Can biliary pancreatitis occur in patients without a gallbladder?

Biliary Pancreatitis Can Occur in Patients Without a Gallbladder

Yes, biliary pancreatitis can occur in patients without a gallbladder, primarily due to common bile duct stones (CBDS) that may form or remain after cholecystectomy. 1 While the risk is lower compared to patients with gallbladders containing stones, post-cholecystectomy patients can still develop biliary stones in the common bile duct that may lead to pancreatitis.

Mechanism and Risk Factors

In post-cholecystectomy patients, biliary pancreatitis can develop through several mechanisms:

• Retained or recurrent common bile duct stones: Stones that were present before cholecystectomy but not removed, or new stones that form in the biliary tract
• Stone formation in the biliary tree: Even without a gallbladder, stones can form in the bile ducts
• Bile duct dilatation: May contribute to stasis and subsequent stone formation

The incidence of recurrent CBDS in patients with an empty gallbladder in situ is significantly lower (5.9% to 11.3%) compared to patients with residual gallbladder stones (15-23.7%) 1. This suggests that while the risk is reduced after cholecystectomy, it is not eliminated.

Diagnosis of Biliary Pancreatitis in Post-Cholecystectomy Patients

When a post-cholecystectomy patient presents with symptoms suggestive of pancreatitis:

• Laboratory evaluation: Look for elevated pancreatic enzymes and liver function tests
• Imaging:
  • Transabdominal ultrasound (TUS) should be performed, though its sensitivity for choledocholithiasis varies between 50-80% 2
  • Magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound (EUS) are preferred for their higher sensitivity in detecting small stones 2
  • CT scan may be less sensitive for small stones but can help evaluate the pancreas for inflammation and complications

Management Approach

For post-cholecystectomy patients with biliary pancreatitis:

1. Initial supportive care: Vigorous fluid resuscitation, pain control, correction of electrolyte abnormalities 1

2. Evaluation for CBD stones:

   • MRCP or EUS should be performed to confirm the presence of stones
   • These are preferred over immediate ERCP due to lower procedural risks 3

3. Therapeutic intervention:

   • Urgent ERCP (within 24 hours) is indicated for patients with concomitant cholangitis 1
   • Early ERCP (within 72 hours) should be performed in those with high suspicion of persistent CBD stones (visible stone on imaging, persistently dilated CBD, or jaundice) 1
   • Endoscopic sphincterotomy and stone extraction is the definitive treatment for post-cholecystectomy biliary pancreatitis 4

4. Nutritional support: Should be provided if oral intake is restricted for more than 7 days, with nasojejunal tube feeding preferred over total parenteral nutrition 1

Outcomes and Prognosis

Endoscopic sphincterotomy with stone extraction is highly effective in preventing recurrent attacks of biliary pancreatitis in post-cholecystectomy patients. Studies have shown that after successful endoscopic treatment, the recurrence rate of pancreatitis is very low 4.

Common Pitfalls and Caveats

• Misdiagnosis: Don't assume that post-cholecystectomy patients cannot have biliary pancreatitis
• Delayed ERCP: Failure to perform timely ERCP in patients with cholangitis or persistent biliary obstruction can lead to increased morbidity and mortality
• Incomplete stone clearance: Thorough evaluation of the entire biliary tree is essential during ERCP to prevent recurrent episodes
• Overlooking microlithiasis: A significant rate of so-called "idiopathic pancreatitis" is actually caused by microlithiasis and/or biliary sludge 2

Remember that while the risk of biliary pancreatitis is lower in post-cholecystectomy patients, it remains an important differential diagnosis in any patient presenting with pancreatitis symptoms, regardless of cholecystectomy status.