Excessive alcohol use is often cited as the most common cause of acute pancreatitis, yet gallstones are actually the most common cause. Less common causes include hypertriglyceridemia (but not hypercholesterolemia) and only when triglyceride values exceed 1500 mg/dl (16 mmol/L), hypercalcemia, viral infection (e.g., mumps), trauma (to the abdomen or elsewhere in the body) including post-ERCP (i.e., Endoscopic Retrograde Cholangiopancreatography), vasculitis (i.e., inflammation of the small blood vessels within the pancreas), and autoimmune pancreatitis.
Pregnancy can also cause pancreatitis, but in some cases the development of pancreatitis is probably just a reflection of the hypertriglyceridemia which often occurs in pregnant women. Pancreas divisum, a common congenital malformation of the pancreas may underlie some cases of recurrent pancreatitis. Pancreatitis is less common in pediatric population.
The more mundane, but far more common causes of pancreatitis, as mentioned above, must always be considered first. However, the known porphyrinogenicity of many drugs, hormones, alcohol, chemicals and the association of porphyrias with autoimmune disorders and gallstones do not exclude the diagnosis of heme disorders when these explanations are used. A primary medical disorder, including an underlying undetected inborn error in metabolism, supersedes a secondary medical complication or explanation. As mentioned above, pancreatitis is less common in children but if seen, abuse or abdominal trauma should be suspected.
Rarely, calculi can form or become lodged in the pancreas or its ducts. Treatment varies but is of course aimed are removal of the offending stone. This can be accomplished endoscopically, surgically, or even by the use of ESWL.
Autoimmune disorders, lipid disorders, gallstones, drug reactions and pancreatitis itself are not primary medical disorders.
It is worth noting that pancreatic cancer is seldom the cause of pancreatitis.
Type 2 diabetes subjects have 2.8 fold higher risk for pancreatitis compared to non diabetic subjects.
People with diabetes should promptly seek medical care if they experience unexplained severe abdominal pain with or without nausea and vomiting.
Some of the causes of acute pancreatitis can be remembered by the acronym GET SMASHED.
Hypercalcaemia, hypertriglyceridaemia, hypothermia;
Drugs e.g., azathioprine, diuretics;
Acute hepatic porphyrias, including acute intermittent porphyria, hereditary coproporphyria and variegate porphyria, are genetic disorders that can be linked to both acute and chronic pancreatitis. Acute pancreatitis has also occurred with erythropoietic protoporphyria.
Conditions that can lead to gut dysmotility predispose patients to pancreatitis. This includes the inherited neurovisceral porphyrias and related metabolic disorders. Alcohol, hormones and many drugs including statins are known porphyrinogenic agents. Physicians should be on alert concerning underlying porphyrias in patients presenting with pancreatitis and should investigate and eliminate any drugs that may be activating the disorders.
Still, notwithstanding their potential role in pancreatitis, the porphyrias (as a group or individually) are considered to be rare disorders. However, since there are no systematic studies to determine the actual incidence of latent dominantly-inherited porphyrias in the world population, there is DNA or enzyme evidence of high rates of latency of classic textbook symptoms in families where porphyrias have been detected and the technology is not developed to detect all latent porphyrias, the diagnosis of underlying inborn errors of metabolism impacting heme should not be routinely eliminated in pancreatitis.
Many medications have been reported to cause pancreatitis. Some of the more common ones include the AIDS drugs DDI and pentamidine, diuretics such as furosemide and hydrochlorothiazide, the anticonvulsants divalproex sodium and valproic acid, the chemotherapeutic agents L-asparaginase and azathioprine, and estrogen. Just as is the case with pregnancy-associated pancreatitis, estrogen may lead to the disorder because of its effect of raising blood triglyceride levels.
Pancreatitis due to statins first started appearing in the medical literature as early as 1990. All statins currently in use reportedly can cause pancreatitis, a not surprising observation when one considers that all statins are reductase inhibitors and can be expected to have similar side effect profiles.
Hereditary pancreatitis may be due to a genetic abnormality that renders trypsinogen active within the pancreas, which in turn leads to digestion of the pancreas from the inside.
Pancreatic diseases are notoriously complex disorders resulting from the interaction of multiple genetic, environmental and metabolic factors.
Three candidates for genetic testing are currently under investigation:
- Trypsinogen mutations (Trypsin 1)
- Cystic Fibrosis Transmembrane Conductance Regulator Gene (''CFTR'') mutations
- ''SPINK1'' which codes for PSTI - a specific trypsin inhibitor.
Viruses can cause profound inflammation in, and destruction of, the pancreas. This is true of several viruses in the coxsackievirus group.
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