How to manage a case of hypertriglyceridemia?

1. Acute Pancreatitis in a patient with DM

2.  44 Y/O Lady Presented to the ER with a one day
History of pain abdomen. The pain was localized in
the Epigastrium with radiation to the back.
 Associated with nausea.
ROS
 No fever, chest pain, shortness of breath or
palpitations.

3.  H/o Hypertriglyceridemia
 Depression
 Mitral Valve Prolapse
 H/o Gestational Diabetes Mellitus 10 years back.
 Obesity . BMI of 31.
 Irritable bowel syndrome
 H/O pain abdomen 2- 3 episodes treated with PPI in the
preceding few weeks.
Past surgical History
 PSH – Cholecystectomy 4 years ago.

4.  Simvastatin 20 mg . On a stable dose for more than a
year.
 Oral contraceptive pills
 Lexapro
Social History
 Uses alcohol rarely ,twice per year.
 No H/O tobacco or illicit drug use.

5.  Significant for heart disease and DM in parents.
Physical Exam
 BP : 86/24 mm hg
 Temp : 36.4
 Pulse :110/min

6.  CVS : regular with no murmurs'
 RS: Clear
 Abdomen: distended, epigastrium –tender
BS – Hypoactive
CT Scan
 Fatty liver.
 Mild hepatomegaly
 Inflammatory changes around the body and tail of
pancreas .

7.  TLC : 14,800
 Hgb : 12.8
 BUN :19
 S.creatinine : 2.52.
 S.Amylase :1578
 S.lipase :3047
 S.Calcium:4.4,ionised-2.3
 Total Cholesterol :1067
 Triglycerides:14,608

8.  HDL:37
 VLDL:2922
 FBS:320,395
 HBA1C:10.1
 LFT :WNL
Urine analysis
 Protein 2+
 Ketones 3+
 Glucose 3+

9.  Admitted in the Micu
 IV hydration
 IV Insulin sliding scale
 Calcium Gluconate
 Doripenem and vancomycin

10.  Acute renal failure
 Hypocalcaemia
 Hypotension
 Metabolic acidosis

11. Date Cholestero Triglycerid HDL LDL VLDL
l es
5/10/09 934 14124 31 - 2824
5/11/09 1067 14608 37 - 2922
5/13/09 651 6160 14 - 1232
5/14/09 435 1960 28 - 392
5/15/09 291 618 34 - 123
5/16/09 276 469 28 124 93
6/15/09 163 206 28 94 69
6/18/09 152 179 28 88 35

12.  Treatment only with a low dose statin prior to
admission
 No lab work for more than a year prior to admission
 H/O of pain abdomen prior to the episode which was
not investigated.
 Presence of protinuria in the initial urine sample . ?
Underlying Diabetic nephropathy.

13.  A1C of 10.1 at admission . ? Duration of hyperglycemia.
 H/O gestational DM.
 Possible etiology of the fatty liver. ? DM and obesity.

14. 22/6/09
 Pt was asymptomatic.
 A1C – 6.6
 Spot urine-protein +
Medications
 Lantus 19 units
 Apidra 4/4/4
 Metoprolol ER 25mg
 Tricor 145mg
 Lexapro

15. 7/20/09
 No osmotic symptoms
 Pt had symptoms of hot flashes.
 Blood glucose monitoring
Fasting – 139,97,105,109,100,117
Prelunch – 149,142,129,125,116
Predinner-145,84,139,97
Bedtime-66,77,141,203.

16.  Hgb-9.7
 S.calcium-10.4
 BUN -13
 S.Creatinine-1.32
 Gfr-44
 C-Peptide-1.0
 GAD Abs-<1.0

17. Urinalysis
 Appearance-cloudy
 Protein-trace(15mg/dl)
 Glucose-negative
 Ketones-negative
 TSH -1.430
 VitaminD-OH-41.7
 PTH-16

18.  Despite a close medical monitoring during pregnancy,
the further follow up within the health care system
and information about long term consequences of
GDM for later type 2 diabetes mellitus development
seems to be generally lacking.
 The patients dyslipedemia seem to be exacerbated by
her uncontrolled DM, obesity and the use of OCPs.
 Substantial lowering of A1C effectively controls serum
triglycerides.

19. Thank You