If you clicked on this post title hoping for advice on how to party your way through medical school, our apologies. Oftentimes when on internal medicine rounds, attendings will go for the low-hanging fruit of differentials:
What are the causes of pancreatitis? So while everyone can somehow remember scorpion stings as a potential etiology, we’re here to help you knock out a few more causes and set you up to impress that ever so intimidating attending.
Mnemonic: I GET SMASHED
Usage: Remembering the causes of acute pancreatitis
For this mnemonic, each letter corresponds to a particular cause:
I = idiopathic
G = gallstones
E = EtOH
T = trauma
S = steroids
M = mumps/malignancy
A = autoimmune
S = scorpion stings
H = hypertriglyceridemia/hypercalcemia
E = (post) ERCP
D = drugs
Let's break down each of these categories.
Also known as the fancy medical way of saying, “I dunno.” What more can we say?
Gallstones & EtOH (Alcohol): The Most Common Causes of Pancreatitis
While appearing brilliant on rounds is one thing, eventually you will want to be able to channel your differentials into what’s most useful and what’s just fluff to impress those around you.
If pancreatitis were a band, its first album would be called “Gallstones and Alcohol.” As mentioned above, these are your two most common etiologies, so always consider them if you are considering pancreatitis as a diagnosis.
Those pesky gallstones—the most common cause of acute pancreatitis. That being said, the vast majority of patients with gallstones never develop it. In those patients who are unlucky enough to get acute pancreatitis from their stones, pain tends to be well localized and reaches maximum intensity in less than half an hour.
About a third of acute pancreatitis cases are caused by alcohol (the other common cause of acute pancreatitis. This pain tends to be poorly localized and develop slowly.) You might also see hepatomegaly.
Trauma and Pancreatitis
Trauma is another one to consider in the setting of … a trauma. If you smash any vital organ with a steering wheel or baseball bat, cells will die, and spill their contents into your patient’s bloodstream. This includes blunt or penetrating trauma. Luckily, the retroperitoneal location of the pancreas helps protect against this in most trauma cases.
Steroids and Pancreatitis
This is technically a type of drug-induced pancreatitis. A possible mechanism for the damage is that steroids increase the viscosity of pancreatic juices.
Mumps and Pancreatitis
Mumps can cause acute pancreatitis, but other infections can as well. These included coxsackievirus, CMV, VZV, herpes, HIV, hepB, salmonella, mycoplasma, legionella, aspergillus, toxoplasma ... you name it.
Autoimmune pancreatitis only accounts for ~5% of cases, so only in 1 out of your 20 patients will have their own immune system to blame. And in terms of the manifestations of autoimmune pancreatitis, it rarely presents as acute pancreatitis. You should suspect this if your patient has lost weight recently, is jaundiced, or if their pancreas is large on imaging.
Scorpions?! Enough said. This probably shouldn’t be your first guess for why your patient has pancreatitis.
Hypertriglyceridemia and Hypercalcemia
Hypertriglyceridemia/hypercalcemia are likely to be caused by some familial error of metabolism. This would likely be diagnosed early in life. Patients with triglycerides above 1000mg/dL are at especially high risk of developing acute pancreatitis.
For other symptoms of hypercalcemia, remember that other helpful mnemonic: "stones, bones, abdominal groans, thrones and psychiatric overtones".
(Post-)ERCP and Pancreatitis
This is a rare complication of endoscopic retrograde cholangiopancreatography (ERCP), but it can happen. If you go instrumenting around the pancreas and slicing open the sphincter of Oddi, you’ve got a 5-10% chance of developing pancreatitis.
Drug Reactions and Pancreatitis
Most commonly, these are: thiazides, sulfa drugs, and didanosine. Luckily, drug-induced pancreatitis is rare. Most cases of drug-induced pancreatitis have great outcomes with low mortality.
And drugs - they can affect just about any body system. So keep them in mind for inflammation/dysfunction of any organ. If ever asked for the cause of a physiologic perturbance or vital sign change, offering “drug reaction” as a possible cause will hardly ever be wrong.
So there you have it… A way to get smashed in medical school AND look smarter in the process!
Here are more mnemonics for your Step 1 studies: