Hipertrigliseridemi İlişkili Nekrotizan Pankreatit Hastasında Yoğun Bakım Yönetimi
Özet
Nekrotizan pankreatit mortalite ve morbiditesi yüksek olan, tedavisi konusunda belirsizlikler içeren, önemli bir pankreatit türüdür ve etiyolojisinde hipertrigliseridemi de olabilmektedir.
Bölüm; hipertrigliseridemiye sekonder gelişen akut pankreatit olgumuzun yoğun bakım ünitesinde tedavi sürecini içermektedir. 35 yaş, erkek, ek hastalığı olmayan nekrotizan pankreatit hastası çoklu organ yetmezliği sebebiyle yoğun bakım ünitesine interne edilmiş ve 18 gün invaziv mekanik ventilasyon ile desteklenmiştir.16 seans plazma değişimi, 1 kez sürekli renal replasman tedavisi, hedeflenmiş terapötik ısı yönetimi, trigliserit düşürücü medikal tedavi, çoklu antibiyoterapi uygulanmış, ileri hemodinamik monitörizasyon ile yakın takip edilmiştir. Servis taburculuğu ardından sırasıyla girişimsel radyoloji tarafından perkütan drenaj ve genel cerrahi tarafından açık cerrahi ile nekroze koleksiyon drene edilmiştir. Uzayan tedavi süreci, servis yatışları sonunda (5 ay) kazanılmış güçsüzlük gelişen hasta fizik tedavi ve rehabilitasyon servisinde 2 ay yatırılarak tedavi edilip, bir yılın sonunda aktif yaşamına dönebilmiştir.
Necrotizing pancreatitis is a severe form of pancreatitis with high mortality and morbidity rates and remains a clinical challenge due to uncertainties in its management. Hypertriglyceridemia may also be among its etiological factors.
This chapter presents the treatment process of a case of acute pancreatitis secondary to hypertriglyceridemia managed in the intensive care unit. A 35-year-old, male patient with no known comorbidities was admitted to the ICU with necrotizing pancreatitis and multiple organ failure, requiring invasive mechanical ventilation support for 18 days. The patient underwent 16 sessions of plasma exchange, a single session of continuous renal replacement therapy (CRRT), targeted therapeutic temperature management, triglyceride-lowering medical treatment, and multiple antibiotic regimens, and was closely monitored using advanced hemodynamic monitoring techniques. Following discharge from the ICU, the patient underwent percutaneous drainage performed by interventional radiology and subsequently open surgical necrosectomy performed by general surgery. After a prolonged hospitalization period (5 months), the patient developed acquired weakness and was transferred to a physical therapy and rehabilitation unit, for 2 months. At the end of one year, the patient was able to return to an active lifestyle.
Referanslar
Gao L, Li W. Hypertriglyceridemia and acute pancreatitis: Clinical and basic research - A narrative review. J Pancreatol [Internet]. 2024 Mar 1 [cited 2025 Jul 28];7(1):53–60. Available from: /doi/pdf/10.1097/JP9.0000000000000153?download=true
Kiss L, Fűr G, Pisipati S, et al. Mechanisms linking hypertriglyceridemia to acute pancreatitis. Acta Physiologica [Internet]. 2023 Mar 1 [cited 2025 Jul 28];237(3):e13916. Available from: https://mayoclinic.elsevierpure.com/en/publications/mechanisms-linking-hypertriglyceridemia-to-acute-pancreatitis
Lee PJ, Papachristou GI. New insights into acute pancreatitis. Nature Reviews Gastroenterology & Hepatology 2019 16:8 [Internet]. 2019 May 28 [cited 2025 Jul 28];16(8):479–96. Available from: https://www.nature.com/articles/s41575-019-0158-2
Qiu M, Zhou X, Zippi M, et al. Comprehensive review on the pathogenesis of hypertriglyceridaemia-associated acute pancreatitis. Ann Med [Internet]. 2023 Dec 12 [cited 2025 Jul 28];55(2):2265939. Available from: https://www.tandfonline.com/doi/pdf/10.1080/07853890.2023.2265939
Hassanloo J, Béland-Bonenfant S, Paquette M, et al. Prevalence, severity and management of hypertriglyceridemia-associated pancreatitis; A 7-year retrospective cohort study at Canadian quaternary care hospitals. J Clin Lipidol [Internet]. 2022 Jul 1 [cited 2025 Jul 28];16(4):455–62. Available from: https://pubmed.ncbi.nlm.nih.gov/35659855/
Ge P, Luo Y, Okoye CS, et al. Intestinal barrier damage, systemic inflammatory response syndrome, and acute lung injury: A troublesome trio for acute pancreatitis. Biomedicine & Pharmacotherapy [Internet]. 2020 Dec 1 [cited 2025 Jul 29];132:110770. Available from: https://www.sciencedirect.com/science/article/pii/S075333222030963X?via%3Dihub
Mosztbacher D, Hanák L, Farkas N, et al. Hypertriglyceridemia-induced acute pancreatitis: A prospective, multicenter, international cohort analysis of 716 acute pancreatitis cases. Pancreatology [Internet]. 2020 Jun 1 [cited 2025 Jul 28];20(4):608–16. Available from: https://pubmed.ncbi.nlm.nih.gov/32402696/
Souza GD de, Souza LRQ, Cuenca RM, et al. UNDERSTANDING THE INTERNATIONAL CONSENSUS FOR ACUTE PANCREATITIS: CLASSIFICATION OF ATLANTA 2012. Arquivos Brasileiros de Cirurgia Digestiva : ABCD [Internet]. 2016 Jul 1 [cited 2025 Jul 28];29(3):206. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC5074676/
