Photo Quiz

What Is Causing a Man’s Severe Abdominal Pain and Yellow Blood?

Munish H. Lapsia, MD; Mai Vo, MD; Mary E. Przybysz, MD; and David J. Wallace, MD, MPH

Volume 57 - Issue 1 - January 2017

AUTHORS:
Munish H. Lapsia, MD; Mai Vo, MD; Mary E. Przybysz, MD; and David J. Wallace, MD, MPH

CITATION:
Lapsia MH, Vo M, Przbysz ME, Wallace DJ. What is causing a man's severe abdominal pain and yellow blood? Consultant. 2017;57(1):46.

 

A 36-year-old man presented to the emergency department with a 2-day history of severe abdominal pain, nausea, and vomiting. On physical examination, his abdomen was mildly distended and tender to palpation in the upper quadrants. Laboratory test results revealed a serum lipase level of 1189 U/L (reference range, 15-70 U/L).

The patient was admitted to the intensive care unit and was treated with aggressive intravenous hydration, analgesics, and restriction of oral intake. On hospital day 2, he developed respiratory failure that required intubation and hypotension that necessitated vasopressors.

His blood sample, drawn after insertion of a central venous catheter line, is shown below.

yellow blood

What explains his clinical course and the appearance of his blood?

  1. Acute cholecystitis
  2. Acute pancreatitis
  3. Choledocholithiasis
  4. Penetrating duodenal ulcer

Answer on next page.

Answer: Hypertriglyceridemia-Induced Acute Pancreatitis

The patient received a diagnosis of hypertriglyceridemia-induced acute pancreatitis (HTG-AP).

Visual inspection of the patient’s blood showed it to be grossly lipemic, with characteristic opaque yellow serum. His serum triglyceride (TG) level was 4,603 mg/dL (reference range, <150 mg/dL).

The patient was treated with a continuous insulin infusion, intravenous heparin, and plasmapheresis with albumin exchange. After 1½ total blood volume exchanges, the patient’s serum TG level decreased to 500 mg/dL. His condition gradually improved, and he was transferred out of the intensive care unit on hospital day 4 and was discharged home on day 12. He was prescribed an oral fibrate to continue as an outpatient.

Discussion

Hypertriglyceridemia is an important cause of acute and recurrent pancreatitis in patients with familial lipid metabolic disorders, diabetic ketoacidosis, excessive alcohol use, hypothyroidism, hormone supplementation, medication use, and pregnancy. Hypertriglyceridemia reportedly causes to 1% to 4% of cases of acute pancreatitis.1 Serum triglyceride levels greater than 1000 mg/dL are considered necessary to diagnose HTG-AP. The condition is associated with persistent systemic inflammatory response syndrome2 and is independently associated with organ failure.3

Therapeutic options for HTG-AP include dietary modifications, antihyperlipidemic agents, heparin infusion, intravenous insulin, and plasmapheresis.4 Although plasmapheresis effectively removes excess serum TGs, the impact on outcome remains unclear.5 Nevertheless, the therapy should be considered for patients with a high severity of illness or HTG-AP during pregnancy.6 

 

Munish H. Lapsia, MD, is a critical care medicine fellow in the Department of Critical Care Medicine at the University of Pittsburgh School of Medicine in Pittsburgh, Pennsylvania.

Mai Vo, MD, is the associate program director of the Orlando Health Critical Care Medicine Fellowship Program at Orlando Regional Medical Center in Orlando, Florida.

Mary E. Przybysz, MD, is a critical care medicine consultant at Carolinas Medical Center in Charlotte, North Carolina.

David J. Wallace, MD, MPH, is an assistant professor in the Department of Critical Care Medicine and the Department of Emergency Medicine at the University of Pittsburgh School of Medicine in Pittsburgh, Pennsylvania.

References:

  1. Tsuang W, Navaneethan U, Ruiz L, Palascak JB, Gelrud A. Hypertriglyceridemic pancreatitis: presentation and management. Am J Gastroenterol. 2009;104(4):984-991.
  2. González-Moreno EI, González-González JA, Garza-González E, Bosques-Padilla FJ, Maldonado-Garza HJ. Elevated serum triglycerides associated with systemic inflammatory response syndrome and persistent organ failure in acute pancreatitis. Am J Gastroenterol. 2016;111(1):149.
  3. Nawaz H, Koutroumpakis E, Easler J, et al. Elevated serum triglycerides are independently associated with persistent organ failure in acute pancreatitis. Am J Gastroenterol. 2015;110(10):1497-1503.
  4. Wu BU, Banks PA. Clinical management of patients with acute pancreatitis. Gastroenterology. 2013;144(6):1272-1281.
  5. Click B, Ketchum AM, Turner R, Whitcomb DC, Papachristou GI, Yadav D. The role of apheresis in hypertriglyceridemia-induced acute pancreatitis: a systematic review. Pancreatology. 2015;15(4):313-320.
  6. Basar R, Uzum AK, Canbaz B, et al. Therapeutic apheresis for severe hypertriglyceridemia in pregnancy. Arch Gynecol Obstet. 2013;287(5):839-843.