What workup is recommended for a patient with a history of recurrent pancreatitis, no alcohol use, recent marijuana use, and previous cholecystectomy (gallbladder removal), presenting with their 4th episode of pancreatitis?

From the Guidelines

For a patient with recurrent pancreatitis (4th episode) who has no alcohol use, recent marijuana use, and previous cholecystectomy, I recommend a comprehensive workup focusing on identifying less common etiologies, starting with endoscopic ultrasound (EUS) as the preferred diagnostic test, as suggested by the most recent guidelines 1. This approach is supported by the latest evidence, which emphasizes the importance of EUS in evaluating unexplained acute and recurrent pancreatitis, with a diagnostic yield of 29%–88% of patients 1. The workup should also include:

• Magnetic resonance cholangiopancreatography (MRCP) to evaluate for pancreatic ductal abnormalities, pancreas divisum, or choledocholithiasis
• Laboratory testing, such as triglyceride levels, calcium levels, IgG4 levels (for autoimmune pancreatitis), and genetic testing for hereditary pancreatitis (PRSS1, SPINK1, CFTR mutations)
• Consideration of cannabinoid hyperemesis syndrome as a potential contributor, given the patient's recent marijuana use
• Advice to discontinue marijuana use, as some studies suggest cannabis may be an underrecognized cause of recurrent pancreatitis
• Nutritional counseling for a low-fat diet and adequate hydration to prevent future episodes while the underlying cause is being determined If structural abnormalities are found, endoscopic retrograde cholangiopancreatography (ERCP) may be both diagnostic and therapeutic. It is essential to prioritize the patient's morbidity, mortality, and quality of life when determining the best course of action, and to consider the most recent and highest-quality evidence available, such as the 2022 AGA clinical practice update on the endoscopic approach to recurrent acute and chronic pancreatitis 1.

From the Research

Workup for Recurrent Pancreatitis

The patient's history of recurrent pancreatitis, no alcohol use, recent marijuana use, and previous cholecystectomy requires a thorough workup to determine the underlying cause.

• Primary investigations should include:
  • Liver function tests (LFT) 2
  • Serum calcium and triglyceride levels 2
  • Abdominal ultrasonography (USG) 2
  • Contrast-enhanced computed tomography (CECT) abdomen 2
• Secondary investigations may be necessary if the primary workup is negative, and may include:
  • Endoscopic ultrasound (EUS) 2, 3
  • Magnetic resonance cholangiopancreatography (MRCP) 2, 3
  • Endoscopic retrograde cholangiopancreatography (ERCP) 2
• The role of genetic testing may be considered in younger patients 3
• It is essential to rule out malignancy in patients over 50 years of age 2

Considerations for Recurrent Pancreatitis

• Recurrent acute pancreatitis can be caused by various factors, including gallstones, alcohol, and non-alcohol non-biliary causes 3, 4
• Idiopathic recurrent acute pancreatitis is diagnosed after excluding all known causes, and recurrence is higher in these patients 3
• Patients with non-biliary recurrent acute pancreatitis are prone to develop chronic pancreatitis 3
• The workup and management of recurrent acute pancreatitis should be individualized based on the patient's specific circumstances 4, 5

Additional Factors to Consider

• Marijuana use has been reported as a potential cause of pancreatitis, although the evidence is limited 5
• A detailed history of the patient's substance use, including marijuana, should be taken into account during the workup 6
• Abstinence from alcohol and other substances may be recommended to prevent recurrence 6