From the Guidelines
Gallstone pancreatitis management should prioritize a two-pronged approach, focusing on treating the acute pancreatitis and addressing the underlying gallstone disease, with laparoscopic cholecystectomy during index admission recommended in mild cases, as stated in the 2019 WSES guidelines 1.
Initial Management
Initial management includes:
- Hospital admission
- Nothing by mouth (NPO) status
- Aggressive IV fluid resuscitation with lactated Ringer's solution at 5-10 mL/kg/hr
- Adequate pain control with opioid analgesics like morphine or hydromorphone
- Antiemetics such as ondansetron 4-8 mg IV every 8 hours for nausea
Role of ERCP and Sphincterotomy
For severe cases with persistent biliary obstruction, urgent ERCP with sphincterotomy is recommended within 24-48 hours to remove obstructing stones, as suggested by the updated guideline on the management of common bile duct stones (CBDS) 1.
- ERCP and sphincterotomy may be performed in patients with significant comorbidities or acute severe pancreatitis, where removal of the gall bladder should be deferred until it is safe to operate.
- Consideration should be given to elective biliary sphincterotomy in patients who are unable to undergo cholecystectomy.
Timing of Cholecystectomy
- Laparoscopic cholecystectomy during index admission is recommended in mild acute gallstone pancreatitis, as stated in the 2019 WSES guidelines 1.
- When ERCP and sphincterotomy are performed during the index admission, same admission cholecystectomy is still advised since there is an increased risk for other biliary complications.
- In acute gallstone pancreatitis with peripancreatic fluid collections, cholecystectomy should be deferred until fluid collections resolve or stabilize and acute inflammation ceases.
Nutritional Support
Nutritional support should be initiated early, preferably enteral feeding within 48 hours if tolerated, as recommended by the AGA institute medical position statement on acute pancreatitis 1.
- Nasojejunal tube feeding, using an elemental or semielemental formula, is preferred over total parenteral nutrition.
- Total parenteral nutrition should be used in those unable to tolerate enteral nutrition.
From the FDA Drug Label
A few patients developed acute cholecystitis, ascending cholangitis, biliary obstruction, cholestatic hepatitis, or pancreatitis during octreotide acetate injection therapy or following its withdrawal. The FDA drug label does not answer the question of how to manage gallstones pancreatitis.
From the Research
Gallstone Pancreatitis Management
- The management of gallstone pancreatitis (GSP) is dependent on the severity of the disease, with most patients suffering from mild attacks and expected to make a full recovery 2.
- Patients with mild GSP can be managed supportively and undergo laparoscopic cholecystectomy with intraoperative cholangiography (IOC) during their initial hospitalization to prevent recurrence 2, 3.
- Early cholecystectomy within 48 hours of admission has been supported by several randomized clinical trials for patients with isolated, mild GSP 3, 4.
- For patients with severe disease, cholecystectomy should be delayed, and the optimal timing remains unclear 3.
- Preoperative endoscopic retrograde cholangiopancreatography (ERCP) is only useful for patients with suspected cholangitis or biliary obstruction 3, 5.
- Patients with severe GSP require ICU admission, close clinical monitoring, and aggressive fluid resuscitation, with antibiotics used judiciously and usually warranted only in the presence of infection or sepsis 2, 6.
Treatment Approaches
- Goal-directed, moderate fluid resuscitation decreases the risk of fluid overload and mortality compared with aggressive resuscitation 3.
- ERCP should be performed when signs of cholangitis are present, and early ERCP should be considered in patients with severe GSP who do not improve clinically 2, 5.
- CT scanning should be performed to assess for necrosis or peripancreatic fluid collections, and patients with no fluid collections can undergo cholecystectomy once their clinical condition improves 2.
- Patients with peripancreatic fluid collections should be followed with serial CT scans, and laparoscopic cholecystectomy should be performed once resolution of the fluid collection is documented 2.
Antibiotic Therapy
- Initial therapy of acute cholecystitis and cholangitis is directed towards general support of the patient, including fluid and electrolyte replacement, correction of metabolic imbalances, and antibacterial therapy 6.
- Antimicrobial therapy is usually empirical, with initial therapy covering the Enterobacteriaceae, in particular Escherichia coli 6.
- Coverage of anaerobes, in particular Bacteroides spp., is warranted in patients with previous bile duct-bowel anastomosis, in the elderly, and in patients in serious clinical condition 6.