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Several factors may be involved in the etiology of pancreatitis, including traumatic injury, drugs, toxins, infectious agents, and biliary disease. As opposed to the general pediatric population, the diagnosis in the pediatric intensive care unit (PICU) population may be masked by the inability of the patient to communicate due to associated disease processes, use of sedative/analgesic agents, or altered cognitive function. Due to these issues, a high index of suspicion is necessary to arrive at a timely diagnosis. This issue is of significant importance, as the compromised ICU patient may be unable to tolerate the added stress of a secondary illness such as pancreatitis. The authors present five cases, review the possible etiologies of pancreatitis in the PICU patient, and discuss its presentation in this unique patient population. The incidence in our PICU of five cases in approximately 1,200 admissions over an 18-month period suggests that this problem is of a greater magnitude than we would have previously thought.