Acute pancreatitis causes
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2]; Tarek Nafee, M.D. [3]
Overview
Acute pancreatitis may be either idiopathic or caused by alcohol, gallstones, trauma, steroids, mumps, autoimmune diseases, ERCP, hypercalcemia, hyperlipidemia, hypertriglyceridemia or certain medications. Gallstones are the most common cause of acute pancreatitis, followed by chronic alcohol consumption (4-5 drinks daily for ~5 years). There are numerous primary and secondary causes of acute pancreatitis that must be considered in a patient's work up.
Causes
Gallstones are the most common cause of acute pancreatitis, followed by chronic alcohol consumption (4-5 drinks daily for ~5 years).[1] However; there are numerous primary and secondary causes of acute pancreatitis that must be considered in a patient's work up.[2]
Synopsis
The following table summarizes the most common causes of acute pancreatitis:[3]
| Cause | Frequency | Comment |
|---|---|---|
| Gallstones | 40% | Gallstones or sludge |
| Alcohol | 30% | 4-5 drinks daily for 5 years |
| Hypertriglyceridemia | 2-5% | >1000 mg/dL |
| Genetic | unknown | Causing recurrent acute or chronic pancreatitis |
| Drug-induced | <5% | Most commonly azathioprine, 6-mercaptopurine, didanosine, valproic acid, ACEi, mesalamine |
| Autoimmune | <1% | Presents as Type I or Type II |
| ERCP (Iatrogenic) | 5-10% of procedures | Treated with rectal NSAIDs or temporary pancreatic duct stent placement |
| Trauma | Blunt force trauma to the mid-abodmen | Blunt force trauma to the mid-abdomen |
| Infection | <1% | Primarily caused by CMV, mumps, or EBV.
May be caused by ascaris or clonorchis |
| Surgical | 5-10% of patients on cardiopulmonary bypass | - |
| Obstruction | Rare | Caused by celiac disease, crohn's disease, and perpetrated by pancreas divisium or sphincter of Oddi dysfunction |
Anatomical causes
Sphincter of Oddi dysfunction and pancreas divisium have been traditionally associated with the development of acute pancreatitis; however, recent data suggests otherwise.[4] Pancreas divisium has been associated with genetic mutations that may be the true underlying cause of pancreatitis. Alternatively, the presence of the abnormal anatomy alone may not predispose patients to acute pancreatitis; however, in lieu of a genetic mutation may superimpose on the existing anatomical variation to contribute in the pathogenesis of acute pancreatitis.[5][6]
Environmental causes
Chronic alcoholism and smoking have been associated with the development of acute pancreatitis. Though alcohol has been proposed to be pathogenic in combination with the presence of an underlying genetic mutation. Alcoholism causing pancreatitis is more common in males than females. This may be due to the propensity of males to consume alcohol more than females, or due to the genetic mutations occurring more commonly in males.[7][8]
Iatrogenic causes
Common iatrogenic causes of pancreatitis include ERCP procedures as well as use of medication. Hundreds of medications have been implicated in causing pancreatitis; however, the most common drugs include:[9][10]
- Steroid use
- Azathioprine
- 6-Mercaptopurine
- Didanosine
- Valproic acid
- Angiotensin Converting Enzyme inhibitors (ACEi)
- Mesalamine
It is extremely difficult to identify a particular drug which may be responsible for the development of pancreatitis as there are usually multiple possibilities to the underlying etiology of the pancreatitis in patients with comorbidities; however, patients hospitalized for acute pancreatitis are often found to be using one or more drugs associated with the development of the disease.[11][12]
Genetic causes
Several genes have been proposed to play a role in the pathogenesis of acute pancreatitis. While the exact role of every implicated genetic mutation is not fully understood, the following genes have been associated with the development of acute pancreatitis:[13][14]
Common Causes
A common mnemonic for the causes of pancreatitis spells "I get smashed", an allusion to heavy drinking (one of the many causes):
- I - idiopathic
- G - gallstone. Gallstones that travel down the common bile duct and which subsequently get stuck in the ampulla of vater can cause obstruction in the outflow of pancreatic juices from the pancreas into the duodenum. The back-flow of these digestive juices causes lysis (dissolving) of pancreatic cells and subsequent pancreatitis.
- E - ethanol (alcohol) - Alcohol has been proposed to cause acute pancreatitis in combination with genetic factors. It is more commonly a cause in males than females. This may be due to the propensity of males to chronically abuse alcohol, or by genetic factors more commonly present in males.
- T - trauma
- S - steroids - Commonly used in patients with autoimmune diseases. Type I presents with obstructive jaundice and elevated IgG4 levels. Type II presents in younger patients with no increase in IgG4 levels.
