Triglyceride Pancreatitis

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mauricekenter

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So you have a new onset pancreatitis patient who denies alcohol, GB ultrasound is normal, LFTs and such are all normal. Do you guys get a lipid panel to check for triglycerides on these people? It's the 3rd most common cause and I never routinely do this.

What if it isn't a new onset, but the old records show it never being done? Is there anytime we should ever be ordering this?

Thanks for your help!

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I don't really see the ED as the place for getting a lipid panel in that situation. He's likely coming in anyway so he'll get a proper one in the hospital.
 
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Also ideally should be fasting. I leave this step to the medicine squad. Granted, the TG level would be massive fasting or not, but why order a lab that is supposed to be fasting when the patient hasn't been. There might be other utility to the IP team or the PCP to have a meaningful lipid panel.

Also, I make sure to scour all my patients with unclear etiology pancreatitis for scorpion stingers. High yield.
 
Also ideally should be fasting. I leave this step to the medicine squad. Granted, the TG level would be massive fasting or not, but why order a lab that is supposed to be fasting when the patient hasn't been. There might be other utility to the IP team or the PCP to have a meaningful lipid panel.

Also, I make sure to scour all my patients with unclear etiology pancreatitis for scorpion stingers. High yield.

Hahaha I lived in AZ for a decade and of all the scorpion stings I heard of (including my own), I never heard of it inducing pancreatitis. But then again I wasn't examining these people. How often is it actually seen?
 
^^The scorpion species classically associated with pancreatitis is found in Trinidad.
 
Also ideally should be fasting. I leave this step to the medicine squad. Granted, the TG level would be massive fasting or not, but why order a lab that is supposed to be fasting when the patient hasn't been. There might be other utility to the IP team or the PCP to have a meaningful lipid panel.

Also, I make sure to scour all my patients with unclear etiology pancreatitis for scorpion stingers. High yield.
There is evidence to support non-fasting lipid panels being better predictors of cardiac disease.

At any rate, I don't order triglyceride levels in the ED to say "hey, it's normal so they can go home." Rather it's always icing on the cake when you tell the hospitalist you aren't sure what caused the pancreatitis but you have a triglyceride level pending. They think of you as trying to figure something out and looking out for the patient instead of just moving the meat. It helps later when you have a difficult dispo.
 
Just chiming in to echo what Southerndoc said. Doesn't help dispo, but to show IM that I am aware of the differential.

Also, you can order the triglyceride level on its own...you don't need to order the entire lipid profile.

The times when it's been positive, though, the entire specimen is lipemic to begin with. That's a pretty decent indirect indicator in my opinion.
 
Just chiming in to echo what Southerndoc said. Doesn't help dispo, but to show IM that I am aware of the differential.

Also, you can order the triglyceride level on its own...you don't need to order the entire lipid profile.

The times when it's been positive, though, the entire specimen is lipemic to begin with. That's a pretty decent indirect indicator in my opinion.

This has been exactly my experience as well--calls from lab of grossly lipemic blood with TG ending up being >3000 the 3 times I've seen it. And, as most people with pancreatitis are functionally NPO with pain and vomiting, lots of those specimens would qualify as fasting regardless.
 
Rather it's always icing on the cake when you tell the hospitalist you aren't sure what caused the pancreatitis but you have a triglyceride level pending. They think of you as trying to figure something out and looking out for the patient instead of just moving the meat. It helps later when you have a difficult dispo.

