Pancreatitis, the inflammation of the pancreas, is a potentially life-threatening condition that manifests in both acute and chronic forms. The causes are multifactorial and understanding them is crucial for timely diagnosis, effective treatment, and prevention of complications.
To make this topic easier to grasp and retain, we will use a popular and student-friendly mnemonic:
“SIT very Close to DAD on Bed”
This phrase encodes multiple etiologies, from toxins to trauma, and from gallstones to drugs.
What Is Pancreatitis?
The pancreas is an essential organ involved in:
- Endocrine function (producing insulin and glucagon)
- Exocrine function (producing digestive enzymes)
Pancreatitis occurs when pancreatic enzymes become prematurely activated within the pancreas itself, leading to auto-digestion of pancreatic tissue.
Forms of Pancreatitis:
| Type | Description |
|---|---|
| Acute Pancreatitis | Sudden inflammation, often reversible |
| Chronic Pancreatitis | Long-term damage leading to fibrosis and dysfunction |
Mnemonic: “SIT very Close to DAD on Bed”
Let’s decode each letter of the mnemonic to understand the causes in depth.
S – Scorpion Sting
Though rare, scorpion envenomation is a documented cause of acute pancreatitis, especially in tropical regions like India and Brazil.
Mechanism:
- Venom induces release of catecholamines
- Causes pancreatic vasoconstriction
- Leads to pancreatic ischemia and injury
Clinical Tip: Always ask about exotic bites or stings in endemic areas.
I – Idiopathic Pancreatitis
“Idiopathic” means no identifiable cause even after extensive workup. However, ongoing research reveals hidden causes in many of these cases:
- Genetic mutations (e.g., SPINK1, PRSS1)
- Autoimmune pancreatitis (IgG4-related)
Idiopathic cases account for 10–30% of pancreatitis cases.
T – Trauma
Blunt or penetrating abdominal trauma can cause pancreatic duct injury.
Examples:
- Road traffic accidents
- Child abuse (in pediatrics)
- Post-surgical or iatrogenic trauma
Imaging: CT scan is essential for evaluation.
V – Valproic Acid
Valproic acid, an anti-epileptic drug, is associated with rare but serious pancreatitis.
Mechanism:
- Direct toxicity to acinar cells
- Free radical formation
Always monitor amylase and lipase levels in patients on long-term valproate therapy.
C – Corticosteroids
Prolonged or high-dose use of steroids can lead to:
- Hypertriglyceridemia
- Immunosuppression
- Direct enzyme activation in the pancreas
Pancreatitis usually resolves after tapering the dose or stopping the drug.
D – Drugs (HIV drugs and others)
A wide range of medications are linked with drug-induced pancreatitis.
Common culprits:
- Didanosine (HIV)
- Azathioprine
- Tetracyclines
- Furosemide
- Estrogens
Mechanisms include:
- Hypersensitivity
- Direct cytotoxicity
- Metabolic side effects
Drug discontinuation usually results in recovery.
A – Alcohol
One of the most well-known and common causes of both acute and chronic pancreatitis.
How alcohol causes pancreatitis:
- Increases pancreatic enzyme secretion
- Dehydrates pancreatic secretions
- Triggers inflammation and fibrosis
Chronic alcohol use damages acinar and ductal cells, eventually causing pancreatic calcification.
Daily intake >80g over 5 years is a red flag.
D – Diuretics
Certain loop and thiazide diuretics are associated with pancreatitis, especially in the elderly.
Examples:
- Furosemide
- Hydrochlorothiazide
Mechanism:
- Volume depletion → ischemia
- Electrolyte disturbances → acinar injury
B – Biliary Causes (Gallstones)
Gallstones are the most common cause of acute pancreatitis worldwide.
