DOI: https://doi.org/10.36347/sjmcr.2026.v14i11.005

Pages: 2420-2424

Introduction. Hypertriglyceridemia (HTG) is the third most common cause of acute pancreatitis (AP). Serum lipase may remain below three times the upper limit of normal (ULN), which delays diagnosis. Case presentation. A 29-year-old obese man (BMI 30 kg/m²) was admitted to the intensive care unit 72 h after the onset of epigastric pain radiating to the back. He had respiratory distress (PaO2/FiO2 120), KDIGO stage 3 acute kidney injury, thrombocytopenia (120,000/mm³) and hypocalcemia. The serum was lactescent, triglycerides were 9.57 g/L and lipase was 66 IU/L, below 3 × ULN. Computed tomography showed Balthazar grade E AP with pancreatic necrosis of less than 30% (CTSI 6). The modified Marshall score was 4 and three SIRS criteria were met. Other causes of AP were excluded, including biliary lithiasis by magnetic resonance cholangiopancreatography (MRCP). Organ failures were corrected with echocardiography-guided fluid resuscitation, norepinephrine, renal protective measures, oxygen therapy and non-invasive ventilation. HTG was treated with insulin, unfractionated heparin, fenofibrate and lipid-free parenteral nutrition; triglycerides decreased by 93% in 4 days without plasmapheresis. The patient was transferred to the gastroenterology department on day 5. Conclusion. Lipase below 3 × ULN does not rule out hypertriglyceridemic AP, including severe forms. Diagnosis then relies on clinical presentation, imaging and exclusion of other causes.