What is the treatment for gallstone pancreatitis?

Treatment of Gallstone Pancreatitis

The definitive treatment for gallstone pancreatitis includes urgent ERCP with sphincterotomy within 72 hours for severe cases, followed by laparoscopic cholecystectomy during the same hospital admission for mild cases or after resolution of systemic inflammation for severe cases. 1

Initial Management

• All patients with severe acute pancreatitis should be managed in a high dependency unit or intensive therapy unit with full monitoring and systems support 2, 1
• Initial treatment includes:
  • Fasting
  • Intravenous fluid replacement (preferably lactated Ringer solution)
  • Analgesics
  • Close monitoring of vital signs 3
• Severity assessment should be performed using clinical signs, blood tests, and imaging to guide treatment decisions 1

Management Based on Severity

Severe Gallstone Pancreatitis

• Urgent therapeutic ERCP with sphincterotomy should be performed within the first 72 hours after onset of pain in patients with:
  • Predicted or actual severe pancreatitis
  • Cholangitis
  • Jaundice
  • Dilated common bile duct 2, 1
• ERCP should always be performed under antibiotic cover to prevent infection 1
• Dynamic CT scanning should be obtained within 3-10 days of admission to assess for pancreatic necrosis and peripancreatic fluid collections 1
• Cholecystectomy should be delayed until signs of lung injury and systemic disturbance have resolved 1, 4
• Patients with infected necrosis require intervention to completely debride all cavities containing necrotic material 2

Mild Gallstone Pancreatitis

• Laparoscopic cholecystectomy should be performed within 2-4 weeks, preferably during the same hospital admission 1, 4
• Delaying definitive treatment beyond two weeks after discharge increases the risk of potentially fatal recurrent acute pancreatitis 4, 5
• Preoperative assessment of the common bile duct by liver biochemistry and ultrasound examination should be performed 1

Special Considerations

• For patients who cannot undergo cholecystectomy due to high surgical risk, ERCP with sphincterotomy is an alternative definitive treatment 1, 4
• Early enteral feeding reduces length of hospital stay, rate of infectious complications, and risks of morbidity and mortality 6
• Prophylactic antibiotics may be considered in severe acute pancreatitis, though evidence is conflicting 2, 1

Common Pitfalls and Caveats

• Failure to perform ERCP in patients with cholangitis or biliary obstruction can lead to increased morbidity and mortality 1, 4
• Without cholecystectomy, approximately 20-30% of patients are readmitted within 90 days with a biliary condition or recurrent acute pancreatitis 6, 5
• Studies show that adherence to guidelines for gallstone pancreatitis management is low, particularly in older patients, with only 57% undergoing cholecystectomy during initial hospitalization 5
• Patients who do not undergo cholecystectomy have significantly higher readmission rates (44% vs 4%) 5
• In patients who cannot undergo cholecystectomy, ERCP with sphincterotomy reduces the risk of recurrent pancreatitis but does not eliminate it completely 4, 5