HYPERTRIGLYCERIDEMIA

INDUCED ACUTE
PANCREATITIS
Maisie Porter
 PRESENTATION OVERVIEW

Signs, Symptoms,
and Diagnostic Literature Review Summary
Tests

1 2 3 4 5 6 7

Patient Overview Disease Overview NCP References

 THE PATIENT
JB

ADMITTING DIAGNOSIS
DEMOGRAPHICS
Admitted to ED on 10/29/21, discharged 11/16
37 yo white male Presented with acute, severe epigastric pain with
radiation to his back associated with nausea and
vomiting
SOCIAL
HISTORY Lives in Durham
Has a partner
Works in IT
Rare alcohol use
No smoking
No illicit drug use
Walking and tennis
 Familial hypertriglyceridemia
Recurrent hypertriglyceride-induced
pancreatitis c/b pseudocysts
Adult onset T1DM
NAFLD
Crohn's colitis

PERTINENT Chronic splenic vein thrombosis

PAST HTN

MEDICAL Depression

HISTORY ADD
 HX OF PRESENT ILLNESS
Acute Pancreatitis

Hx of recurrent Unsuccessful EUS CT-guided drain Followed by

pancreatitis c/b cystogastrostomy placed at Endocrine and GI
pseudocysts July 2020 pancreatic tail in outpatient
since March 2020 August 2020 setting
 PRESENTATION OVERVIEW

Signs, Symptoms,
and Diagnostic Literature Review Summary
Tests

1 2 3 4 5 6 7

Patient Overview Disease Overview NCP References

ADMITTING DIAGNOSTIC TESTS LAB
SIGNS AND EVALUATION
SYMPTOMS CT abdomen pelvis with
↑ Lipase (450 U/L)
Acute, severe epigastric contrast
abdominal pain with radiation CBC with differential
to the pt's back, associated CMP
with N/V. Lipase CT RESULT
Shock panel, venous
"Based on the
Triglycerides
clinical/laboratory/imaging
BMP
workup completed here in
HFP
the ED my clinical
ECG 12-lead
impression is pancreatitis."
THE DIAGNOSIS
HYPERTRIGLYCERIDEMIA
INDUCED ACUTE PANCREATITIS
 PRESENTATION OVERVIEW

Signs, Symptoms,
and Diagnostic Literature Review Summary
Tests

1 2 3 4 5 6 7

Patient Overview Disease Overview NCP References

 CHRONIC PANCREATITIS
A progressive disorder characterized by ongoing
inflammation and destruction that may occur
insidiously.

PANCREATITIS ACUTE PANCREATITIS

The sudden onset of reversible inflammation of
Inflammation of the
pancreas. the pancreas.

TOP 3 CAUSES
Gallstones
Alcohol use
Hypertriglyceridemia (7%)

8, 12
 ACUTE PANCREATITIS PATHOPHYSIOLOGY
Systemic immunoinflammatory response →
localized autodigestion
of the pancreas + other remote organ systems

1 2 3 4 5

Unspecified trigger Premature Activation and Amplification Release of cytokines,

activation of release of trypsin process inflammatory
proteolytic into the mediators, and
digestive cytoplasm of the inflammatory cell
enzymes acinar cell recruitment

7
ATLANTA CRITERIA
2 out of the 3 following:
Abdominal pain
Serum amylase or lipase levels 3x normal level
Imaging
ACUTE
RANSON CRITERIA PANCREATITIS
Modified vs. unmodified
5 parameters upon adm, 5-6 parameters at 48 hrs
↓ Score = ↓ Probability of complications/
mortality

SEVERE ACUTE PANCREATITIS

A CONDITION
The presence of any organ failure or local
Diagnostic Criteria &
pancreatic complications (i.e. pseudocyst,
Classification
abscess, or necrosis)

4, 5
 HYPERMETABOLIC,
HYPERDYNAMIC DISEASE ACUTE
PROCESS

PANCREATITIS
Effects on Nutrition
SYSTEMIC INFLAMMATORY
Status
RESPONSE

CONSEQUENCES:
Reduced oral intake Nutrient losses
Reduced oral intake Nutrient losses
Oxidative stress Catabolism Abd pain Maldigestion
Food aversions Malabsorption
-Maldigestion N/V Protein loss
-Malabsorption Gastroparasis/ileus Fistulas
Energy expenditure -Protein loss Partial duodenal obstruction The Power of
Inflammation
-Fistulas Visual Charts
-Inflammation)
7
FREQUENTLY COEXISTS WITH
SECONDARY CONDITIONS
-i.e. poor diet, alcohol use, obesity, metabolic
syndrome, T2DM

