What is biliary pancreatitis?

Biliary Pancreatitis: Definition and Management

Biliary pancreatitis is an acute inflammatory condition of the pancreas caused by gallstones or biliary sludge that obstruct the common bile duct, leading to pancreatic inflammation and potential systemic complications. This condition accounts for approximately 50% of all acute pancreatitis cases and requires prompt diagnosis and management to reduce morbidity and mortality 1.

Pathophysiology and Diagnosis

Biliary pancreatitis occurs when gallstones migrate from the gallbladder and obstruct the ampulla of Vater, causing pancreatic duct blockage and subsequent inflammation. The diagnosis can be suggested by:

• Laboratory findings: Elevated liver function tests (LFTs), particularly within the first 48 hours of presentation 2
• Imaging evidence: Presence of gallbladder stones, ductal stones, or bile duct dilation 2
• Associated symptoms: Coexistent cholangitis (fever, jaundice, right upper quadrant pain) 2

Lipase is the preferred diagnostic enzyme over amylase, and C-reactive protein >150 mg/L after 48 hours indicates severe disease 1.

Severity Assessment

Severity stratification is crucial and should be performed within 48 hours of admission using:

• Clinical impression
• APACHE II score
• C-reactive protein levels after 48 hours 1

Dynamic CT scanning with non-ionic contrast should be obtained within 3-10 days of admission to assess for pancreatic necrosis and detect complications 2, 1.

Management Algorithm

1. Initial Management

• Fluid resuscitation: Aggressive intravenous fluid therapy
• Pain control: Opioids as first-line treatment 1
• Nutritional support:
  • For mild cases: Early oral feeding with a low-fat, soft diet 1
  • For severe cases: Enteral nutrition is preferred over parenteral nutrition 1

2. Specific Management Based on Clinical Presentation

For Patients with Cholangitis or Biliary Obstruction:

• Urgent ERCP with biliary sphincterotomy and stone extraction within 72 hours of presentation (high-quality evidence; strong recommendation) 2
• For patients with severe sepsis or septic shock: ERCP within 24 hours 2
• ERCP should always be performed under antibiotic cover 1

For Patients with Severe Gallstone Pancreatitis Without Improvement:

• If condition fails to improve within 48 hours despite intensive resuscitation, urgent ERCP and sphincterotomy are indicated 1
• When ERCP fails or is unavailable, percutaneous biliary drainage is an alternative 2

For Patients with Mild Gallstone Pancreatitis:

• Laparoscopic cholecystectomy should be performed within 2-4 weeks of the attack 2
• Preoperative assessment of the common bile duct with liver biochemistry and ultrasound examination 2

Prevention of Recurrence

The most effective strategy to prevent recurrent biliary pancreatitis is definitive management of gallstones:

• Combined approach: The greatest reduction in risk of recurrent events occurs when patients undergo both sphincterotomy and cholecystectomy 2
• For patients unable to undergo cholecystectomy (due to comorbidities or severe pancreatitis), elective biliary sphincterotomy should be considered, although this is less effective than cholecystectomy for preventing other biliary complications 2

Special Considerations

• Percutaneous drainage should only be performed for infected necrosis or symptomatic collections causing pain or mechanical obstruction 1
• Asymptomatic fluid collections should not be drained due to risk of introducing infection 1
• In patients with altered anatomy (e.g., Roux-en-Y gastric bypass), special endoscopic approaches may be needed 2

Pitfalls to Avoid

• Delayed diagnosis: Failure to recognize biliary etiology can lead to increased morbidity and mortality
• Overuse of antibiotics: Prophylactic antibiotics are not required for mild acute pancreatitis 1
• Delayed cholecystectomy: In mild cases, delaying definitive gallstone management beyond 4 weeks increases risk of recurrent attacks
• Premature drainage: Draining asymptomatic fluid collections can introduce infection 1

Early recognition and appropriate management of biliary pancreatitis, including timely ERCP for selected patients and definitive gallstone management, are essential to reduce morbidity and mortality from this common but potentially serious condition.