Clinical Mnemonics · Internal Medicine & Infection
I GET SMASHED
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In 30 seconds
Lists the causes of acute pancreatitis in rough order of frequency to guide the diagnostic workup.
The college version
Lists the causes of acute pancreatitis in rough order of frequency to guide the diagnostic workup.
I — Idiopathic
No cause found after full workup
Diagnosed when no cause is found after history, labs (lipase, calcium, triglycerides, LFTs), and imaging. Roughly 10-20% of cases; many later turn out to be microlithiasis or sludge missed on standard imaging.
Physiology. Advanced workup (endoscopic ultrasound, genetic testing) keeps shrinking this bucket; many cases are occult biliary disease.
Safety. Recurrent 'idiopathic' pancreatitis needs referral for advanced imaging - don't shrug it off.
G — Gallstones
Most common cause (~40%)
The leading cause of acute pancreatitis. A stone lodging at the ampulla of Vater obstructs the ducts, causing reflux/back-pressure. Suspect when LFTs are elevated with pancreatitis.
Physiology. Obstruction raises intraductal pressure and causes bile reflux, prematurely activating trypsin. Small stones that pass into the ampulla are most dangerous.
Safety. Biliary pancreatitis can progress to cholangitis - fever + jaundice + pain (Charcot's triad) needs urgent intervention.
E — Ethanol (alcohol)
Second most common cause (~30%)
The second most common cause, usually after chronic heavy use. Tends to be more severe and to recur, leading to chronic pancreatitis.
Physiology. Alcohol increases enzyme secretion, causes sphincter of Oddi spasm, makes secretions thick/proteinaceous (forming plugs), and is directly toxic to acinar cells.
Safety. Watch for alcohol withdrawal (tremor, agitation, seizures) in the hospitalized patient with alcohol-induced pancreatitis.
T — Trauma
Blunt abdominal injury
Blunt abdominal trauma can injure or transect the pancreatic duct, causing enzyme leak and pancreatitis - which may be delayed for hours after the injury.
Physiology. The retroperitoneal pancreas is crushed against the spine, disrupting ducts and acini; liberated enzymes digest surrounding tissue.
Safety. A pancreatic duct disruption may need surgery/drainage - persistent or worsening pain after trauma warrants repeat imaging.
S — Steroids
Rare, debated drug cause
Corticosteroids are a rare and debated cause; the mechanism is unclear (possibly via hypertriglyceridemia). Many 'steroid-induced' cases may be from the underlying disease.
Physiology. Proposed mechanisms include steroid-induced hypertriglyceridemia and direct acinar injury; causation is not firmly established.
Safety. Do not stop a patient's steroids without an order - abrupt withdrawal can cause adrenal crisis.
M — Mumps
Viral pancreatitis (rare, vaccine-preventable)
Mumps (and less commonly coxsackievirus or CMV) can cause viral pancreatitis; now rare in vaccinated populations.
Physiology. The virus directly infects acinar cells, causing inflammation and enzyme release.
Safety. Usually self-limited - supportive care (fluids, pain control) is the mainstay.
A — Autoimmune
IgG4-related disease
A rare cause, associated with IgG4-related disease, that can mimic pancreatic cancer (mass + jaundice) and often responds dramatically to steroids.
Physiology. Lymphoplasmacytic infiltration and IgG4-positive plasma cells drive inflammation and fibrosis.
Safety. Must be distinguished from malignancy before treating - misdiagnosing cancer as 'autoimmune' delays curative treatment.
S — Scorpion sting
Rare, geographically limited cause
Classically the Trinidad scorpion (Tityus trinitatis); rare and limited to endemic regions (Caribbean, Latin America, parts of Africa/Asia).
Physiology. Venom triggers massive acetylcholine release from pancreatic nerve endings, causing intense stimulation, enzyme hypersecretion, and pancreatitis.
Safety. A travel-medicine zebra - but in endemic areas, consider it in any sting with abdominal pain.
H — Hypercalcemia / Hypertriglyceridemia
Metabolic causes (uncommon but treatable)
Hypercalcemia (hyperparathyroidism or malignancy) can activate trypsinogen. Hypertriglyceridemia (>1,000 mg/dL) produces free fatty acids toxic to acinar cells - an increasingly recognized, under-diagnosed cause.
Physiology. Calcium promotes trypsinogen activation and intraductal precipitation; free fatty acids from triglyceride hydrolysis injure acinar cells, and chylomicrons cause hyperviscosity/capillary plugging.
