From the Guidelines
Recurrent pancreatitis is most commonly caused by gallstones, and cholecystectomy during the initial admission can prevent recurrent episodes. The causes of recurrent pancreatitis are multifactorial, including gallstones, alcohol abuse, hypertriglyceridemia, and genetic factors 1. Gallstones can block the pancreatic duct, leading to inflammation when digestive enzymes become trapped in the pancreas. Chronic alcohol consumption damages pancreatic cells directly and alters duct secretions. Hypertriglyceridemia (triglyceride levels above 1000 mg/dL) can trigger episodes, particularly in patients with underlying genetic lipid disorders.
Key Causes and Management
- Genetic mutations like those in the PRSS1, SPINK1, and CFTR genes increase susceptibility to recurrent attacks
- Anatomical abnormalities like pancreas divisum may contribute to recurrent pancreatitis, although the role of endoscopic therapy in these cases is still being studied 1
- Certain medications such as azathioprine, 6-mercaptopurine, and some antibiotics can cause pancreatitis
- Post-ERCP complications are also a recognized cause
- Idiopathic recurrent pancreatitis occurs when no cause is identified despite thorough investigation
Treatment Approach
Management focuses on treating the underlying cause, such as cholecystectomy for gallstones, which has been shown to substantially reduce the risk of recurrent biliary events and readmission for recurrent pancreatitis 1. Alcohol cessation, triglyceride-lowering medications, or discontinuing offending drugs are also crucial. Patients should avoid alcohol and tobacco, maintain a low-fat diet, stay hydrated, and take pancreatic enzyme supplements if prescribed to prevent further attacks.
In patients with pancreas divisum and recurrent acute pancreatitis, the decision to proceed with endoscopic therapy should be carefully considered, weighing the potential benefits against the risks of post-ERCP pancreatitis and other complications 1.
From the Research
Causes of Recurrent Pancreatitis
- Recurrent pancreatitis can be caused by numerous factors, including alcohol consumption, gallstones, subtle obstructive causes, and occult autoimmune disorders 2
- Idiopathic recurrent acute pancreatitis (IRAP) can be mechanical, toxic-metabolic, anatomical, or miscellaneous in nature 3
- The main causes of acute pancreatitis, which can lead to recurrent episodes, are gallstones and alcohol use 4
- Other factors that can contribute to the recurrence of acute pancreatitis include:
- Biliary or alcoholic events 5
- Severe hypertriglyceridemia (HTG) 6
- Younger age, alcohol abuse, and increased triglyceride levels 6
- Peak triglycerides level of greater than 3000 mg/dL and most recent triglycerides level of greater than 500 mg/dL 6
- Lifestyle factors, clinical complications, and surgical interventions 5
Risk Factors for Recurrence
- Alcohol and smoking are major risk factors for recurrent episodes of pancreatitis 4
- Patients with idiopathic RAP are at risk of developing chronic pancreatitis (CP) 3
- Malignancy should be ruled out in any patient with IRAP > 50 years of age 3
- Early CP can present initially as RAP 3
Diagnosis and Management
- Diagnosis of recurrent pancreatitis requires a detailed history and investigations, including liver function tests, serum calcium and triglyceride, abdominal ultrasonography, and contrast-enhanced computed tomography (CECT) abdomen 3
- Treatment of patients with IRAP is aimed at the specific aetiology, and empirical cholecystectomy should be discouraged with the availability and widespread use of endoscopic ultrasound (EUS) 3