Pathogenesis:
- Gallstones migrate into common bile duct
- Temporarily block the pancreatic duct
- Leads to enzyme backup and tissue auto-digestion
Investigations:
- Ultrasound (initial)
- MRCP or ERCP (advanced)
Detailed Table: Pancreatitis Causes by Mnemonic
| Mnemonic Letter | Etiology | Details |
|---|---|---|
| S | Scorpion Sting | Rare; neurotoxic venom; prevalent in tropics |
| I | Idiopathic | No known cause; may involve genetics or autoimmune forms |
| T | Trauma | Blunt trauma, especially pediatric or post-surgical |
| V | Valproic Acid | Anti-epileptic drug with toxic effects on acinar cells |
| C | Corticosteroids | May induce enzyme activation or alter fat metabolism |
| D | Drugs | HIV meds, tetracycline, azathioprine, estrogens |
| A | Alcohol | Major global cause; dose-dependent damage to pancreas |
| D | Diuretics | Loop and thiazide diuretics linked to pancreatitis in elderly |
| B | Biliary Causes | Gallstones blocking duct → enzyme activation → acute pancreatitis |
Symptoms of Acute Pancreatitis
Common clinical presentation includes:
- Sudden severe epigastric pain radiating to back
- Nausea and vomiting
- Abdominal distension
- Low-grade fever
- Guarding and rebound tenderness
Complications:
- Pancreatic pseudocyst
- Necrosis and hemorrhage
- Acute kidney injury
- ARDS (Acute Respiratory Distress Syndrome)
Diagnostic Criteria: Modified Atlanta Classification
To diagnose acute pancreatitis, 2 of the 3 must be met:
- Abdominal pain typical of pancreatitis
- Serum amylase/lipase >3 times the upper normal limit
- Imaging findings (CT, MRI, USG)
Investigations
| Test | Purpose |
|---|---|
| CBC, CRP | Inflammation markers |
| Serum Amylase and Lipase | Confirm diagnosis |
| Liver Function Tests | Rule out biliary involvement |
| USG Abdomen | Detect gallstones |
| Contrast-enhanced CT | Assess necrosis, fluid collections |
| Serum Calcium, Triglycerides | Metabolic causes |
Treatment Overview
Acute Pancreatitis
Initial Management (Supportive care):
- NPO (nil by mouth)
- IV fluids (aggressive hydration)
- Pain control (opioids)
- Anti-emetics
- Monitor vitals and urine output
Specific Therapies:
- Gallstone pancreatitis → ERCP or cholecystectomy
- Alcohol-induced → Cessation support
- Drug-induced → Discontinue offending drug
Chronic Pancreatitis
- Pancreatic enzyme supplements
- Diabetes management
- Nutritional support
- Surgical options for ductal decompression or pain
Prognostic Scoring Systems
These help predict the severity of pancreatitis:
| Scoring System | Components |
|---|---|
| Ranson’s Criteria | Age, WBC, glucose, AST, LDH, etc. |
| BISAP Score | BUN, Impaired mental status, SIRS |
| APACHE II Score | ICU-based scoring for critically ill |
Prevention Tips
- Avoid excessive alcohol intake
- Early treatment of gallstones
- Avoid unnecessary drug usage
- Manage hyperlipidemia and hypercalcemia
- Educate on trauma prevention, especially in children
Frequently Asked Questions (FAQs)
Q1. What is the most common cause of acute pancreatitis?
A: Globally, gallstones and alcohol are the leading causes.
Q2. How does alcohol induce pancreatitis?
A: It stimulates acinar cell enzyme secretion, alters ductal secretion viscosity, and promotes inflammation.
Q3. What drugs most commonly cause pancreatitis?
A: Valproate, azathioprine, didanosine, tetracycline, and corticosteroids.
Q4. Can children get pancreatitis from trauma?
A: Yes, especially due to bicycle handlebar injuries or non-accidental trauma (child abuse).
Q5. Is chronic pancreatitis reversible?
A: No. It leads to irreversible damage and fibrosis of the pancreas over time.