HYPERTRIGLYCERIDEMIA
CLASSIFIED AS PRIMARY OR SECONDARY
-Primary: familial or inherited etiology
Type 1 (LPLD)
↑
Type 4 ( VLDL)
↑
Type 5 ( VLDL & chylomicrons)
-Secondary: one or more secondary factors
contribute

DUH'S VALUE A high level of

triglycerides in
>500 mg/dL
the blood.
6
PATHOPHYSIOLOGY
OF HTG CAUSING AP
TWO THEORIES

5
 PRESENTATION OVERVIEW

Signs, Symptoms,
and Diagnostic Literature Review Summary
Tests

1 2 3 4 5 6 7

Patient Overview Disease Overview NCP References

Energy
NUTRITION
-Indirect calorimetry
-25 kcal/kg/day INTERVENTIONS
Protein
-1.2 - 1.5 g/kg/day

Choice of nutritional support is determined by disease

severity
3 options: EN, PN, PO
>Disease severity = more likely to benefit from EN
Aspen, Espen, & Article 1: Nutrition
EN vs. PN (ASPEN & ESPEN) Management in Acute Pancreatitis: Clinical
Practice Consideration
-EN preferred over PN
↓
- Mortality rate, risk of complications, and mean LOS
3, 7, 9
 DIGESTION

PROCESS NUTRITION
INTERVENTIONS:
Eat food
PANCREATIC REST
Duodenum
BACKGROUND
Stimulate CCK and
secretin
Stimulate bile, bicarb, and
pancreatic enzymes
Breakdown nutrients TRADITIONAL THINKING

Absorbed in small
↑Pancreatic auto-digestion
intestine Worsening pancreatitis

GOAL
↓ Pancreatic stimulation
Article 1 & Presentation by Dr. Satish Nagula: "Contemporary PN, EN, elemental formulas, stepwise
Management of Acute Pancreatitis: Dispelling Myths and Optimizing intro to PO
9, 10
Care"
 Pancreatic rest as sole Ineffective
management: No impact on pt outcome
NUTRITION
INTERVENTIONS:
PANCREATIC REST
ASPEN'S VIEW
Reduce pancreatic enzyme
Resolving
output to subclinical levels
inflammation
= sufficient

7
When to start
-Severe, necrotic pancreatitis = within 48 hours of adm (ASPEN)
-Within 24-72 hours of adm w/ intolerance to oral feeding
(ESPEN)

Continuous vs. Bolus

-Continuous > bolus NUTRITION
-Better feeding tolerance, fewer delivery interruptions
INTERVENTIONS:
Tube Choice EN
-NGT = first line of therapy (easier, cheaper, time-friendly)
-NJT used if there is digestive intolerance

Aspen, Espen, & Article 1

Formula Choice
-Polymeric > elemental/semi-elemental

3, 7, 9
 EN helps maintain... EN helps reduce...
NUTRITION
INTERVENTIONS: EN Gut function Bacterial, endotoxin,
and pancreatic
WHY DOES IT WORK?
enzyme
translocation

Gut integrity

Gut permeability

Gut-associated
lymphoid tissue
Systemic
inflammation, multi-
organ failure, and
Gut microbiota
infection, disease
composition
severity

ASPEN & Presentation by Dr. Satish Nagula

7, 10
PROS & CONS OF NUTRITION ROUTES
Article 2: Pragmatic Management of Nutrition in Severe Acute Pancreatitis

PROS CONS
↑ risk of worsening pancreatitis
Oral
No procedures or devices required
↑ risk of morbidity/mortality
Easier to adjust regimen/calories
Easier to transition to home regimen
↑ range of variation in caloric intake
Difficult to ensure adequate intake at home

Bedside access Possible ↑ risk of pancreatic stimulation

Nasogastric No need for enteral pump Not suitable in patients with GOO and/or need for gastric
Permits ↑ feeding rates and bolus feeds venting

Post pyloric placement may be difficult

Potential ↓ risk of aspiration Requires pump
Bolus feeding not possible
Nasojejunal Post-pyloric placement
Possible ↓ pancreatic stimulation ↑ risk of tube clogging/dislodgment
Tube migration risk

Bypass need for luminal absorption Requires central venous access

Can be used for pts with bowel obstruction or ↑ risk for line related infections and DVT
PN perforation ↑ risk of mucosal barrier dysfunction and/or bacterial
Can be used for pts with intractable N/V translocation/infection
↑ morbidity/mortality compared with EN 13
 NUTRITION
INTERVENTIONS
HOW DO WE FEED PANCREATITIS
PATIENT FOCUSED APPROACH
PATIENTS?