Capurso G, Ponz de Leon Pisani R, Lauri G, et al. Clinical usefulness of scoring systems to predict severe acute pancreatitis: A systematic review and meta-analysis with pre and post-test probability assessment. United European Gastroenterol J [Internet]. 2023 Nov 1 [cited 2025 Aug 2];11(9):825–36. Available from: /doi/pdf/10.1002/ueg2.12464
Teng TZJ, Tan JKT, Baey S, et al. Sequential organ failure assessment score is superior to other prognostic indices in acute pancreatitis. World J Crit Care Med [Internet]. 2021 Nov 9 [cited 2025 Aug 2];10(6):355–68. Available from: https://pubmed.ncbi.nlm.nih.gov/34888161/
Park JY, Jeon TJ, Ha TH, et al. Bedside index for severity in acute pancreatitis: comparison with other scoring systems in predicting severity and organ failure. Hepatobiliary & Pancreatic Diseases International [Internet]. 2013 Dec 15 [cited 2025 Aug 2];12(6):645–50. Available from: https://www.sciencedirect.com/science/article/abs/pii/S1499387213601010
Shuanglian Y, Huiling Z, Xunting L, et al. Establishment and validation of early prediction model for hypertriglyceridemic severe acute pancreatitis. Lipids Health Dis [Internet]. 2023 Dec 1 [cited 2025 Aug 2];22(1). Available from: https://pubmed.ncbi.nlm.nih.gov/38066493/
Ali H, Moond V, Vikash F, et al. Risk score to predict inpatient mortality of acute pancreatitis patients admitted to the intensive care unit. Pancreatology [Internet]. 2024 Dec 1 [cited 2025 Aug 2];24(8):1213–8. Available from: https://pubmed.ncbi.nlm.nih.gov/39462699/
Van Den Berg FF, Boermeester MA. Update on the management of acute pancreatitis. Curr Opin Crit Care [Internet]. 2023 Apr 1 [cited 2025 Jul 29];29(2):145. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9994841/
Arvanitakis M, Ockenga J, Bezmarevic M, et al. ESPEN guideline on clinical nutrition in acute and chronic pancreatitis. Clinical Nutrition [Internet]. 2020 Mar 1 [cited 2025 Jul 29];39(3):612–31. Available from: https://www.clinicalnutritionjournal.com/action/showFullText?pii=S0261561420300091
Maatman TK, Zyromski NJ. Surgical Step-Up Approach in Management of Necrotizing Pancreatitis. Gastroenterol Clin North Am [Internet]. 2025 Mar 1 [cited 2025 Jul 28];54(1):53–74. Available from: https://pubmed.ncbi.nlm.nih.gov/39880533/
Wu Y, Pan Y. Association between magnesium sulfate administration and short-term mortality in acute pancreatitis patients admitted to the ICU: a retrospective cohort study based on the MIMIC-III and MIMIC–IV database. Magnes Res [Internet]. 2025 Dec 1 [cited 2025 Aug 2];38(1):26–39. Available from: https://pubmed.ncbi.nlm.nih.gov/40626736/
Farooq U, Abbasi AF, Tarar ZI, et al. Understanding the role of frailty in local and systemic complications and healthcare resource utilization in acute pancreatitis: Findings from a national cohort. Pancreatology [Internet]. 2024 Feb 1 [cited 2025 Aug 2];24(1):6–13. Available from: https://www.sciencedirect.com/science/article/abs/pii/S1424390323018719?via%3Dihub
Nakai Y, Hamada T, Saito T, et al. Time to think prime times for treatment of necrotizing pancreatitis: Pendulum conundrum. Digestive Endoscopy [Internet]. 2023 Sep 1 [cited 2025 Aug 2];35(6):700–10. Available from: /doi/pdf/10.1111/den.14598
Ke L, Li G, Mao W, et al. Early versus delayed catheter drainage for patients with necrotizing pancreatitis and early persistent organ failure (TIMING): a multicenter randomized controlled trial. Intensive Care Med [Internet]. 2025 Jul 14 [cited 2025 Jul 28]; Available from: https://pubmed.ncbi.nlm.nih.gov/40658249/
Boxhoorn L, van Dijk SM, van Grinsven J, et al. Immediate versus Postponed Intervention for Infected Necrotizing Pancreatitis. New England Journal of Medicine [Internet]. 2021 Oct 7 [cited 2025 Jul 28];385(15):1372–81. Available from: https://pubmed.ncbi.nlm.nih.gov/34614330/
Valentin C, Cosquer G Le, Tuyeras G, et al. Step-up approach for the treatment of infected necrotising pancreatitis: real life data from a single-centre experience with long-term follow-up. BMC Gastroenterol [Internet]. 2024 Dec 1 [cited 2025 Jul 29];24(1). Available from: https://pubmed.ncbi.nlm.nih.gov/38943052/
Bang JY, Lakhtakia S, Thakkar S, et al. Upfront endoscopic necrosectomy or step-up endoscopic approach for infected necrotising pancreatitis (DESTIN): a single-blinded, multicentre, randomised trial. Lancet Gastroenterol Hepatol [Internet]. 2024 Jan 1 [cited 2025 Jul 29];9(1):22–33. Available from: https://pubmed.ncbi.nlm.nih.gov/37980922/
Tenner S, Vege SS, Sheth SG, et al. American College of Gastroenterology Guidelines: Management of Acute Pancreatitis. American Journal of Gastroenterology [Internet]. 2024 Mar 1 [cited 2025 Aug 2];119(3):419–37. Available from:https://journals.lww.com/ajg/fulltext/2024/03000/american_college_of_gastroenterology_guidelines_.14.aspx
