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.