Start diet early when pt is HUNGRY

Can skip the clear liquid diet, start with low-

fat or regular diet

Objective data have no bearing on feeding

tolerance
Presentation by Dr. Satish Nagula

10
 PRESENTATION OVERVIEW

Signs, Symptoms,
and Diagnostic Literature Review Summary
Tests

1 2 3 4 5 6 7

Patient Overview Disease Overview NCP References

 ANTHROPOMETRICS

HEIGHT: ADMIT ADMIT BMI:

182.9 cm (6 ft) WEIGHT: 30.7 kg/m2
(4/2/21) 102.8 kg (226 lb Obese grade I
10.1 oz) (11/05/21
0600)
 ANTHROPOMETRICS

CURRENT DESIRABLE USUAL NFPE

WT BODY WT BODY WT -No overt losses
96.8 kg (213 lb 6.5 (%DBW) (%UBW) -Skin: Intact
oz) - bed wt on 80.9 kg (178 lb) 220 lb per pt

11/15/21 -Pt at 119.6% of report

DBW 11/15 -Pt at 97% of UBW
11/15
 gk ni tW

0
25
50
75
100
125
07
/1
9/2
0
08
/1
9/2
0
09
/1
5/2
0
10
/2
7/2
0
11
/0
6/2
0
12
/1
5/2
0
01

Date
/0
5/2
1
02
Weight History

/2
3/2
1
03
/2
3/3
2
ANTHROPOMETRICS

04
/0
2/2
1
06
/0
1/2
1
06
/1
5/2
1
11
/0
5/2
1
-5.7% (6.2 kg) in 5 mo
 ANTHROPOMETRICS
Weight Changes this Adm

125

100

75 -5.7% in under 3 weeks during

gk ni tW

adm - clinically significant

50

25

0
1

1
/2

/2

/2

/2

/2

/2

/2

/2

/2

/2
5

5
/0

/0

/0

/0

/0

/1

/1

/1

/1

/1
11

11

11

11

11

11

11

11

11

11
Date
NUTRITIONAL
REQUIREMENTS
Calculation Weight Used: 99.7 kg,
standing wt on 11/11/21

ENERGY PROTEIN FLUID

2490 - 2690 kcal/day 100 -130 g/day 1 mL/kcal or

(25-27 kcal/kg) (1-1.3 g/kg) per team
MEDICATIONS
PTA DURING ADM

Diabetes Scheduled and sliding scale insulin

Metformin XR Senokot-S
Jardiance Pepcid
Lantus 2g Mg sulfate x1 11/12
Ozempic Reglan x1 11/11
Novolog (wasn't taking 10/25) PRN
Dexcom Zofran
Other Compazine
Adderall XR Miralax
Tricor
Lisinopril
Citrucel
Crestor
 LIPASE LEVELS
3/30/20 - 10/29/21
824 U/L

>450 U/L

>135 U/L

>4000 U/L
2
TRIGLYCERIDE
LEVELS 7,5 55 mg /d L
6/1/21 - 11/12/21

23 8 mg /d L

11
CAUSES

HIGH
Uncontrolled hyperglycemia &
under-insulinzation
SGLT2i

TRIGLYCERIDE

LEVELS
Decreased insulin Endocrinology Note
requirements 11/2/22

Decreased activity of lipoprotein

lipase RECOMMENDATIONS

Discontinue Ozempic and Jardiance

Insulin therapy - long acting and short acting

Acute rise in triglyceride levels
Metformin

Education The Power of

Visual Charts
POC GLUCOSE LEVELS
10/29/21 - 11/16/21

Hemoglobin A1C 10/29/21: 8.8%

GLUCOSE LEVELS
10/30/21 - 11/16/21

9
NUTRITION HX

Fruit, sometimes Jimmy

Breakfast Dean Breakfast
Sandwich

Sandwich, frozen pizza,

Lunch
Chex mix, fruit

Chicken or beef,
Dinner steamed vegetables,
and a starch
DIET RECALL ON 11/5/21
Appetite reduced since adm, suspect meeting <50% of needs