This does make us feel like we have doctor friends and not monkeys working in the ED

We are very cynical about these things :laugh:
 
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Hi! This is my first time EVER on a forum of any kind! I'm not quite sure how it all works but when I was looking noticed the words Pancreatitis & Trygliseride so I thought I'd share my story.
At 34yrs old I was rushed to my local GP with the most awful upper abdo pain, my GP immediately had me rushed into hospital with "suspected pancreatitis" I had no idea what this was or what the pancreas actually did, all I did know was that this pain was worse than when my appendix exploded inside me at 24!!!
I was given a GB ultra sound, an X-ray, bloods, urine was taken, was begging for pain relief and was given first paracetamol, then Tramadol, did not touch it, was then given codeine and paracetamol, was told I was extremely distended, x-rays showed a very impacted bowel, was told buy ultra sound nurse that there was so much gas she could not give a definitive yes/no on Gaul Stones said tell them to get you sorted first then will look again. After a night of agony it got better and was sent back home next day. I was rushed in no less than 6 times in 4/5 mts every time the same happened and was given food to eat, no ct scan, no broad spectrum anti biotics no real pain relief and repeatedly sent home! Until I was so ill I was staying with my mum, who lived in a different area with a different hospital to go to, first time I was rushed in I was told no food! Given loads of fluids, a CT scan and an Endoscopy. Cut a long story, the results were horrifying! I was told after nearly a year of being taken to the other hospital and sent home, that I had Chronic Pancreatitis, I was asked how much I drink each day-none! I said, I had stopped drinking on weekends after work due to alcohol not mixing with my ADHD at 28yrs old, I was told that I must be lying as I had the pancreas of a 90yr old man or a chronic alcoholic! My mum was with me as was my Fiancé who both confirmed I was T total! I was not believed and when told the implications of this "atrophic pancreas" I burst in to tears! I just could not get my head around it. I was asked why I had been back and forth the other hospital so many times yet I had not been ct scaned? I didn't have the answers, they then agreed to take over and I had to stay with them as not to confuse things. I was also told I was lucky to still be alive as they shouldn't have fed me, I should of been put on a high dependency ward and CT or MRI'd at least with loads of fluids etc. not sent back home. They did more tests but I was referred back to the first hospital as that was my catchment area and told NEVER to go back to the hospital that diagnosed me as it was complicating things! After seeing a specialist there was again accused of being an alcoholic! This started to bother me and offend me, I told them this but was ignored, yet in the same meeting was told my LFT's were "extremely abnormal" @ 124 and this pointed to alcohol abuse! Then 10 mins later was told my Trygliseride lvls were very high and "probably the cause of it" I was so confused! So I did my own research and found that LFT's of 124 on that ONE occasion were nowhere near abnormal, just slightly elevated and all the paracetamol could have done that and real alcoholics lvls could be in the 500-10,000 mark normal being about 40-80! And was told my Trygliseride lvls were 7.4, which when I looked on nhs site were totally way beyond high, as 0.6 being normal over 2.5 high and over 5 very, very high! I was stunned at their total lack of listening skills and what my results were showing them. I was told that it was incurable, degenerative and possibly fatal, but could be managed with pain relief, I was told that I could turn diabetic and my enzymes could stop working, but this might take 20yrs to happen. With In 6mts I was told I was diabetic type 3c this was irrivesable but with daily injections and a total life style change could be managed. A year and a half later was told my enzymes had now stopped working! Was put on Creon and told if I did not take with every meal an snack would basically starve to death! Was passed on to a proper pancreatic unit 60 miles away and they have been brilliant with me! Was told by them that by the time I was passed on to them my pancreas was so bad there was absolutely nothing they could do except pain management and they were sorry. Was given a CT scan and told no way was this alcohol related as there was no calsification present and was either genetic, trauma or high calcium or trygliseride lvls I told them of the results of my first test and they were quite shocked it had not even been treated with statins! Was told by original lipid clinic they were not treating the excessive high levels "as the damage has already been done I'm afraid" these tests were only taken 8-11mts after first admission with "suspected pancreatitis" by GP! was told my other cholesterol lvls were fine at 5.0 and was nothing to do with diet. He said he would not expect this kind of damage until lvls were 10 or grater, but the second test I had 3/4 mts later showed them as 3.5, so my question was this- if they were 7 with their delayed tests and were half that now, who is to say they weren't 14 at time of first admission???? This bothers me because now I'm severely disabled and can't gel wondering if it could have been prevented had the right tests and scans been done straight away. They now admit they were wrong about it being alcohol related but as 70% is either that or Gaul stones then they did jump to that conclusion, no apologies mind. I feel I have been so poorly treated and my life could be so different now had they listened to me and also followed NHS procedure when pancreatitis is suspected, as there is a 34% mortality rate if not diagnosed with in 48-72 hrs. How could this happen?
 
