What are the causes and management of pancreatitis?

Causes of Pancreatitis

Gallstones and alcohol abuse account for approximately 75% of all acute pancreatitis cases, with gallstones being the most common cause overall. 1, 2

Primary Etiologies

Most Common Causes (75% of cases)

• Gallstones: The leading cause of acute pancreatitis, suggested by early elevation in serum aminotransferases or bilirubin 1, 2
• Alcohol: Excessive alcohol consumption is the second most common cause, requiring documentation of intake in units per week 1

Other Important Causes (Remaining 25%)

• Hypertriglyceridemia: A metabolic cause requiring measurement of blood lipid concentrations after the acute phase 1, 2
• Medications: Drug toxicity should be documented through detailed medication history 1, 2
• Post-ERCP trauma: Endoscopic retrograde cholangiopancreatography can induce pancreatitis in 3-5% of procedures 3, 2
• Hypercalcemia: Blood calcium concentrations should be measured if etiology remains unclear 1, 2
• Abdominal or cardiac surgery: Recent surgical procedures should be noted in the clinical history 1, 2
• Infections: Viral exposure through prodromal illness should be documented 1, 2
• Anatomical variations: Pancreas divisum and ampullary tumors require ERCP evaluation in recurrent cases 1
• Autoimmune pancreatitis: Consider in cases with unclear etiology 2
• Ischemia: Vascular compromise can trigger pancreatitis 2
• Hereditary causes: Genetic factors in select patients 2
• HIV infection: Comorbid conditions should be documented 1

Diagnostic Workup for Etiology

Early Assessment (First 48-72 hours)

• Serum aminotransferases and bilirubin: Early elevation suggests gallstone etiology 1
• Alcohol history: Document weekly consumption in units 1
• Medication review: Complete drug history to identify potential toxicity 1
• Ultrasound examination: Early scanning for gallstones, repeated if initially negative 1

Late Assessment (After acute phase)

• Blood lipid levels: Measure if etiology not established to detect hypertriglyceridemia 1
• Calcium levels: Check for hypercalcemia as potential cause 1
• ERCP indications: Perform in presence of jaundice, dilated common duct, or recurrent attacks to exclude anatomical variations, ampullary tumors, and common duct stones 1
• CT scanning: Particularly in elderly patients to exclude pancreatic tumor when etiology remains obscure 1
• MRI scanning: Additional imaging if doubt remains about tumor presence 1

Idiopathic Pancreatitis

The etiology should be determined in 75-80% of cases, with no more than 20-25% classified as "idiopathic" (Grade B recommendation). 1

Advanced Evaluation for Idiopathic Cases

• Endoscopic ultrasound: Emerging technique for detecting common bile duct stones 1
• Bile sampling: Assessment for microlithiasis in patients with repeated attacks and no identified cause 1
• Sphincter of Oddi manometry: Under evaluation for select cases 1
• MRI cholangiography: Additional imaging modality under evaluation 1

Common Pitfalls to Avoid

• Incomplete alcohol history: Failure to accurately document alcohol intake in units per week can miss a major etiology 1
• Single negative ultrasound: Gallstones require repeat ultrasound if initially negative, as they are easily missed 1
• Premature closure on "idiopathic": More than 20-25% idiopathic cases suggests inadequate workup 1
• Missing medication causes: Incomplete drug history overlooks iatrogenic pancreatitis 1
• Delayed lipid and calcium testing: These should be measured after acute phase if etiology unclear 1