What are the potential causes of pancreatitis in a 23-year-old female?

Causes of Pancreatitis in a 23-Year-Old Female

In a 23-year-old female, gallstones and alcohol are the two most common causes of acute pancreatitis, followed by medications, hypertriglyceridemia, and hypercalcemia as important considerations. 1

Primary Etiologies to Investigate

Gallstones (Most Common)

• Gallstone pancreatitis is the leading cause in young women and should be evaluated immediately with transabdominal ultrasound at admission 1
• Gallstones account for a significant proportion of acute pancreatitis cases, particularly in females of reproductive age 2
• If ultrasound is initially negative but clinical suspicion remains high, repeat imaging should be performed 3

Alcohol Consumption

• Ethanol is a predominant cause of acute pancreatitis alongside gallstones 1
• Even modest alcohol consumption can trigger pancreatitis in susceptible individuals 2
• A detailed alcohol history is essential, as patients may underreport consumption 3

Important Secondary Causes in Young Women

Medications (Drug-Induced Pancreatitis)

• 44 of the top 100 most prescribed medications in the United States have been implicated in acute pancreatitis 4
• Class I medications (strongest evidence) include: valproic acid, azathioprine, estrogen preparations, tetracycline, steroids, trimethoprim/sulfamethoxazole, and furosemide 4
• Valproic acid specifically causes life-threatening pancreatitis in both children and adults, with cases occurring shortly after initial use or after several years 5
• Obtain comprehensive medication history including oral contraceptives, antibiotics, and any recent medication changes 3

Metabolic Causes

• Hypertriglyceridemia: Check serum triglycerides at admission, as this is a notable cause in young patients 1
• Hypercalcemia: Measure calcium levels to exclude hyperparathyroidism or other causes of elevated calcium 3, 1

Anatomical and Structural Abnormalities

• In young patients with recurrent or unexplained pancreatitis, consider pancreatic ductal abnormalities, pancreas divisum, or microlithiasis 3
• Endoscopic ultrasound (EUS) is the preferred test for detecting these abnormalities when initial workup is negative 3

Less Common but Important Considerations

Autoimmune Pancreatitis

• Consider in young patients, particularly if there is concurrent autoimmune disease
• May present with atypical features compared to typical acute pancreatitis

Infectious Causes

• Parasitic infections such as Fasciola hepatica can cause acute edematous pancreatitis in young patients with no significant medical history 6
• Consider in patients with appropriate exposure history or travel to endemic areas 6

Genetic Factors

• In recurrent pancreatitis without identified cause, genetic testing may be warranted
• Family history of pancreatitis or unexplained pancreatic disease should raise suspicion 3

Diagnostic Workup Algorithm

Initial laboratory tests at admission should include: 1

• Lipase or amylase (≥3× upper limit of normal supports diagnosis)
• Liver function tests (AST, ALT, alkaline phosphatase, bilirubin)
• Serum triglycerides
• Serum calcium
• Complete blood count
• Renal function tests
• Glucose

Initial imaging: 1

• Transabdominal ultrasound to evaluate for gallstones
• Chest imaging to assess for complications

If etiology remains unclear after initial workup: 3

• Endoscopic ultrasound (EUS) is preferred for detecting microlithiasis, anatomical variants, and small tumors
• MRI with MRCP as complementary or alternative to EUS
• ERCP should NOT be performed for diagnostic purposes alone due to associated risks 3

Critical Pitfalls to Avoid

• Do not assume "idiopathic" pancreatitis without thorough investigation—the etiology should be determined in 75-80% of cases 3
• Do not overlook medication-induced pancreatitis, especially in patients taking valproic acid, estrogen preparations, or immunosuppressants 4
• Do not miss gallstones on a single negative ultrasound—repeat imaging if clinical suspicion persists 3
• Do not forget to check triglycerides and calcium, as these metabolic causes are treatable and prevent recurrence 1
• In young women of reproductive age, always inquire about oral contraceptive use, as estrogen preparations are Class I medications for drug-induced pancreatitis 4