Hi! This is my first time EVER on a forum of any kind! I'm not quite sure how it all works but when I was looking noticed the words Pancreatitis & Trygliseride so I thought I'd share my story.
At 34yrs old I was rushed to my local GP with the most awful upper abdo pain, my GP immediately had me rushed into hospital with "suspected pancreatitis" I had no idea what this was or what the pancreas actually did, all I did know was that this pain was worse than when my appendix exploded inside me at 24!!!
I was given a GB ultra sound, an X-ray, bloods, urine was taken, was begging for pain relief and was given first paracetamol, then Tramadol, did not touch it, was then given codeine and paracetamol, was told I was extremely distended, x-rays showed a very impacted bowel, was told buy ultra sound nurse that there was so much gas she could not give a definitive yes/no on Gaul Stones said tell them to get you sorted first then will look again. After a night of agony it got better and was sent back home next day. I was rushed in no less than 6 times in 4/5 mts every time the same happened and was given food to eat, no ct scan, no broad spectrum anti biotics no real pain relief and repeatedly sent home! Until I was so ill I was staying with my mum, who lived in a different area with a different hospital to go to, first time I was rushed in I was told no food! Given loads of fluids, a CT scan and an Endoscopy. Cut a long story, the results were horrifying! I was told after nearly a year of being taken to the other hospital and sent home, that I had Chronic Pancreatitis, I was asked how much I drink each day-none! I said, I had stopped drinking on weekends after work due to alcohol not mixing with my ADHD at 28yrs old, I was told that I must be lying as I had the pancreas of a 90yr old man or a chronic alcoholic! My mum was with me as was my Fiancé who both confirmed I was T total! I was not believed and when told the implications of this "atrophic pancreas" I burst in to tears! I just could not get my head around it. I was asked why I had been back and forth the other hospital so many times yet I had not been ct scaned? I didn't have the answers, they then agreed to take over and I had to stay with them as not to confuse things. I was also told I was lucky to still be alive as they shouldn't have fed me, I should of been put on a high dependency ward and CT or MRI'd at least with loads of fluids etc. not sent back home. They did more tests but I was referred back to the first hospital as that was my catchment area and told NEVER to go back to the hospital that diagnosed me as it was complicating things! After seeing a specialist there was again accused of being an alcoholic! This started to bother me and offend me, I told them this but was ignored, yet in the same meeting was told my LFT's were "extremely abnormal" @ 124 and this pointed to alcohol abuse! Then 10 mins later was told my Trygliseride lvls were very high and "probably the cause of it" I was so confused! So I did my own research and found that LFT's of 124 on that ONE occasion were nowhere near abnormal, just slightly elevated and all the paracetamol could have done that and real alcoholics lvls could be in the 500-10,000 mark normal being about 40-80! And was told my Trygliseride lvls were 7.4, which when I looked on nhs site were totally way beyond high, as 0.6 being normal over 2.5 high and over 5 very, very high! I was stunned at their total lack of listening skills and what my results were showing them. I was told that it was incurable, degenerative and possibly fatal, but could be managed with pain relief, I was told that I could turn diabetic and my enzymes could stop working, but this might take 20yrs to happen. With In 6mts I was told I was diabetic type 3c this was irrivesable but with daily injections and a total life style change could be managed. A year and a half later was told my enzymes had now stopped working! Was put on Creon and told if I did not take with every meal an snack would basically starve to death! Was passed on to a proper pancreatic unit 60 miles away and they have been brilliant with me! Was told by them that by the time I was passed on to them my pancreas was so bad there was absolutely nothing they could do except pain management and they were sorry. Was given a CT scan and told no way was this alcohol related as there was no calsification present and was either genetic, trauma or high calcium or trygliseride lvls I told them of the results of my first test and they were quite shocked it had not even been treated with statins! Was told by original lipid clinic they were not treating the excessive high levels "as the damage has already been done I'm afraid" these tests were only taken 8-11mts after first admission with "suspected pancreatitis" by GP! was told my other cholesterol lvls were fine at 5.0 and was nothing to do with diet. He said he would not expect this kind of damage until lvls were 10 or grater, but the second test I had 3/4 mts later showed them as 3.5, so my question was this- if they were 7 with their delayed tests and were half that now, who is to say they weren't 14 at time of first admission???? This bothers me because now I'm severely disabled and can't gel wondering if it could have been prevented had the right tests and scans been done straight away. They now admit they were wrong about it being alcohol related but as 70% is either that or Gaul stones then they did jump to that conclusion, no apologies mind. I feel I have been so poorly treated and my life could be so different now had they listened to me and also followed NHS procedure when pancreatitis is suspected, as there is a 34% mortality rate if not diagnosed with in 48-72 hrs. How could this happen?

