Impact of Alcoholic Etiology on Mortality and Clinical Outcome in Acute Pancreatitis: A Retrospective Cohort Study Across the COVID-19 Pandemic

<b>Background/Objectives:</b> Alcoholic acute pancreatitis (AP) is a major cause of hospital admissions in Eastern Europe. However, data from secondary-care centers on the impact of the COVID-19 pandemic are limited. <b>Methods:</b> We retrospectively analyzed all adult AP admissions to a secondary-care hospital between March 2018 and March 2025. Cases were classified by etiology and grouped into pre-pandemic, pandemic, and post-pandemic periods. We compared demographic, clinical, severity, recurrence, outcome, resource use, and cost data between alcoholic and non-alcoholic AP. <b>Results:</b> Among 1096 patients (63.5% male; median age 55 years), alcohol was the leading etiology (40.1%), peaking during the pandemic. Alcoholic AP was more common in men, rural residents, and smokers, and less common in patients with obesity or diabetes. Recurrence was higher in alcoholic AP (21.8% vs. 15.9%; <i>p</i> = 0.015). Severe disease was more frequent in alcoholic than biliary AP (38.4% vs. 22.3%; <i>p</i> = 0.001). Overall mortality was 8.4%, declining after the pandemic (10.4% pre-pandemic vs. 6.5% post-pandemic). In multivariable Cox models, pleural effusion (HR 7.88; 95% CI 3.27-18.99) and age (HR 1.02; 95% CI 1.00-1.03) independently predicted mortality in the overall cohort. In alcoholic AP, pleural effusion was the only independent predictor (HR 13.19; 95% CI 2.48-70.08). In non-alcoholic AP, pleural effusion (HR 6.83; 95% CI 2.40-19.44) and signs of shock (HR 3.49; 95% CI 1.14-10.71) were independent predictors. <b>Conclusions:</b> Alcoholic AP was the most frequent etiology, with higher recurrence and severity than biliary AP, but alcoholic etiology itself did not predict mortality. Mortality drivers differed by etiology: pleural effusion in alcoholic AP, and pleural effusion plus signs of shock in non-alcoholic AP. ICU transfer was associated with death in descriptive analyses but was treated as a downstream mediator and not included in adjusted models.