You’re working Black Friday when a young diabetic female arrives to your ED complaining of abdominal pain and lethargy after eating every carbohydrate and gram of fat in sight yesterday. Who could blame her? She also stopped taking her insulin approximately 2 weeks ago. Being the astute physician that you are, you are concerned for DKA and order all the appropriate labs. Moments later, your nurse runs to you, frantically, thinking she hit a lymphatic duct and shows you her blood samples, as pictured above.

[spacer height=”20px”]You’re like, what the?
[spacer height=”20px”]Could this be gross lipemia?
[spacer height=”20px”]Does this really exist?
[spacer height=”20px”]Yes it does. This ain’t a sci fi flick.
[spacer height=”20px”]So why might one have gross lipemia?  Typically this is caused by triglyceride levels exceeding 1000 mg/dl. Causes of such elevated TG levels may be primary in nature due to genetic disorders of lipid metabolism or secondary, which most commonly include: Type I or II DM, type I DM in DKA especially due to lack of insulin and elevated stress hormones, alcohol, estrogen, hypothyroidism, pregnancy, and medications like propofol, protease inhibitors, beta blockers, and thiazides. If you see this, do your in-patient team a service and order a lipid panel.
[spacer height=”20px”]Additionally, don’t disregard that abdominal pain as a typical DKA induced discomfort, because hypertriglyceridemia (HTG) is the third most common cause of acute pancreatitis, accounting for approximately 1-4% of cases. There have been several studies showing correlations between diabetes, often DKA, with hypertriglyceridemia and the development of pancreatitis. The number of complications associated with HTG induced pancreatitis is roughly equal to other causes, with one study showing 13% with abscesses, 15% with necrosis and 37% with pseudocysts (Fortson, et al). Importantly, lipase levels may not be elevated in HTG induced pancreatitis, with the same aforementioned study showing only 67% with elevations and the remaining diagnoses made based on CT scan.  So, if you see this patient, order that lipase and consider CT based on your clinical assessment.
[spacer height=”20px”]Today’s pearl inspired by Dr.’s Cruz and Li.
[spacer height=”20px”]Fortson, Mark R., Sandra N. Freedman, and P. D. Webster 3rd. “Clinical assessment of hyperlipidemic pancreatitis.” The American journal of gastroenterology 90.12 (1995): 2134-2139.
[spacer height=”20px”]Nair, Satheesh, Dhiraj Yadav, and C. S. Pitchumoni. “Association of diabetic ketoacidosis and acute pancreatitis: observations in 100 consecutive episodes of DKA.” The American journal of gastroenterology 95.10 (2000): 2795-2800.
[spacer height=”20px”]Yadav, Dhiraj, and C. S. Pitchumoni. “Issues in hyperlipidemic pancreatitis.”Journal of clinical gastroenterology 36.1 (2003): 54-62.