Breakfast Bites of pancake

1/2 of a turkey
Lunch
sandwich

3-4 bites of turkey,

Dinner
salad, and broccoli
 NUTRITION COURSE
INTERVENTION OVERVIEW

11/01-11/11 11/11 11/12 11/13

Pt with good intake on very NJT placed for NJ tube feeds TF reached goal
low fat diet, but having pancreatic rest started, pt NPO
abd pain with eating

11/14 11/15 11/16

CLD started Low fat, low cholesterol Diet advanced to
diet started; NJT regular
removed
Continue very low fat diet NUTRITION SCREEN
-Snacks from floor stock
FOR LOS 11/5/21
Trial Boost Glucose Control with RECOMMENDATIONS & INTERVENTIONS
breakfast

-190 kcal, 16 g pro, 16 g CHO per carton

Constipation and nausea r/t food

Suspect pt is meeting <50% of
Continue bowel regimen and anti-emetics
normal during this adm
per team
POC Glucose: 163-217 mg/dL x24
hours
Psyllium, Senokot-S, PRN Zofran
Weigh 2x/week to trend

9
 NUTRITION COURSE
INTERVENTION OVERVIEW

11/01-11/11 11/11 11/12 11/13

Pt with good intake on very NJT placed for NJ tube feeds TF reached goal
low fat diet, but having pancreatic rest started, pt NPO
abd pain with eating

11/14 11/15 11/16

CLD started Low fat, low cholesterol Diet advanced to
diet started; NJT regular
removed
NUTRITION
INITIAL INTERVENTIONS
-Continue NPO per team; when
ASSESSMENT
DIAGNOSIS medically able, recommend low
11/12/21 fat diet
-NI-5.3 Inadequate protein-
-Enteral Nutrition: start Peptamen
energy intake related to
1.5 @15mL/hr via NJ tube, adv by
pancreatitis as evidenced by
30mL q6h to goal of 70mL/hr
NPO for pancreatic rest, enteral
3% wt loss x2 weeks Minimum water flushes of
nutrition not yet started.
NPO day 1 for bowel rest, NJ 30mL q4h for tube patency
tube placed 11/11 -Monitor blood glucose, as
Eating well but had abd pain Peptamen 1.5 is lower in fat and
with eating higher in CHO
POC glucose: 138-260 mg/dL x -Weigh 1-2x weekly to trend
24 hr
 11/12/21 - TUBE FEEDS STARTED
Enteral Nutrition: start Peptamen 1.5 @15mL/hr via NJ
tube, adv by 30mL q6h to goal of 70mL/hr
At goal, provides 1680mL formula, 2520kcal, 316g
CHO, 114g protein, 1158mL free water
Minimum water flushes of 30mL q4h for tube
patency

TUBE FEED
ORDER 11/13/21 - TF AT
GOAL

11/15/21 - NJT
REMOVED, TF
DISCONTINUED
 MONITORING & EVALUATION
11/12-11/15

11/12 - TF started
Tube Feeds 11/13 - TF reached goal
TF at goal for 2 days (11/13-11/15)

Glucose and POC glucose levels measured

Blood Glucose Levels
frequently; remained elevated

Weight Recorded daily

Low-fat, low
Started 11/15
cholesterol diet
 NUTRITION COURSE
INTERVENTION OVERVIEW

11/01-11/11 11/11 11/12 11/13

Pt with good intake on very NJT placed for NJ tube feeds TF reached goal
low fat diet, but having pancreatic rest started, pt NPO
abd pain with eating

