From the Guidelines
In gallstone pancreatitis, approximately 70-80% of gallstones are expected to pass spontaneously into the duodenum. This estimate is based on the natural history of common bile duct stones (CBDS) and their potential to cause complications such as pancreatitis, as discussed in the updated guideline on the management of CBDS 1. The passage of stones into the duodenum can occur without warning, and some patients may not experience any difficulties secondary to CBDS. However, the risk of unfavourable outcomes, including pancreatitis, cholangitis, and obstruction of the bile duct, is higher in patients with CBDS who do not undergo stone extraction, as reported in the GallRiks study 1.
The likelihood of spontaneous stone passage is influenced by stone size, with smaller stones more likely to pass without intervention. In the context of gallstone pancreatitis, the priority is to manage the acute episode and prevent recurrent attacks, which can occur in up to 30-40% of patients within 6-8 weeks if the gallbladder is not removed. The management of CBDS, including stone extraction, is crucial in preventing unfavourable outcomes, as highlighted in the guideline 1.
Key factors to consider in the management of gallstone pancreatitis include:
- Stone size and likelihood of spontaneous passage
- Risk of unfavourable outcomes, including pancreatitis and cholangitis
- Need for stone extraction and cholecystectomy to prevent recurrent attacks
- Importance of prompt intervention, including endoscopic retrograde cholangiopancreatography (ERCP), in patients with severe pancreatitis or persistent biliary obstruction, as supported by the guideline 1.
From the Research
Gallstone Pancreatitis and Stone Passage
- The relationship between the severity of pancreatitis and stone passage is not fully understood, but some studies suggest a positive correlation between severe pancreatitis and passed stone 2.
- A study of 183 patients with gallstone pancreatitis found that 94% of patients with severe pancreatitis had stones in the gallbladder alone, suggesting stone passage into the duodenum 2.
- However, the exact percentage of patients who pass stones in gallstone pancreatitis is not specified in the available studies.
Management of Gallstone Pancreatitis
- The management of gallstone pancreatitis depends on the severity of the disease, with mild cases often being self-limiting and severe cases requiring meticulous management 3.
- Cholecystectomy is often recommended to prevent future recurrence, with the timing of the procedure depending on the severity of the disease 4, 5.
- Endoscopic retrograde cholangiopancreatography (ERCP) may be useful in certain cases, such as those with suspected cholangitis or biliary obstruction 4, 6.
Severity of Gallstone Pancreatitis
- Severe gallstone pancreatitis occurs in about 20% of cases and is associated with significant mortality 3.
- The severity of pancreatitis can be difficult to assess, and a comprehensive review of clinically relevant evidence and recommendations is necessary to guide clinicians in diagnosis and management 4.