First, that's the NHS for you. Second, your post is going to get removed, probably, because SDN is not for medical advice.
 
Ok thx for advice on how it works maybe I could edit it and take the last bit away with question mark? I just want to educate people on this condition and share my personal experiences. As I said in post this is first one ever and not quite sure how it all works. So what just opinions is it?
 
Lol looking at it now I realise it is not that type of forum. I'll learn lol.
 
Lipids and admit, but it's really just to impress medicine. I only order it if it's a non alcoholic, non GB disease type pt that didn't just crawl out of a scorpion pit.
 
I don't need the lipids. Just call me with pancreatitis and were square. They're going to be npo I'll get the lipids later. I do want a ruq if there lfts or bili are up and if they have gb pain. Otherwise I'm fine with a lipase and clinical story it's an easy admit. Don't even really need the ct unless they're quite sick
 
Whether IM asks for it or not I will always order it in someone who denies EtOH and has no evidence for gallstones as the cause of pancreatitis. It's useful because invariably I get interns who are so convinced the patient's lying about not being an alcoholic that it's nice to point out that there is another reasonable explanation for it. Honestly, it's the cause in around 10% of my acute pancreatitis patients. (The rest are obvious EtOH or gallstone etiology). Do I ever wait for the levels to come back? no. Same reason I never wait for the u/s results to come back. It won't affect my management, only the inpatient's team. Pancreatitis is an easy 1 hour in and admitat my shop.
 
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For what it is worth, as a Medicine trained physician I'd be more impressed if triglycerides had been ordered, but it would not make the decision to admit any different. The reality is that if the clinical condition of the patient is not consistent with discharge they do need to come in, emesis and inability to take PO means they need analgesia and meds, they need a bed. Essentially agree with Boston.
I've played this game often, I've been able to tee up the guy for discharge from Emergency once in a while, admitted them often, transferred to the ICU every so often...that's medicine for ya! Of course, those who enter the ICU with critical illness are the most interesting and fun, but that's a biased opinion from an intensivist junkie!
Now ICU pancreatitis isn't the usual dance like a septic shock pt, but they have some cool things about them and bring the challenges of ARDS to the table.
 
...I was walking by while the RN was drawing her blood and saw the color of the sample... Asked if she would pull a purpletop for me and just watched the magic... Pretty amazing! Remember also medication induced, and idiopathic ~10% of cases... This patient had other stigmata on physical exam
 

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...I was walking by while the RN was drawing her blood and saw the color of the sample... Asked if she would pull a purpletop for me and just watched the magic... Pretty amazing! Remember also medication induced, and idiopathic ~10% of cases... This patient had other stigmata on physical exam

LOL, that's insane...
 
Just had a case.. Nurses drew blood.. told me it was lipemic.. TGs were over 4k. Lipase normal.. hx of pacreatits due to etoh.

If the nurses tell me its lipemic i order a cholesterol panel. If it is normal blood i dont.
 
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