11/14 11/15 11/16

CLD started Low fat, low cholesterol Diet advanced to
diet started; NJT regular
removed
NUTRITION
FOLLOW-UP
INTERVENTIONS
ASSESSMENT
DIAGNOSIS -Continue regular diet to optimize
11/16/21 PO intake
-NI-5.3 Inadequate protein-
energy intake related to
-Reduce frequency of Boost
pancreatitis as evidenced by
Glucose Control to once daily with
previous NPO status with need
5.7% weight loss in under 3 lunch per pt request (250 kcal,
for enteral nutrition, EN at goal
weeks - clinically significant 23g CHO, 14g protein per serving)
x2 days before being d/c'd.
Regular diet
(improving).
Good appetite, drinking 1 -Weigh 1-2x weekly to trend
Boost/day
POC glucose: 164-295 mg/dL x
24 hr
 MONITORING & EVALUATION
11/16 - Discharge (11/16)

Regular Diet Started 11/16

Weights Recorded weekly

 PRESENTATION OVERVIEW

Signs, Symptoms,
and Diagnostic Literature Review Summary
Tests

1 2 3 4 5 6 7

Patient Overview Disease Overview NCP References

 Energy
Protein
JB AT DUH LITERATURE
Tube choice
Semi-elemental Polymeric
Pancreatic rest
formula formula
Low-fat diet
Regular diet

SUMMARY
Comparison of
Treatment Choices
 PRESENTATION OVERVIEW

Signs, Symptoms,
and Diagnostic Literature Review Summary
Tests

1 2 3 4 5 6 7

Patient Overview Disease Overview NCP References

 REFERENCES
1. Alkaade S, Vareedayah AA. A Primer on Exocrine Pancreatic Insufficiency, Fat Malabsorption, and Fatty Acid Abnormalities. American Journal of Managed
Care. 2017;23(12).
2. American Society for Clinical Pathology. (n.d.). Choosing wisely: Don’t test for amylase in cases of suspected acute pancreatitis. Instead, test for lipase.
American Family Physician . Retrieved January 10, 2022, from https://www.aafp.org/afp/recommendations/viewRecommendation.htm?
recommendationId=317
3. Arvanitakis M, Ockenga J, Bezmarevic M, et al. Espen guideline on clinical nutrition in acute and chronic pancreatitis. Clinical Nutrition. 2020;39(3):612-
631. doi:10.1016/j.clnu.2020.01.004
4. Basit H, Ruan GJ, Mukherjee S. Ranson Criteria. [Updated 2021 Sep 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.
Available from: https://www.ncbi.nlm.nih.gov/books/NBK482345/
5. de Pretis, N., Amodio, A., & Frulloni, L. (2018). Hypertriglyceridemic pancreatitis: Epidemiology, pathophysiology and clinical management. United
European gastroenterology journal, 6(5), 649–655. https://doi.org/10.1177/2050640618755002
6. Garg, R., & Rustagi, T. (2018). Management of Hypertriglyceridemia Induced Acute Pancreatitis. BioMed research international, 2018, 4721357.
https://doi.org/10.1155/2018/4721357
7. Gottschlich, M. M., Tiu, A., & McClave, S. A. (2007). Pancreatitis. In The A.S.P.E.N. Nutrition Support Core Curriculum: A case-based approach - the adult
patient (pp. 558–574). essay, American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).
8. Kota, S. K., Kota, S. K., Jammula, S., Krishna, S. V., & Modi, K. D. (2012). Hypertriglyceridemia-induced recurrent acute pancreatitis: A case-based review.
Indian journal of endocrinology and metabolism, 16(1), 141–143. https://doi.org/10.4103/2230-8210.91211
9. Lakananurak, N., & Gramlich, L. (2020). Nutrition management in acute pancreatitis: Clinical practice consideration. World journal of clinical cases, 8(9),
1561–1573. https://doi.org/10.12998/wjcc.v8.i9.1561
10. Nagula S. Contemporary Management of Acute Pancreatitis: Dispelling Myths & Optimizing Care. lecture presented at the: A Division of Gastroenterology
Grand Rounds presented by Satish Nagula, MD, Associate Professor of Medicine, Director of Endoscopic Ultrasound; December 12, 2021.
11. Ni L, Yuan C, Chen G, Zhang C, Wu X. SGLT2i: Beyond the glucose-lowering effect. Cardiovascular Diabetology. 2020;19(1). doi:10.1186/s12933-020-
01071-y
12. Quinlan, J. D. (2014). Acute Pancreatitis. Am Fam Physician, 90(9), 632–639.
13. Uppal, D. (2018). Pragmatic Management of Nutrition in Severe Acute Pancreatitis. Nutrition Issues in Gastroenterology, (179), 20–33.