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A 38-year-old man with poorly controlled type 2 diabetes (HbA1c 10.2%) presents with severe epigastric pain radiating to the back, vomiting, and a serum amylase 6× the upper limit of normal. He drinks 60 units of alcohol per week. His plasma is visibly lipemic. Triglycerides are 38 mmol/L, total cholesterol 14 mmol/L, HDL-C 0.6 mmol/L, LDL-C cannot be calculated. CT confirms acute pancreatitis with no gallstones or biliary dilatation.
Questions
a) What is the most likely aetiology of the pancreatitis, and what is the pathophysiological mechanism? (2 marks)
b) Outline the immediate management of this metabolic emergency. (4 marks)
c) What is the long-term management strategy to prevent recurrence, naming specific drugs and doses? (4 marks)
Model answer
a) — Aetiology and mechanism (2 marks). The diagnosis is hypertriglyceridaemic pancreatitis due to severe hypertriglyceridaemia (TG over 10 mmol/L, here 38). Triglycerides are hydrolysed by pancreatic lipase to free fatty acids that injure acinar cells; chylomicrons also sludge in pancreatic capillaries causing ischaemia. Uncontrolled diabetes and alcohol excess are the precipitants. (1 mark diagnosis; 1 mark mechanism.)
b) — Immediate management (4 marks).
- Admit and make nil-by-mouth; give aggressive IV crystalloid resuscitation and opioid analgesia.
- Insulin infusion (activates lipoprotein lipase, accelerating chylomicron clearance) — typically 0.05–0.1 units/kg/hour with dextrose to maintain euglycaemia.
- Fenofibrate 145–200 mg once daily by nasogastric/enteral route once tolerated; a PPAR-α agonist that lowers triglycerides.
- Omega-3 fatty acids (e.g. icosapent ethyl) once enteral feeding is established.
- Therapeutic plasma exchange if TG remains severely elevated, the patient deteriorates, or there is pregnancy/refractory disease. Heparin is avoided because of rebound hypertriglyceridaemia and bleeding risk. (4 marks for the bundle; mark generously for insulin + fibrate + fluids/analgesia + plasmapheresis indication.)
c) — Long-term prevention (4 marks).
- Strict dietary fat restriction to under 10–15% of total energy (about 20–30 g/day).
- Complete alcohol abstinence and optimisation of glycaemic control (HbA1c target under 7% if achievable).
- Weight loss (5–10% if obese) and regular aerobic exercise.
- Fenofibrate 145–200 mg daily long-term; consider icosapent ethyl 2 g twice daily (4 g/day) if TG remains 1.5–5.6 mmol/L on a statin with ASCVD/diabetes risk.
- High-intensity statin for ASCVD risk reduction once pancreatitis resolves and lipids are controlled.
- Consider genetic testing for familial chylomicronaemia syndrome (LPL, ApoC-II, ApoA5, GPIHBP1 mutations) if young, recurrent, or strong family history. (4 marks for a comprehensive preventive plan including diet, alcohol, glycaemia, fibrate, and genetic testing.)