What is the treatment for pancreatitis secondary to gallstones?

Treatment for Pancreatitis Secondary to Gallstones

For patients with gallstone pancreatitis, urgent therapeutic ERCP with sphincterotomy should be performed within 72 hours of symptom onset in cases of severe pancreatitis, cholangitis, jaundice, or dilated common bile duct, followed by cholecystectomy during the same hospital admission or within two weeks. 1, 2

Initial Assessment and Management

• All patients with severe acute pancreatitis should be managed in a high dependency unit or intensive care unit with full monitoring and systems support 2
• Initial management includes:
  • Aggressive fluid resuscitation (preferably with Ringer's lactate rather than normal saline) 3
  • Pain control using a multimodal approach 4
  • Regular monitoring of vital signs, including hourly pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature 2

Management Based on Severity

Severe Gallstone Pancreatitis

• Urgent therapeutic ERCP with sphincterotomy should be performed within 72 hours in patients with:
  • Predicted or actual severe pancreatitis of gallstone etiology
  • Cholangitis
  • Jaundice
  • Dilated common bile duct 2, 1
• ERCP should always be performed under antibiotic cover to prevent infection 2
• If the patient's condition fails to improve within 48 hours despite intensive resuscitation, urgent ERCP and sphincterotomy are indicated 2
• Cholecystectomy should be delayed until signs of lung injury and systemic disturbance have resolved 1

Mild Gallstone Pancreatitis

• Patients should undergo laparoscopic (or open) cholecystectomy within 2-4 weeks, preferably during the same hospital admission 1, 2
• Preoperative assessment of the common bile duct by liver biochemistry and ultrasound examination should be performed 2

Nutritional Support

• If nutritional support is required, the enteral route should be used if tolerated 2
• The nasogastric route for feeding can be used as it appears to be effective in 80% of cases 2
• Early enteral feeding has shown definitive clinical benefits 3
• A normal "on-demand" diet has a positive effect on recovery and may reduce length of hospital stay 4

Antibiotic Use

• The evidence regarding prophylactic antibiotics in severe acute pancreatitis is conflicting 2
• If antibiotic prophylaxis is used, it should be given for a maximum of 14 days 2
• Intravenous cefuroxime may be considered for prophylaxis in severe cases 2
• Procalcitonin-based algorithms may help distinguish between inflammation and infection, potentially reducing unnecessary antibiotic use 3

Management of Complications

• Dynamic CT scanning should be obtained within 3-10 days of admission using non-ionic contrast to assess for pancreatic necrosis and peripancreatic fluid collections 2, 1
• Patients with persistent symptoms and >30% pancreatic necrosis, or those with smaller areas of necrosis and clinical suspicion of sepsis, should undergo image-guided fine needle aspiration 2
• Patients with infected necrosis will require intervention to completely debride all cavities containing necrotic material 2
• Delay of drainage as much as possible is advised since it is associated with fewer procedures 4

Special Considerations

• For patients who cannot undergo cholecystectomy due to high surgical risk, ERCP with sphincterotomy is an alternative definitive treatment 1
• Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis or with other complications 2

Common Pitfalls to Avoid

• Failing to perform urgent ERCP in patients with cholangitis or biliary obstruction can lead to increased morbidity and mortality 1
• Delaying definitive management of gallstones increases the risk of recurrent pancreatitis 5
• Overly aggressive fluid resuscitation may be harmful; a more moderate approach with Ringer's lactate is now preferred 3, 4
• Routine use of prophylactic antibiotics without clear indications should be avoided 6