Heparin and insulin in the treatment of acute hypertriglyceridaemia-induced pancreatitis

Hypertriglyceridaemia is thought to be the aetiology in 3% of patients with acute pancreatitis, often associated with poorly controlled diabetes melli tus or chronic alcohol abuse. However, in patients with non-biliary pancrea titis, chylomicronaemia is an underrated cause of acute pancreatitis. The a ctivity of lipoprotein lipase (LPL) is crucial in removing triglycerides fr om the plasma; LPL gene mutations combined with secondary alterations in pl asma lipoproteins, such as occur in pregnancy, diabetes mellitus, and alcoh ol abuse can cause severe hypertriglyceridaemia and pancreatitis. Heparin a nd insulin stimulate LPL activity. During a 12 months' period we consecutively screened all patients with the diagnosis of acute non-biliary pancreatitis for hypertriglyceridaemia, to e valuate the prevalence of hypertriglyceridaemia-induced pancreatitis and to assess the outcome under standardised treatment with intravenous heparin a nd insulin. Hypertriglyceridaemia-induced pancreatitis was diagnosed in 5 o ut of 46 patients (11%) with acute pancreatitis. In 2 patients hypertriglyc eridaemia was associated with diabetes mellitus, in one patient with pregna ncy and in another with chronic alcohol abuse. Four patients had to be refe rred to the intensive care unit. Plasma concentrations of triglycerides wer e (median +/- range) 43 mmol/l (14.7 to 80.4); pancreas amylase was 574 U/l (155 to 1606), and lipase was 1003 U/l (330 to 3010). All patients had oed ematous pancreatitis demonstrated by CT scan. Treatment with i.v. heparin a nd i.v. insulin decreased triglyceride levels to less than 10 mmol/l within 2.8 days (1 to 6), the amylase and lipase levels returned to normal after 3 and 4 days respectively, and the abdominal pain was resolved. Hypertriglyceridaemia is a common and underdiagnosed etiology of acute non- biliary pancreatitis. Intravenous heparin and insulin is safe and effective in the treatment of hypertriglyceridaemia-induced pancreatitis. Low fat di et, supplements of (n-3) fatty acids ("fish oil") and fibrates are recommen ded for longterm maintenance therapy.