From the Guidelines
The workup for recurrent pancreatitis should begin with a thorough history and physical examination, followed by laboratory tests including liver function tests, triglycerides, calcium levels, and pancreatic enzymes (amylase and lipase), and if no clear etiology is identified, endoscopic ultrasound (EUS) is the preferred diagnostic test, as recommended by the AGA clinical practice update 1. The initial evaluation should also include an abdominal ultrasound to evaluate for gallstones, which are a common cause. If EUS is not available or inconclusive, magnetic resonance imaging (MRI) with contrast and cholangiopancreatography (MRCP) are considered to be complementary or alternative tests to EUS in the evaluation of unexplained recurrent pancreatitis 1. Key points to consider in the workup include:
- Laboratory tests: liver function tests, triglycerides, calcium levels, and pancreatic enzymes (amylase and lipase)
- Imaging: abdominal ultrasound, and if necessary, EUS or MRI/MRCP
- Consideration of genetic testing for hereditary pancreatitis (PRSS1, SPINK1, CFTR mutations) in younger patients or those with a family history
- Evaluation of autoimmune pancreatitis with IgG4 levels
- Management involves treating the underlying cause, which may include cholecystectomy for gallstones, alcohol cessation counseling, triglyceride-lowering medications for hypertriglyceridemia, or endoscopic therapy for structural abnormalities 1. It is essential to note that endoscopic retrograde cholangiopancreatography (ERCP) should be reserved for therapeutic interventions rather than diagnosis due to its risk of precipitating pancreatitis 1. Recurrent episodes without an identifiable cause may require pancreatic enzyme supplementation and a low-fat diet to reduce pancreatic stimulation. The most recent and highest quality study recommends EUS as the preferred diagnostic test for unexplained acute and recurrent pancreatitis 1, and MRI/MRCP as a reasonable complementary or alternative test to EUS, based on local expertise and availability 1.
From the Research
Recurrent Pancreatitis Workup
The workup for recurrent pancreatitis involves a detailed history and investigations to determine the underlying cause.
- Primary investigations include:
- Secondary investigations, if the primary workup is negative, include:
Considerations in Recurrent Pancreatitis
- Malignancy should be ruled out in patients with idiopathic recurrent acute pancreatitis (IRAP) over 50 years of age 2
- Early chronic pancreatitis can present initially as recurrent acute pancreatitis 2
- The role of Sphincter of Oddi dysfunction (SOD) as a cause of IRAP remains controversial 2
- Pancreas divisum (PD) is now believed to be a cofactor, with associated genetic mutations being the main factor 2