What are the possible causes of pancreatitis in a 15-year-old male with no significant past medical history and normal triglyceride levels?

Possible Causes of Pancreatitis in a 15-Year-Old Male with Normal Triglycerides

In a 15-year-old male with no significant past medical history and normal triglycerides, focus your evaluation on gallstones (via abdominal ultrasound), medications (prescription and over-the-counter), trauma history, and viral infections, as these represent the most common etiologies in this age group after excluding hypertriglyceridemia. 1

Initial Diagnostic Approach

The AGA Institute guidelines emphasize that etiology should be established in at least 75% of acute pancreatitis cases through systematic evaluation 1. For this adolescent patient, the workup should specifically target:

Most Likely Causes in This Population

Biliary Disease:

• Gallstones remain a leading cause even in adolescents, particularly with obesity or hemolytic conditions 1
• Obtain abdominal ultrasonography immediately at admission to evaluate for cholelithiasis or choledocholithiasis 1
• If initial ultrasound is inadequate, repeat after recovery or consider endoscopic ultrasonography (EUS) as an accurate alternative 1

Medication-Induced:

• Obtain detailed prescription and nonprescription drug history including supplements, as drug-induced pancreatitis is commonly overlooked 1
• Common culprits in adolescents include valproic acid, azathioprine, 6-mercaptopurine, L-asparaginase, corticosteroids, and certain antibiotics 1, 2

Trauma:

• Specifically inquire about recent abdominal trauma, sports injuries, or motor vehicle accidents 1
• Blunt abdominal trauma can cause pancreatitis even days after the initial injury 1

Secondary Considerations

Metabolic Causes (Despite Normal Triglycerides):

• Measure serum calcium level at admission to exclude hypercalcemia 1
• While triglycerides are normal, confirm this was a fasting measurement; if not, obtain fasting levels after recovery 1
• Hypercalcemia from hyperparathyroidism or other causes can trigger pancreatitis 1

Infectious Etiologies:

• Viral infections (mumps, Coxsackie virus, EBV, CMV) are more common in pediatric populations 1
• Consider recent viral illness history in your evaluation 1

Autoimmune Disease:

• Assess for presence of concomitant autoimmune diseases, though less common in this age group 1
• Consider autoimmune pancreatitis if other causes are excluded 1

Anatomic/Congenital Abnormalities:

• Pancreas divisum and other ductal anomalies are relevant in younger patients 1
• Choledochal cysts can present in adolescence 1

Critical Laboratory Evaluation at Admission

Obtain the following at presentation 1:

• Amylase or lipase level (confirm diagnosis)
• Liver chemistries: bilirubin, AST, ALT, alkaline phosphatase (evaluate biliary etiology)
• Calcium level (exclude hypercalcemia)
• Triglyceride level (confirm normal; if elevated despite history, may indicate underlying disorder)

Important Clinical Pitfalls

Avoid Extensive Invasive Testing Initially:

• Extensive or invasive evaluation is NOT recommended for a single episode of unexplained pancreatitis in patients younger than 40 years 1
• This guideline specifically protects young patients from unnecessary procedures 1
• Reserve EUS and ERCP for recurrent episodes only 1

Do Not Pursue Genetic Testing Initially:

• Genetic testing is not recommended as part of initial workup, though may be considered in selected patients with recurrent disease or strong family history 1
• Family history of pancreatic disease should be documented but does not mandate immediate genetic evaluation 1

Recognize Idiopathic Pancreatitis:

• Even with thorough evaluation, approximately 25% of cases remain idiopathic 1
• In a young patient with a single episode and normal basic workup, observation with supportive care is appropriate 1

When to Pursue Advanced Imaging

CT or EUS is NOT indicated in this patient unless:

• He is older than 40 years (not applicable here) to screen for pancreatic malignancy 1
• He develops recurrent episodes requiring evaluation for anatomic abnormalities 1
• Initial ultrasound suggests biliary pathology requiring further characterization 1

Management Implications

Regardless of etiology, provide 1:

• Vigorous fluid resuscitation
• Supplemental oxygen as required
• Correction of electrolyte and metabolic abnormalities
• Pain control

The specific etiology will guide secondary prevention strategies, making accurate diagnosis important for long-term management 1.