S3282 Not Your Typical Triglycerides: A Rare Case of Estrogen-Linked Pancreatitis

Introduction: Acute pancreatitis (AP) is an inflammatory condition of the pancreas, most commonly caused by gallstones or alcohol. Drug-induced pancreatitis is a rare but important etiology, with estrogen-containing oral contraceptives (OCPs) implicated in some cases—typically in the setting of significant hypertriglyceridemia. We present a unique case of estrogen-associated AP in a young woman with only mildly elevated triglycerides, highlighting the importance of considering hormonal triggers even when traditional thresholds are not met. Case Description/Methods: A 20-year-old woman, G1P1, with a history of gastroesophageal reflux disease, presented with severe right upper quadrant pain. Imaging revealed hepatomegaly with fatty infiltration and cholelithiasis without cholecystitis. She underwent a laparoscopic cholecystectomy and was discharged on a combination OCP (norethindrone acetate 1 mg, ethinyl estradiol 20 mcg). One week later, she returned with epigastric pain radiating to the back. Computed tomography scan showed no pancreatic abnormalities, but serum lipase was markedly elevated at 1057 U/L, consistent with AP. Her comprehensive metabolic panel was normal; triglycerides were 250 mg/dL. Magnetic resonance cholangiopancreatography (MRCP) ruled out biliary obstruction. The OCP was discontinued, resulting in rapid clinical improvement and normalization of lipase to 150 U/L at a follow-up appointment. Discussion: Estrogen is known to elevate triglyceride levels by increasing hepatic VLDL production and inhibiting lipoprotein lipase activity, potentially leading to pancreatitis. However, most reported cases involve levels >1000 mg/dL. Our patient developed AP at just 250 mg/dL, with no other identifiable cause, suggesting either heightened estrogen sensitivity or an idiosyncratic reaction. This case challenges the conventional threshold for hypertriglyceridemia-induced AP and underscores the importance of considering estrogen-containing OCPs as a potential etiology, even with only mild lipid elevation. Clinicians should maintain a high index of suspicion for medication-induced pancreatitis in young women presenting with compatible symptoms shortly after initiating OCP therapy. Prompt recognition and discontinuation of the causative agent are key to favorable outcomes.