Acute pancreatitis is an acute inflammatory process of the pancreas
that may involve surrounding tissue and remote organ systems. The
disease can range from mild inflammation to severe extensive pancreatic
necrosis and multi-organ failure with mortality rates of 20% to
30% or higher.1–3 Most cases
are mild with a mortality rate <1% and resolve spontaneously
with supportive care.4–6 Diagnosis can
be difficult, because there is no pathognomonic clinical presentation
and no diagnostic gold standard.7
Table 82-1 lists common causes of pancreatitis.
The specific mechanism that triggers pancreatic inflammation remains
unclear. Although the etiology varies with sex, age group, and country, gallstones (including
microlithiasis) are the leading cause of acute pancreatitis,
accounting for at least 35% to 40% of cases8,9 and
significantly more than two thirds of cases in some regions.7
Table 82-1 Causes of Acute
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Table 82-1 Causes of Acute
|Gallstones (including microlithiasis)|
|Alcohol (acute and chronic alcohol consumption)|
|Endoscopic retrograde cholangiopancreatography|
|Autoimmune disease (e.g., systemic lupus erythematosus, Sjögren
|Genetic factors (PRSS1, SPINK1, CFTR)|
|Postoperative complications (abdominal or cardiac surgery)|
|Bacterial infections (Legionella, Leptospira, Mycoplasma, Salmonella)|
|Viral infections (mumps virus, coxsackievirus, cytomegalovirus,
echovirus, hepatitis B virus)|
|Parasitic infections (Ascaris, Cryptosporidium, Toxoplasma)|
|Posterior penetrating ulcer|
|Pancreatic or ampullary tumor|
|Pancreas divisum with ductular narrowing on pancreatogram|
|Oddi sphincter dysfunction|
Alcohol use is the second most frequent cause.10 The
association between alcohol consumption and acute pancreatitis is
not well understood. The incidence in alcoholics is surprisingly
low, which indicates not only that the amount of alcohol ingested
is important but that unknown factors affect susceptibility to the
Other causes of acute pancreatitis are uncommon, situational,
or subject to controversy (such as pancreas divisum or Oddi sphincter
dysfunction). About 5% of patients are at risk of developing
acute pancreatitis within 30 days after endoscopic retrograde cholangiopancreatography
(ERCP).12 Hypertriglyceridemia is a rare cause
(1% to 4%), and a serum level of >11 mmol/L
can worsen attacks.13,14
Many drugs are reported to be associated with acute pancreatitis, but
they account for only 1.4% to 2.0% of all cases.
Drugs associated with pancreatitis are classified into three groups.
Class I drugs are those associated with ≥20 case reports with at
least one drug reexposure. Class II drugs are those described in
≥10 to 20 case reports with or without reexposure. All other drugs
associated with the disease belong to Class III15 (Table 82-2).
Table 82-2 Drugs Associated
with Acute Pancreatitis
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