- M - mumps (paramyxovirus) and other viruses (Epstein-Barr virus, Cytomegalovirus)
- A - autoimmune disease (Polyarteritis nodosa, Systemic lupus erythematosus)
- S - scorpion sting - Tityus Trinitatis - Trinidad/ snake bite
- H - hypercalcemia, hyperlipidemia/hypertriglyceridemia and hypothermia
- E - ERCP (Endoscopic Retrograde Cholangio-Pancreatography - a procedure that combines endoscopy and fluoroscopy)
- D - drugs (SAND - steroids & sulfonamides, azathioprine, NSAIDS, diuretics such as furosemide and thiazides, & didanosine) and duodenal ulcers. Drugs often present with mild pancreatitis and rarely are associated with signs of drug allergy such as rash.
Causes by Organ System
Causes in Alphabetical Order
References
- ↑ Yadav D, Lowenfels AB (2006). "Trends in the epidemiology of the first attack of acute pancreatitis: a systematic review". Pancreas. 33 (4): 323–30. doi:10.1097/01.mpa.0000236733.31617.52. PMID 17079934.
- ↑ Forsmark CE, Vege SS, Wilcox M (November 17,2016). "Acute Pancreatitis". The New England Journal of Medicine: 1972–1981. doi:10.1056/NEJMra1505202. Retrieved November 25,2016. Check date values in:
|access-date=, |date=(help) - ↑ Forsmark CE, Vege SS, Wilcox M (November 17,2016). "Acute Pancreatitis". The New England Journal of Medicine: 1972–1981. doi:10.1056/NEJMra1505202. Retrieved November 25,2016. Check date values in:
|access-date=, |date=(help) - ↑ Coté GA, Imperiale TF, Schmidt SE, Fogel E, Lehman G, McHenry L; et al. (2012). "Similar efficacies of biliary, with or without pancreatic, sphincterotomy in treatment of idiopathic recurrent acute pancreatitis". Gastroenterology. 143 (6): 1502–1509.e1. doi:10.1053/j.gastro.2012.09.006. PMID 22982183.
- ↑ DiMagno MJ, Dimagno EP (2012). "Pancreas divisum does not cause pancreatitis, but associates with CFTR mutations". Am J Gastroenterol. 107 (2): 318–20. doi:10.1038/ajg.2011.430. PMC 3458421. PMID 22306946.
- ↑ Forsmark CE, Vege SS, Wilcox M (November 17,2016). "Acute Pancreatitis". The New England Journal of Medicine: 1972–1981. doi:10.1056/NEJMra1505202. Retrieved November 25,2016. Check date values in:
|access-date=, |date=(help) - ↑ Coté GA, Yadav D, Slivka A, Hawes RH, Anderson MA, Burton FR; et al. (2011). "Alcohol and smoking as risk factors in an epidemiology study of patients with chronic pancreatitis". Clin Gastroenterol Hepatol. 9 (3): 266–73, quiz e27. doi:10.1016/j.cgh.2010.10.015. PMC 3043170. PMID 21029787.
- ↑ Forsmark CE, Vege SS, Wilcox M (November 17,2016). "Acute Pancreatitis". The New England Journal of Medicine: 1972–1981. doi:10.1056/NEJMra1505202. Retrieved November 25,2016. Check date values in:
|access-date=, |date=(help) - ↑ Kaurich T (2008). "Drug-induced acute pancreatitis". Proc (Bayl Univ Med Cent). 21 (1): 77–81. PMC 2190558. PMID 18209761.
- ↑ Forsmark CE, Vege SS, Wilcox M (November 17,2016). "Acute Pancreatitis". The New England Journal of Medicine: 1972–1981. doi:10.1056/NEJMra1505202. Retrieved November 25,2016. Check date values in:
|access-date=, |date=(help) - ↑ Bertilsson S, Kalaitzakis E (2015). "Acute Pancreatitis and Use of Pancreatitis-Associated Drugs: A 10-Year Population-Based Cohort Study". Pancreas. 44 (7): 1096–104. doi:10.1097/MPA.0000000000000406. PMID 26335010.
- ↑ Forsmark CE, Vege SS, Wilcox M (November 17,2016). "Acute Pancreatitis". The New England Journal of Medicine: 1972–1981. doi:10.1056/NEJMra1505202. Retrieved November 25,2016. Check date values in:
|access-date=, |date=(help) - ↑ Whitcomb DC (2013). "Genetic risk factors for pancreatic disorders". Gastroenterology. 144 (6): 1292–302. doi:10.1053/j.gastro.2013.01.069. PMC 3684061. PMID 23622139.
- ↑ Forsmark CE, Vege SS, Wilcox M (November 17,2016). "Acute Pancreatitis". The New England Journal of Medicine: 1972–1981. doi:10.1056/NEJMra1505202. Retrieved November 25,2016. Check date values in:
|access-date=, |date=(help) - ↑ 15.0 15.1 "JAMA Network | JAMA Internal Medicine | Glucagonlike Peptide 1–Based Therapies and Risk of Hospitalization for Acute Pancreatitis in Type 2 Diabetes MellitusA Population-Based Matched Case-Control StudyGLP-1 and the Risk of Acute Pancreatitis". Retrieved 2013-02-26.