What is the treatment for gallstone pancreatitis?

Treatment of Gallstone Pancreatitis

Gallstone pancreatitis requires urgent ERCP with sphincterotomy within 72 hours for severe cases with cholangitis, jaundice, or dilated common bile duct, followed by laparoscopic cholecystectomy during the same hospital admission for mild cases or after resolution of systemic inflammation for severe cases. 1, 2

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 3, 1
• Aggressive fluid resuscitation with lactated Ringer solution should be initiated within the first 12-24 hours to decrease risk of progression to systemic inflammatory response syndrome 4
• Early enteral feeding reduces length of hospital stay, infectious complications, and mortality risks 4
• Dynamic CT scanning should be obtained within 3-10 days of admission to assess for pancreatic necrosis and peripancreatic fluid collections 1

Management Based on Severity

Severe Gallstone Pancreatitis

• Urgent therapeutic ERCP with sphincterotomy must 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 3, 1
• ERCP should always be performed under antibiotic cover to prevent infection 1
• Failure of the patient's condition to improve within 48 hours despite intensive initial resuscitation is an indication for urgent ERCP and sphincterotomy 1
• Cholecystectomy should be delayed until signs of lung injury and systemic disturbance have resolved 1, 2

Mild Gallstone Pancreatitis

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

Management of Complications

• For patients with infected pancreatic necrosis, intervention is required to debride all cavities containing necrotic material 3, 2
• Sterile necrosis can be closely monitored and does not require necrosectomy unless the patient's clinical condition deteriorates 6
• Patients with peripancreatic fluid collections should be followed with serial CT scans 6
• If fluid collections do not resolve after 6 weeks, patients should undergo concurrent cholecystectomy and fluid drainage procedures 6

Special Considerations

• For patients who cannot undergo cholecystectomy due to high surgical risk, ERCP with sphincterotomy is an alternative definitive treatment 1, 2
• Without cholecystectomy, approximately 20-30% of patients are readmitted within 90 days with a biliary condition or acute pancreatitis 4, 5
• In a study of Medicare beneficiaries, only 57% of patients with mild gallstone pancreatitis underwent cholecystectomy during initial hospitalization, leading to higher readmission rates (44% vs 4%) for those who did not have surgery 5

Common Pitfalls and Caveats

• Failure to recognize the urgency of ERCP in patients with cholangitis or biliary obstruction can lead to increased morbidity and mortality 1, 2
• Delaying cholecystectomy beyond the recommended timeframe significantly increases risk of recurrent pancreatitis 2, 5
• Not all patients with gallstone pancreatitis will have elevated amylase levels; serum lipase has higher positive predictive value and specificity 4
• The management of these patients requires close clinical observation and a multidisciplinary approach between surgeon, radiologist, gastroenterologist, and intensivist 6