Hyperlipidemic Pancreatitis

From: http://www.medal.org/

Overview :
Severe hyperlipidemia may precipitate episodes of acute pancreatitis. Future episodes of acute pancreatitis can be prevented by aggressive management of the unerlying lipid disorder and any secondary factors.

Conditions associated with hyperlipidemic pancreatitis:
(1) hereditary/familial hyperlipidemia types I, IV or V (Fredrickson's classification)
(2) hyperlipidemia with an acute increase from an acquired/secondary cause

Secondary causes for an acute rise in triglycerides:
(1) ethanol abuse
(2) obesity
(3) diabetes mellitus
(4) pregnancy
(5) hypothyroidism
(6) chronic renal failure
(7) parenteral lipid or propofol infusion
(8) medications (thiazides, tamoxifen, exogenous estrogen including oral contraceptives, beta blockers, protease inhibitors)

Laboratory findings:
(1) increased chylomicrons and/or VLDL
(2) serum triglycerides > 1,000 mg/dL
(3) milky (lactescent) serum
(4) amylase and lipase levels are variable, ranging from normal to elevated

NOTE: Marked elevation in serum cholesterol will not cause pancreatitis.

Management is directed to keep serum triglyceride levels below 1,000 mg/dL:
(1) dietary restriction of fat
(2) lipid lowering medications
(3) if secondary, avoidance of precipitating factors

References:
Liu Q, Prinz RA. Pancreatitis associated with hyperlipidemia and hyperparathyroidism. pages 271-280. IN: Howard JM, Idezuki Y, et al. Surgical Diseases of the Pancreas, Third Edition. Williams & Wilkins. 1998.
Toskes PP. Hyperlipidemic pancreatitis. Gastroenterol Clin N Am. 1990; 19: 783-791.
Yadav D, Pitchumoni CS. Issues in hyperlipidemic pancreatitis. J Clin Gastroenterol. 2003; 36: 54-62.

From: http://www.clinicalcorrelations.org/?p=478
Why do elevated triglycerides cause acute pancreatitis? The exact mechanism is unclear but it is thought to involve increased concentrations of chylomicrons in the blood. Chylomicrons are usually formed 1-3 hours post-prandially and cleared within 8 hours. However, when triglycerides levels exceed 1,000mg/dL, chylomicrons are almost always present. These low density particles are very large and may obstruct capillaries leading to local ischemia and acidemia. This local damage can expose triglycerides to pancreatic lipases. The degradation of triglycerides to free fatty acids can lead to cytotoxic injury resulting in further local injury that increases inflammatory mediators and free radicals, eventually manifesting as pancreatitis.