An Unusual Case of Hypertriglyceridemia Induced Enteritis

Introduction: Hypertriglyceridemia (HTG) induced pancreatitis is well described however its association with enteritis is rare and unknown. High suspicion is needed for diagnosis and early initiation of treatment. We describe an unusual case of enteritis in a patient with severe HTG who improved remarkably with timely intervention. Case: A 39 yo male with PMH of uncontrolled DM, familial HTG and non-compliance, presented with c/o sharp abdominal pain of 1 day duration in RUQ and RLQ, 8/10 in intensity. He denied any fever, n/v, diarrhea, hematochezia or melena. On exam, abdomen was diffusely tender to palpation without rebound. His blood sample showed milky serum. CBC, CMP and lipase were unremarkable except for elevated anion gap. Triglyceride (TG) level was found to be 7,696mg/dl. Serum lactate could not be measured due to lipemic specimen. Abdominal x-ray showed non-obstructive bowel gas pattern. He was started on insulin/dextrose drip. Due to persistent symptoms, CTA abdomen/pelvis w/contrast was done. It showed soft tissue and fat stranding in loops of small bowel suggestive of enteritis. With treatment, TG level trended down as did the severity of the abdominal pain. His pain completely resolved with TG levels ˜1000 mg/dl. Lipase levels were trended daily however they remained normal through his stay. He was discharged on gemfibrozil, niacin and omega-3-acid ethyl esters with close outpatient follow up. Discussion: HTG induced enteritis is extremely rare and only few cases are described. A review of literature reveals cases of HTG induced colitis in the pediatric population which resolved with reduction in TG levels. The mechanism is unclear given that the rarity of this presentation has precluded investigations. Clinicians should have a high suspicion of this diagnosis in patients with severe HTG and abdominal pain with normal lipase levels. Diagnosis is made with CT/MRI imaging demonstrating signs of bowel inflammation concurrent with serum TG > 1000 mg/dl. Treatment involves reduction of TG levels with insulin drip or plasmapharesis. Niacin and fibrates can be used as outpatient. Conclusion: Increased awareness is needed for physicians to keep HTG as a differential of abdominal pain. Although one can argue that lipemic serum can lead to acute colitis or that the hydrolysis of triglyceride into free fatty acids can be the cause of inflammation in the GI mucosa, a clear mechanism has not been established and more research is needed in this regard.Figure 1