What is gallstone pancreatitis?

Gallstone Pancreatitis: Definition and Management

Gallstone pancreatitis is an acute inflammatory process of the pancreas caused by transient obstruction of the ampulla of Vater by a migrating gallstone, leading to pancreatic enzyme activation and subsequent local and systemic inflammation. 1, 2

Pathophysiology

Gallstone pancreatitis occurs when:

• A gallstone migrates from the gallbladder and temporarily blocks the ampulla of Vater 2, 3
• This obstruction leads to intraglandular activation of pancreatic enzymes 3
• Activated enzymes enter the circulation, causing local pancreatic inflammation and systemic inflammatory response syndrome (SIRS) 1
• In rare cases, the stone may be found in the pancreatic duct itself 4

Clinical Presentation

Patients with gallstone pancreatitis typically present with:

• Upper abdominal pain (often severe and epigastric)
• Nausea and vomiting
• Epigastric or diffuse abdominal tenderness
• Fever and tachycardia in some cases 1

Diagnosis

Diagnosis requires at least 2 of 3 criteria:

1. Abdominal pain consistent with pancreatitis
2. Serum lipase and/or amylase >3 times upper limit of normal
3. Characteristic findings on abdominal imaging 1

Additional diagnostic considerations:

• Ultrasound to identify gallstones
• CT scan to assess severity and complications
• ERCP may be used in uncertain cases to confirm common bile duct stones 3

Severity Classification

The Revised Atlanta Classification defines severity as:

• Mild: No organ failure or local/systemic complications
• Moderately severe: Transient organ failure (<48h) or local complications
• Severe: Persistent organ failure (>48h) 1

Management

Initial Management

• Moderate fluid resuscitation (5-10 ml/kg/h for first 24 hours) 1
• Pain management: Begin with non-opioids (acetaminophen), progressing to opioids if needed 1
• Enteral nutrition within 24-72 hours if oral intake is not possible 1
• Close monitoring of vital signs, urine output, and laboratory parameters 1

Management Based on Severity

Mild Gallstone Pancreatitis:

• Supportive care
• Same-admission laparoscopic cholecystectomy (ideally within 48 hours) 5
• Intraoperative cholangiography to evaluate for common bile duct stones 5

Severe Gallstone Pancreatitis:

• ICU admission
• Aggressive fluid resuscitation
• Judicious use of antibiotics (only for infection/sepsis)
• ERCP when signs of cholangitis are present
• Delayed cholecystectomy after clinical improvement 2

Complications Management

• Peripancreatic fluid collections: Monitor with serial CT scans; drainage if persistent beyond 6 weeks 2
• Sterile necrosis: Close monitoring without intervention unless clinical deterioration occurs 2
• Infected necrosis: Necrosectomy when clinically stable 2

Prevention of Recurrence

• Cholecystectomy is crucial for preventing recurrent episodes 1
• For mild cases, perform during initial hospitalization 1
• For severe cases, delay until clinical resolution 5

Common Pitfalls to Avoid

1. Overaggressive fluid resuscitation: Can lead to fluid overload and increased mortality 5
2. Unnecessary ERCP: Only indicated for cholangitis or biliary obstruction 5
3. Delayed cholecystectomy in mild cases: Increases risk of recurrent attacks 1
4. Premature cholecystectomy in severe cases: Can worsen outcomes 2
5. Failure to recognize progression to severe disease: Regular severity assessment is essential 1

Gallstone pancreatitis requires a multidisciplinary approach involving surgeons, gastroenterologists, radiologists, and intensivists for optimal outcomes 2.