia

Concept Lipase

Distinguished Non-Finalist

Presenter Organization Warren Alpert Medical School of Brown University

Presenting Author Cynthia Zheng

Track Adult

Keywords

hypertriglyceridemia-induced pancreatitis

falsely normal lipase

chylomicronemia syndrome

epigastric abdominal pain

jaundice

insulin drip

severe hypertriglyceridemia

Atlanta criteria

hepatic steatosis

alcohol use disorder

Acute Pancreatitis

Hypertriglyceridemia-Induced Acute Pancreatitis

Atlanta Classification Criteria

Hypertriglyceridemia

Lipase