Can cholelithiasis (gallstones) cause pancreatitis?

Cholelithiasis as a Cause of Pancreatitis

Yes, gallstones (cholelithiasis) are a common cause of acute pancreatitis, particularly when they migrate and transiently obstruct the ampulla of Vater. 1

Pathophysiology of Gallstone Pancreatitis

• Gallstone pancreatitis occurs when gallstones migrate from the gallbladder and transiently obstruct the ampulla of Vater, leading to intraglandular activation of pancreatic enzymes 1
• This obstruction can cause reflux of bile into the pancreatic duct or create ductal hypertension, triggering the inflammatory cascade of pancreatitis 2
• Smaller gallstones and a higher number of stones increase the risk of biliary pancreatitis due to their greater likelihood of migration into the common bile duct 2

Clinical Evidence Supporting Gallstones as a Cause of Pancreatitis

• Gallstones are the most common single cause of acute pancreatitis in Western countries 3, 2
• Gallstones are found in 7-20% of patients undergoing cholecystectomy and represent the commonest cause of both acute cholangitis and acute pancreatitis 4
• The American Gastroenterological Association recognizes gallstone pancreatitis as a distinct clinical entity requiring specific management 5

Diagnostic Approach

• Initial evaluation should include liver biochemical tests (ALT, AST, bilirubin, ALP, GGT) and abdominal ultrasound to identify gallstones 6
• Gallstone pancreatitis typically presents with:
  • Elevated serum amylase (often above 1000 IU/L) 1
  • Evidence of cholestasis (elevated liver enzymes) 2
  • Gallstones visible on imaging studies 6
• The diagnosis of gallstone etiology is based on:
  • History and physical examination findings
  • Laboratory abnormalities showing both pancreatic inflammation and biliary obstruction
  • Ultrasound or CT evidence of gallstones 1

Management Considerations

• Patients with gallstone pancreatitis who have associated cholangitis or persistent biliary obstruction should undergo biliary sphincterotomy and endoscopic stone extraction within 72 hours of presentation 7
• For severe gallstone pancreatitis with no response to treatment within 48 hours, ERCP is indicated 7
• In cases of mild gallstone pancreatitis without evidence of ongoing biliary obstruction, supportive care is appropriate with planned cholecystectomy during the same hospitalization 3
• Prophylactic cholecystectomy is recommended after recovery to prevent recurrent episodes of gallstone pancreatitis 4, 3

Important Clinical Considerations

• While gallstones commonly cause acute pancreatitis, their role in chronic pancreatitis remains controversial 8
• Approximately half of patients with gallstone disease show pancreatic duct abnormalities on ERCP, but the long-term significance of these changes is not fully understood 8
• Potential complications of ERCP include procedure-induced pancreatitis, cholangitis, duodenal perforations, and hemorrhage, with risk increasing to 10% with sphincterotomy 6

Risk Stratification for Suspected Common Bile Duct Stones

• High-risk patients (>50% probability of CBD stones) include those with:
  • Evidence of CBD stone on abdominal ultrasound
  • Total serum bilirubin >4 mg/dL
  • Common bile duct diameter >6 mm (with gallbladder in situ)
  • Bilirubin level 1.8-4 mg/dL 6
• These high-risk patients may benefit from preoperative ERCP, especially if they have signs of cholangitis or biliary obstruction 6