Safety. Very high triglycerides (>1,000) can make lipase falsely normal - check a lipid panel in unexplained cases.
E — ERCP
Post-procedure (iatrogenic) pancreatitis
The most common procedure-related cause (post-ERCP pancreatitis, ~2-5% of procedures, higher in high-risk patients).
Physiology. Cannulation trauma, contrast injection pressure, and sphincter manipulation/thermal injury trigger inflammation and enzyme activation.
Safety. Any significant abdominal pain after ERCP needs prompt evaluation - post-ERCP pancreatitis can be severe.
D — Drugs
Medication-induced pancreatitis
Numerous drugs are associated, including azathioprine, thiazide diuretics, valproic acid, sulfonamides, and ACE inhibitors; usually a diagnosis of exclusion.
Physiology. Mechanisms vary: direct toxicity, hypersensitivity/immune-mediated, or metabolic effects (e.g., thiazides causing hypercalcemia).
Safety. Suspected drug-induced pancreatitis warrants provider review for discontinuation - but don't stop medications without an order.
Memory aids
- I = Idiopathic
- G = Gallstones
- E = Ethanol (alcohol)
- T = Trauma
- S = Steroids
- M = Mumps
- A = Autoimmune
- S = Scorpion sting
- H = Hypercalcemia / Hypertriglyceridemia
- E = ERCP
- D = Drugs
Quick review
- I = Idiopathic — No cause found after full workup
- G = Gallstones — Most common cause (~40%)
- E = Ethanol (alcohol) — Second most common cause (~30%)
- T = Trauma — Blunt abdominal injury
- S = Steroids — Rare, debated drug cause
- M = Mumps — Viral pancreatitis (rare, vaccine-preventable)
- A = Autoimmune — IgG4-related disease
- S = Scorpion sting — Rare, geographically limited cause
- H = Hypercalcemia / Hypertriglyceridemia — Metabolic causes (uncommon but treatable)
- E = ERCP — Post-procedure (iatrogenic) pancreatitis
- D = Drugs — Medication-induced pancreatitis
Eli explains
The same idea, in plain words
Explain it like I’m 10
A memory list of every reason the pancreas can suddenly get inflamed - from gallstones and alcohol (super common) to scorpion stings (super rare) - so you can find the cause.
I — Idiopathic. Doctor-speak for 'we looked everywhere and still don't know why' - a mystery fire with no match found.
G — Gallstones. The pancreas and liver share a drainpipe into the intestine. A gallstone plugs that shared pipe, so the pancreas's digestive juices back up like a clogged sink and it starts digesting itself.
E — Ethanol (alcohol). Alcohol pours a harsh chemical on the pancreas over and over - it makes thick, sticky digestive juice and makes the drainpipe spasm shut, so the juice gets trapped.
T — Trauma. A hard blow to the belly (car crash, bike handlebar) can crush the pancreas and crack its pipes, leaking digestive juice into the surrounding tissue.
S — Steroids. Some strong anti-inflammatory medicines can, in rare cases, irritate the pancreas - but this is unusual and scientists still argue about how.
M — Mumps. Some viruses love the pancreas. The mumps virus (the one that makes cheeks swell) can also infect the pancreas and inflame it.
A — Autoimmune. Normally your immune system only attacks germs. In autoimmune pancreatitis it mistakenly attacks the pancreas itself - the body's own police raiding the factory.
S — Scorpion sting. In some parts of the world, a scorpion sting injects venom that jams the pancreas's 'ON' switch so it works itself into inflammation.
H — Hypercalcemia / Hypertriglyceridemia. Two blood problems can flip the switch: too much calcium (which can turn the digestive scissors on) and too much fat in the blood (which breaks down into harsh acids inside the pancreas).
E — ERCP. A camera-and-tool procedure to look inside the bile/pancreas pipes can accidentally irritate the pancreas and flip the switch.
D — Drugs. Many medicines can, as a rare side effect, irritate the pancreas and cause it to inflame - some pills have 'pancreas' as a hidden side effect.
Study toolsKey vocabulary
Key vocabulary
- I
- Idiopathic
- G
- Gallstones
- E
- Ethanol (alcohol)
- T
- Trauma
- S
- Steroids
- M
- Mumps
- A
- Autoimmune
- S
- Scorpion sting
- H
- Hypercalcemia / Hypertriglyceridemia
- E
- ERCP
- D
- Drugs
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