What is the treatment for pancreatitis caused by gallstones?

Treatment of Gallstone Pancreatitis

Urgent ERCP within 72 hours is recommended for patients with gallstone pancreatitis who have associated cholangitis, persistent biliary obstruction, or severe pancreatitis, followed by early cholecystectomy to prevent recurrent episodes. 1, 2

Initial Management

Severity Assessment and Supportive Care

• All patients with severe acute pancreatitis should be managed in a high dependency unit or intensive therapy unit with full monitoring and systems support 1
• Provide aggressive fluid resuscitation, pain control, and nutritional support
• If nutritional support is required, enteral nutrition should be used if tolerated 1
• Consider prophylactic antibiotics in severe acute pancreatitis to prevent infections 1

Urgent Biliary Decompression

• For patients with cholangitis or persistent biliary obstruction:
  • Urgent ERCP with endoscopic sphincterotomy and stone extraction within 72 hours of presentation 1
  • ERCP should be performed under antibiotic cover 1
  • Biliary stenting may be necessary if stone extraction is not possible 1

Definitive Management

Cholecystectomy Timing

• For mild gallstone pancreatitis:

  • Laparoscopic cholecystectomy should be performed within 2 weeks of presentation, preferably during the same admission 1, 2
  • This timing significantly reduces the risk of recurrent pancreatitis 1, 2

• For severe gallstone pancreatitis:

  • Delay cholecystectomy until signs of lung injury and systemic disturbance have resolved 1
  • In patients with peripancreatic fluid collections, cholecystectomy should be delayed until collections resolve or stabilize (typically 6 weeks) 3

Intraoperative Considerations

• Perform operative cholangiography during cholecystectomy to detect residual common bile duct stones 1
• If stones are found in the common bile duct, they should be removed if possible 1
• Laparoscopic common bile duct exploration can be performed if expertise is available 4

Special Situations

Patients Unfit for Surgery

• For patients who are poor surgical candidates, endoscopic sphincterotomy alone is adequate treatment to prevent recurrent pancreatitis 1, 2
• However, these patients should be informed about the increased risk of other biliary complications 2, 5

Patients with Peripancreatic Fluid Collections

• Monitor with serial CT scans 4
• If fluid collections do not resolve after 6 weeks, consider concurrent cholecystectomy and fluid drainage procedures 4, 3
• Early cholecystectomy in patients with fluid collections is associated with higher rates of infectious complications (47% vs 7%) 3

Common Pitfalls and Caveats

1. Delaying cholecystectomy beyond 2-4 weeks after discharge in mild cases increases the risk of potentially fatal recurrent pancreatitis 1, 2

2. Performing unnecessary ERCP in patients without evidence of CBD stones increases procedural risks without benefit 2

3. Performing early cholecystectomy in severe cases before resolution of inflammatory process can lead to higher complication rates 3

4. Failing to perform operative cholangiography during cholecystectomy may result in missed common bile duct stones 1

5. Treating with ERCP alone without subsequent cholecystectomy in suitable candidates leaves patients at risk for recurrent biliary events 2