Portal Vein Thrombosis and Intra-Abdominal Hypertension Presenting as Complications of Hypertriglyceridemia-Induced Severe Acute Pancreatitis

A 44-year-old male without any significant past medical history presented to the emergency department (ED) with the chief complaint of severe constant epigastric pain for three hours. On physical examination, the abdomen was distended and tender, particularly in the epigastric region. The lab work showed an elevation of the lipase (12,405 U/L) and triglycerides (5,837 mg/dL). An abdominal CT scan with contrast was ordered, which revealed non-necrotic pancreatitis. In addition, the liver ultrasound showed no evidence of gallstones. Subsequently, fluid infusion, meropenem, pain medication, and an insulin drip were started, and the patient was transferred to the intensive care unit (ICU). After six hours in the ICU, he complained of abdominal pain despite taking a high hydromorphone dose. On further physical examination, the abdomen was tender and distended but without rebound tenderness. The gastric distention on kidneys, ureter, and bladder (KUB) and a bladder pressure of 34 mmHg raised the suspicion for intra-abdominal hypertension (IAH), which led us to place a nasogastric tube (NGT) and consult the surgical team. The patient's symptoms and bladder pressure were closely followed and showed significant improvement. On day seven in the ICU, the patient responded well to medications; feeding through the Dobhoff tube was started, and his triglycerides decreased to approximately 1,000 mg/dL. Despite his general improvement and meropenem regimen, the patient spiked a fever of 38.5 °C. Due to the possibility of pancreatitis complications, a CT abdomen with contrast was ordered, which showed partial portal vein thrombosis (PVT). Subsequently, enoxaparin was started, and the patient was closely observed for gastrointestinal bleeding. Eventually, after 17 days in the ICU, the patient was transferred to the floor and then discharged from the hospital with normal lab tests and without evidence of portal thrombosis on abdominal CT. In this report, we illustrate and discuss a case of hypertriglyceridemia (HTG)-induced pancreatitis (HTGP), which progressed to PVT and IAH. Physicians should be aware that patients with HTG are inclined to have severe pancreatitis. In addition, the degree of triglyceride elevation is correlated with the severity of acute pancreatitis.

Keywords: hypertriglyceridemia-induced acute pancreatitis; intraabdominal hypertension; portal vein thrombosis.