Gallstones as a Cause of Pancreatitis

Yes, gallstones are a common cause of acute pancreatitis, accounting for approximately 50% of cases in the western world. 1, 2

Pathophysiology of Gallstone Pancreatitis

Gallstone pancreatitis is caused by transient obstruction of the ampulla of Vater by a migrating gallstone 1
This obstruction leads to intraglandular activation of pancreatic enzymes, triggering local and systemic inflammatory responses 1
In rare cases, gallstones can directly enter and obstruct the pancreatic duct itself 3
The risk of gallstones is increased in Crohn's Disease but not in Ulcerative Colitis 4

Diagnosis is based on at least two of three criteria: upper abdominal pain, elevated serum lipase/amylase (>3x upper limit of normal), and consistent abdominal imaging 4
Initial investigations should include:
- Pancreatic enzymes in plasma 4
- Liver function tests 4
- Ultrasound of gallbladder 4
Dynamic CT scanning should be obtained within 3-10 days of admission using non-ionic contrast to assess for complications 4, 5
Endoscopic ultrasound (EUS) may be required to detect microlithiasis in recurrent cases 4

Patients should undergo laparoscopic cholecystectomy within 2-4 weeks, preferably during the same hospital admission 6, 5
Delaying cholecystectomy beyond two weeks after discharge increases risk of potentially fatal recurrent acute pancreatitis 6
Preoperative assessment should include liver biochemistry and ultrasound examination 5

Patients should be managed in a high dependency unit or intensive care unit with full monitoring and systems support 4, 5
Urgent therapeutic ERCP with sphincterotomy is indicated in cases with:
- Failure to improve within 48 hours despite intensive resuscitation 4
- Cholangitis, jaundice, or dilated common bile duct 6, 5
ERCP should always be performed under antibiotic cover to prevent infection 4, 5
Cholecystectomy should be delayed until signs of lung injury and systemic disturbance have resolved 6, 5

For patients who cannot undergo cholecystectomy due to high surgical risk, ERCP with sphincterotomy alone may be adequate treatment 6, 5
Prophylactic antibiotics, such as intravenous cefuroxime, may be considered in severe acute pancreatitis to prevent septic complications 4, 5
Goal-directed, moderate fluid resuscitation decreases the risk of fluid overload and mortality compared with aggressive resuscitation 2

Failing to perform ERCP in patients with cholangitis or biliary obstruction can lead to increased morbidity and mortality 6, 5
Delaying cholecystectomy beyond the recommended timeframe increases risk of recurrent pancreatitis 6
In patients with inflammatory bowel disease, abdominal pain due to pancreatitis can be difficult to differentiate from that caused by active IBD 4
Asymptomatic elevated lipase is found in 7% of IBD patients, which can complicate diagnosis 4