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Answer 1
  1. Gallstones. Gallstones are the most common cause of acute pancreatitis, accounting for 45% of all cases. This patient’s history of gallstones, as well as her elevated serum bilirubin, alkaline phosphatase, and transaminase levels and markedly elevated serum amylase and lipase levels, strongly suggests biliary and pancreatic duct obstruction due to gallstones. Although the patient had a cholecystectomy, this surgery does not rule out gallstones as a cause of pancreatitis; the patient could continue to form stones or could have retained a stone, even after surgery. Alcohol abuse, although it is a very common cause of acute pancreatitis, would be unlikely to cause such a severe elevation in the transaminase levels. Hypercalcemia is a cause of acute pancreatitis, but this patient has a normal calcium level. Hypertriglyceridemia is also a cause of acute pancreatitis; however, a triglyceride level of 430 mg/dL is insufficiently elevated to account for this patient’s pancreatitis, and other conditions can cause elevated triglyceride levels in this type of patient. Fluoxetine has not been implicated as a cause of acute pancreatitis.

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