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Vetenskaplig fallstudie
Case report — Tirzepatide-Associated Acute Pancreatitis or Biliary Sludge?
Om fallstudien
Fullständig akademisk fallstudie på engelska. Skriven för potentiell publicering i BMJ Case Reports,
Pancreatology eller npj Digital Medicine. Referens [16] = SGF 2024.
Abstract
Background
Tirzepatide (Mounjaro®), a dual GIP/GLP-1 receptor agonist, induces rapid weight loss associated with
biliary cholesterol supersaturation. We report a case in which the attribution of acute pancreatitis to
drug toxicity (ICD-10 K85.3) is questioned by an extensive multi-source dataset — identifying biliary
aetiology as a strong differential diagnosis requiring formal investigation.
Case
A 45-year-old male (type 2 diabetes, diagnosed November 2025) achieved HbA1c 36 mmol/mol and
weight loss 18.8 kg (1.2 kg/week) on tirzepatide 7.5 mg/week. Pancreatitis onset 14 March 2026 at 15:30;
ambulance arrived priority 1 at 18:30; amylase 68 µkat/L (62×ULN). Glooko CGM data revealed pre-pancreatitis
hypoglycaemia (TBR 9.9%, nadir 2.8 mmol/L). Bilirubin 20→30→7 µmol/L (Days 0→2→4) and gamma-GT 1.30 µkat/L
supported biliary aetiology. MRCP and EUS were not performed.
Conclusion
Seven evidence lines support biliary sludge (K85.1) as a strong differential diagnosis. MRCP/EUS and formal
drug causality assessment should be performed before K85.3 is retained as definitive aetiology.
Data sources
20 974
readings
CGM (Glooko)
Abbott LibreView + Dexcom ONE+
266
days
Apple Watch HRV/HR
Aug 2025–Apr 2026
190
measurements
Weight
Apple Health
24
injection logs
Shotsy app
Pharmacokinetic modelling
Seven evidence lines for biliary aetiology
| # | Evidence | Finding | Reference |
|---|
| 1 | Transient hyperbilirubinaemia | 20→30→7 µmol/L (Day 0→2→4) | Passage-kinetics pattern. Tenner 2013: sensitivity 67–74% for biliary pancreatitis. |
| 2 | Gamma-GT elevation at admission | 1.30 µkat/L (ref <0.80 male) | Eddie 2014: elevated GGT predicts biliary aetiology. Persists 0.88 at Day +24. |
| 3 | Lithogenic metabolic baseline | LDL 3.4, TG 2.0, T2D, BMI 35.1 | Ruhl & Everhart NHANES: T2D = 2–3× gallstone risk. |
| 4 | Weight loss rate 1.2 kg/week | 16 weeks, 18.8 kg total | Shiffman 1991: risk increases sharply above 0.5 kg/week. Patient: 2.4× threshold. |
| 5 | Pharmacological gallbladder hypomotility | GIP+GLP-1 dual receptor inhibition | Poulsen 2021: GIP/GLP-1 receptors attenuate CCK-mediated gallbladder contraction. |
| 6 | Pre-pancreatitis hypoglycaemia cascade | TBR 9.9%, nadir 2.8 mmol/L (CGM) | Novel finding: proposed fasting-induced CCK abolition. CGM accuracy caveat applies below 3.5 mmol/L. |
| 7 | HRV-documented SIRS severity | 23.9 ms nadir (−52% from baseline) | Lonini 2018: HRV depression correlates with SIRS grade. |
SGF 2024 compliance (Table 8)
| SGF recommendation | GRADE | Status |
|---|
| MRCP or EUS — negative ultrasound + persistent gallstone suspicion | 1B | Not done |
| Formal drug causality assessment (Naranjo/structured) | 2A | Not done |
| Aetiology identification and treatment | 1C | Unresolved |
| Cholecystectomy if mild biliary pancreatitis confirmed | 1A | Not offered |
| Outpatient follow-up when aetiology unclear | 2C | Not planned |
References (selected)
[1] Frías JP, et al. N Engl J Med. 2021;385:503–515.
[3] Shiffman ML, et al. Am J Gastroenterol. 1991;86:1000–1005.
[5] Poulsen SS, et al. Peptides. 2021;136:170453.
[6] Tkáč I, et al. Diabetes Obes Metab. 2015;17:763–769.
[8] Naranjo CA, et al. Clin Pharmacol Ther. 1981;30:239–245.
[16] Regnér S, et al. SGF Nationella riktlinjer akut pankreatit. Fastställt 2024-05-02.