The Question
A 48-year-old man with a history of type 2 diabetes mellitus and social alcohol use presents to the emergency department with one day of severe, constant epigastric pain that radiates to his back. The pain is associated with nausea and several episodes of non-bilious vomiting. His temperature is 37.9°C (100.2°F), heart rate is 118 beats/minute, blood pressure is 112/74 mm Hg, and respiratory rate is 20 breaths/minute. On examination, he is in moderate distress. His abdomen is tender to palpation in the epigastrium without guarding or rebound. Laboratory studies are significant for a lipase of 4200 U/L, AST of 95 U/L, ALT of 88 U/L, and a total bilirubin of 0.9 mg/dL. A fasting lipid panel reveals a triglyceride level of 2150 mg/dL. An ultrasound of the right upper quadrant shows a normal-appearing gallbladder without stones or sludge and a non-dilated common bile duct. The patient is admitted and started on aggressive intravenous fluid resuscitation and analgesia with improvement in his symptoms. Which of the following is the most appropriate intervention to prevent a future episode of pancreatitis?
See the answer and explanation below:
Post-Call Recovery Reads
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A
Explanation
Clinical Pearl:
In patients with acute pancreatitis secondary to severe hypertriglyceridemia (triglyceride level >1000 mg/dL), fibrate therapy is the cornerstone of secondary prevention after the acute episode resolves.
Explanation:
This patient's presentation with a markedly elevated lipase and a triglyceride level greater than 1000 mg/dL confirms the diagnosis of hypertriglyceridemia-induced acute pancreatitis. While initial management focuses on supportive care, the key to preventing recurrence is aggressively lowering the triglyceride level. Fenofibrate, a fibric acid derivative, is a first-line agent for treating severe hypertriglyceridemia and is the most appropriate intervention to reduce his risk of another episode. Cholecystectomy is indicated for the prevention of recurrent gallstone pancreatitis, but this patient's ultrasound showed no evidence of gallstones or biliary disease. ERCP is an invasive procedure indicated for suspected choledocholithiasis or cholangitis, neither of which is suggested here. Although counseling on alcohol cessation is good general advice, it does not address the primary metabolic cause of this patient's pancreatitis. High-dose statin therapy is less effective than fibrates for the profound triglyceride elevation seen in this case and is not the primary choice for pancreatitis prevention in this setting.
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