Endgames Case Report

Diagnostic difficulties with a lipaemic blood sample

BMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.b5530 (Published 14 January 2010) Cite this as: BMJ 2010;340:b5530
  1. Augustin M S Brooks, specialist trainee year 4 in diabetes and endocrinology 1,
  2. Richard B Paisey, consultant in diabetes and endocrinology1,
  3. Michael J Waterson, consultant biochemist2,
  4. Jamie C Smith, consultant in diabetes and endocrinology1
  1. 1Department of Diabetes and Endocrinology, Torbay Hospital, Torbay, Devon TQ2 7AA
  2. 2Clinical Biochemistry Department, Torbay Hospital, Torbay, Devon TQ2 7AA
  1. Correspondence to: A M S Brooks augustinmarchand{at}hotmail.com

    A 38 year old woman with type 2 diabetes controlled by her diet was referred for emergency assessment in hospital by her general practitioner after complaining of epigastric pain radiating to her back.

    The patient was tachycardic and had epigastric tenderness on examination. A diagnosis of acute pancreatitis was suspected, but the patient’s serum amylase concentration was normal at 52 U/l (normal range 28-100 U/l) so alternative diagnoses were considered. The blood sample was noted to be lipaemic and a lipid profile was requested: serum cholesterol level was 27.9 mmol/l (1078.9 mg/dl) and serum triglyceride concentration was found to be greater than 100 mmol/l (8900 mg/dl). Chest radiograph did not show any gas under the diaphragm.

    The patient was prescribed simvastatin 40 mg once a day and commenced on an insulin infusion to decrease her serum triglyceride levels. She was also treated with intravenous fluids, but her abdominal pain worsened during the first 24 hours of hospital admission despite analgesia.

    Questions

    • 1) What is the suspected diagnosis and what is the likely cause?

    • 2) Why might the serum amylase result be unreliable in these circumstances?

    • 3) Is there another way to measure amylase levels?

    • 4) What further investigation would be most appropriate to establish the diagnosis?

    Answers

    1) What is the suspected diagnosis and what is the likely cause?

    Short answer

    The suspected diagnosis is acute pancreatitis secondary to hypertriglyceridaemia.

    Long answer

    Acute pancreatitis is a potentially life threatening condition with an incidence of 100 …

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