SAEM Clinical Image Series: Mysterious Blood Sample

34-year-old female with a history of hypertension, diabetes mellitus, and pancreatitis presents for epigastric and left upper quadrant abdominal pain. Her symptoms started yesterday evening and have been worsening since onset. She reports chronic epigastric pain that waxes and wanes for several years since her first episode of pancreatitis in 2014. Yesterday she had an abrupt onset of nausea that accompanied the pain without emesis. The pain worsened and is now currently 10/10 in severity. She describes it as severe and deep. She has no bloody or dark stool. She denies any heavy alcohol use, changes in medications, or drug use.

Physical Exam

Vitals: 97.9 F; BP 121/78; Pulse 96; RR 16; SpO2 99%

General: Appears mildly distressed due to pain, but able to engage in history and physical

Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops

Pulmonary: Lungs clear bilaterally without wheezes or rhonchi

Abdominal: Soft, non-distended, upper abdominal tenderness most pronounced in the epigastric region; no rebound but with mild anticipatory voluntary guarding

Skin: No lesions or rashes

Back: No CVA tenderness

Extremities: Warm and well perfused

Laboratory Data

CBC: Unremarkable

CMP: Notable for glucose 191 mg/dL and CO2 19 mEq/L; otherwise unremarkable

Lipase: Mildly elevated

Triglycerides: 9,918 mg/dL

Case Question: How do you explain the appearance of the patient’s blood sample?

The patient’s blood has this appearance because of the markedly elevated triglycerides. At high triglyceride levels, the serum appears lactescent (milky coloration).

Case Question: How does this explain the patient’s presentation?

The patient has hypertriglyceridemia (HTG)-induced pancreatitis.

The triglycerides (TG) themselves are not toxic. It is the breakdown of TGs into toxic free fatty acids (FFA) by pancreatic lipases that causes lipotoxicity during acute pancreatitis. Typically serum TG levels >1000 mg/dL are required for HTG to be considered the etiology of acute pancreatitis. HTG is considered very severe when levels are >2000 mg/dL.

Case Discussion

Treatment

The patient was admitted to the ICU and was treated with an insulin infusion. Insulin promotes the synthesis of lipoprotein lipase, which is a crucial enzyme in the hydrolysis of TG. Lipoprotein lipase hydrolyzes triglycerides into fatty acids and glycerol and facilitates the storage of the fatty acids in adipocytes.

Insulin infusions for hypertriglyceridemia (HTG) typically run at 0.1-0.3 units/kg/hr. D5 infusion can be run concurrently to prevent hypoglycemia. The insulin drip can typically be stopped when TG levels are <500 mg/dL.

Another treatment option is apheresis. As with the insulin drip, continue apheresis until the serum triglyceride level is <500 mg/dL.

Common causes of pancreatitis include:

Gllstones (35-75%)
Alcohol (25-35%)
Idiopathic (10-20%)

Uncommon causes include:

HTG (1-4%)
ERCP and drugs (1.4-2%)

Take Home Points

HTG is a less common, but important cause of pancreatitis, and can be considered the etiology when TG levels are >1000 mg/dL.
Treatment for HTG-induced pancreatitis include either IV insulin drip or apheresis.
HTG causes a classic milky appearance of the blood.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2019 SAEM Annual Meeting | Copyrighted by SAEM 2019 – all rights reserved. View other other cases from this series on ALiEM.

Author information

Sarah Monks, MD

Emergency Medicine Resident
UNC Emergency Medicine

The post SAEM Clinical Image Series: Mysterious Blood Sample appeared first on ALiEM.

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