Milk pancreatitis with hypertriglyceridemia and diabetic ketoacidosis.

Excessive milk intake may lead to diabetic ketoacidosis and acute pancreatitis. A 55-year-old milk salesperson with diabetes and dyslipidemia presented with a 5-day history of fatigue and thirst. The patient had drunk a large amount of milk for 2 months prior to the admission. Laboratory data showed metabolic acidosis, hyperglycemia, ketonuria, hypertriglyceridemia, and elevated serum amylase. Abdominal CT with contrast material revealed the swelling of the pancreas. The patient received medical treatment for diabetic ketoacidosis and acute pancreatitis and was discharged uneventfully on day 18. Dietary advice for diabetics should include the avoidance of excessive amount of milk.

Introduction

Drinking a large amount of soft drinks in diabetics can cause diabetic ketoacidosis, and it may also cause acute pancreatitis with hyperglyceridemia.1 Common dietary advice for diabetics includes avoidance of a large amount of soft drinks, but it rarely includes the avoidance of a large amount of milk or dairy products, especially in group sessions. Our patient, a milk salesperson with type 2 diabetes, took a large amount of milk instead of soft drinks after he received dietary advice for avoiding soft drinks; it led him to have a life‐threatening condition. Thus, the avoidance of excessive milk intake should be also included in dietary advice for diabetics.

Case Report

A 55‐year‐old milk salesperson with type 2 diabetes and dyslipidemia presented with a 5‐day history of fatigue and thirst. He drank alcohol occasionally, but he had not drunk alcohol since 1 week before arriving to our hospital. The blood pressure was 124/84 mm Hg, the pulse rate was 120 per minute, the respiratory rate was 30 per minute, and the temperature was 35.9°C. The patient had Kussmaul deep respiration with ketotic breath odor. His consciousness was drowsy. The skin and mucous membrane were dry. There was moderate tenderness over the epigastrium.

Laboratory data showed metabolic acidosis (pH 7.006 and anion gap 36 mEq/l in the arterial blood gas analysis), hyperglycemia(1193 mg/dL), ketonuria, hypertriglyceridemia (5591 mg/dL), and elevated serum amylase (816 IU/l). Abdominal CT (Figure 1 A, B, C, D; transverse views) with contrast material revealed the swelling of the pancreas (red arrows) surrounded by tissues with increased fat density and no dilatation or no stones of the common bile duct (green arrows). The patient received medical treatment for diabetic ketoacidosis and acute pancreatitis.

Figure 1

Enhanced abdominal CT of this patient

Based on the detailed medical history, the patient reported that he had drunk about 2 L of milk every day for 2 months prior to admission as a dietary replacement of soft drinks such as soda. The medical records of the patient revealed that he visited to the outpatient clinic twice at 6 and 2 weeks before the admission. His home doctor knew that the control of diabetes and hyperglyceridemia had worsen after the dietary advice and just added medications to control them. The patient did not report to the home doctor that the patient had decided to drink milk instead of soda.

He was discharged uneventfully on day 18. He received individualized dietary advice sessions from nutritionist before and after he was discharged. His blood glucose levels had been in good control at the time of the latest outpatient visit.

Discussion

Hypertriglyceridemia has been occasionally considered as a cause of acute pancreatitis with diabetic ketoacidosis.2, 3 Many of them were due to taking excessive soft drinks, and some of them were due to excessive alcohol drinking. To the best of our knowledge, there have been no reported cases with excessive intake of milk as a cause of acute pancreatitis with diabetic ketoacidosis. Although diabetic patients have been usually recommended for avoiding excessive intake of soft drinks and alcohol, they may also need to be educated for avoiding excessive intake of milk.

In the particular history of our patient, there might have been some points for possible chance to prevent him from pancreatitis or diabetic ketoacidosis. One point was the first dietary advice, and other points were the follow‐up visits to the clinic after the first dietary advice. As for the dietary advice, even if it was a group session, it still could have included feedback from patient regarding how they wanted to change their lifestyle after the session and what actually patient commonly ate and drank in average days. As for follow‐up visits, the medical interview could have included checking precisely about his dietary changes as a cause of the worsening control about diabetes and dyslipidemia of the patient rather than simply prescribing additional medications.

Our patient was a milk salesperson, but he might have had only commercial knowledge about milk for promoting it to his customers. Thus, precise nutritional knowledge of commercial dietary products may need to be confirmed in patients who work as salesperson for the products.

One serving (200 mL) of milk includes 8 grams (about 70 kcal) of fat (about 50% of total calorie of the milk).4 Thus, 2 L of milk has 80 grams (about 700 kcal) of fat. Three servings of milk (24 grams of fat) could be safely considered as the maximum limit of daily milk intake in patients with type 2 diabetes who need total caloric restriction.

Conclusions

Dietary advice for diabetics should include the avoidance of not only soft drinks but also a large amount of milk. Furthermore, it is necessary for dietary advice to include individualized dietary habits and to follow‐up them continuously afterward.

Conflicts of Interest

The authors have stated explicitly that there are no conflicts of interest in connection with this article.