Hypertriglyceridemia is an established cause of pancreatitis. In a case-based approach, we present a review of hypertriglyceridemia and how it can cause pancreatitis. We outline how to investigate and manage such patients. A 35 year old man presented to the emergency department with abdominal pain and biochemical evidence of acute pancreatitis. There was no history of alcohol consumption and biliary imaging was normal. The only relevant past medical history was that of mild hyperlipidemia, treated with diet alone. Physical exam revealed epigastric tenderness, right lateral rectus palsy, lipemia retinalis, bitemporal hemianopsia and a delay in the relaxation phase of his ankle reflexes. Subsequent laboratory investigation revealed marked hypertriglyceridemia and panhypopituarism. An enhanced CT scan of the head revealed a large suprasellar mass impinging on the optic chiasm and hypothalamus. The patient was treated supportively; thyroid replacement and lipid lowering agents were started. He underwent a successful resection of a craniopharyngioma. Post-operatively, the patient did well on hormone replacement therapy. He has had no further attacks of pancreatitis. This case highlights many of the factors involved in the regulation of triglyceride metabolism. We review the common causes of hypertriglyceridemia and the proposed mechanisms resulting in pancreatitis. The incidence and management of hypertriglyceridemia-induced pancreatitis are also discussed.

Toxic megacolon (TM) is an infrequent but devastating complication of colitis. Numerous forms of colonic inflammation can give rise to TM but the majority occur in individuals with inflammatory bowel disease (IBD). Recently there has been a marked increase in the number of reports of TM associated with pseudomembranous colitis. Because of the associated high morbidity and mortality, early recognition and management of TM is of paramount importance. The mechanisms involved in development of TM are not clearly delineated, but chemical mediators such as nitric oxide and interleukins may play a pivotal role in the pathogenesis. New evidence suggests that TM and its associated morbidity may be predicted by the extent of small bowel and gastric distension in patients with colitis. CT scanning may also play an important role the management of TM, in that it may be the only noninvasive mode to detect subclinical perforations and abscesses. Management involves close medical attention, supportive care, and treatment of the underlying colitis. Possible exacerbating factors such as narcotic and anticholinergic medications must be withdrawn, and colonic decompression via tube drainage or positional techniques must be considered. Signs of progression or complications of the disease must be treated aggressively with surgical intervention, as delay is associated with even greater risk of mortality.

Existing predictor systems of severe pancreatitis are cumbersome and can require up to 48 hr to complete. This study aimed to determine whether useful likelihood ratios exist for the prediction of severe pancreatitis, corresponding to various ranges of admission hematocrit. A retrospective cohort of 200 patients admitted with acute pancreatitis was identified. Likelihood ratios were calculated for a priori defined hematocrit ranges. Using multivariate logistic regression, initial hematocrit was evaluated as a predictor of severe pancreatitis as defined a priori by local and/or systemic complications (Atlanta criteria, 1992). Planned subgroup analysis was performed on those with a hematocrit >50%, stratified by 24-hr hematocrit. Fourteen patients (7%) developed severe pancreatitis. Likelihood ratios were 0.45, 0.70, and 7.5 for hematocrit ranges of < or =45, 45.1-49.9, and > or =50%, respectively. Hematocrit (as increases by 5%) was a significant predictor of severe pancreatitis (odds ratio [OR] = 2.8; P = 0.001), length of stay (P < 0.0001), necrosis (OR = 3.9; P = 0.001), and need for intensive care (OR 4.5; P = 0.002). The negative predictive value of the lowest range and positive predictive value of the highest range were 97% (95% CI: 92-99%) and 37% (16-62%), respectively. Lack of normalization of hematocrit by 24 hr did not predict severe pancreatitis. Initial hematocrit appears to be an early, simple, and useful predictor of severe pancreatitis. A normal 24-hr hematocrit does not appear to alter the prediction made by the initial hematocrit.

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Hydrogen peroxide is a widely available disinfectant that has been reported to cause colitis. We report a case of a 67-year-old man who presented with an acute proctitis caused by a self-inflicted 3% hydrogen peroxide enema. The patient's intention was to cure himself of a recently diagnosed prostate cancer, because the waiting list for oncological consultation was deemed too long. The pathogenesis of hydrogen peroxide mucosal injury and a review of the literature is discussed.