Who treats pancreatitis with cholelithiasis (gallstones)?

Management of Pancreatitis with Cholelithiasis

Patients with pancreatitis due to cholelithiasis should be managed by a multidisciplinary team including gastroenterologists, surgeons, and interventional radiologists, with severe cases requiring referral to a specialist unit with intensive care capabilities. 1

Initial Management and Team Approach

• Every hospital receiving acute admissions should have a single nominated clinical team to manage all patients with acute pancreatitis 1
• Severe cases require management in a high dependency unit or intensive therapy unit with full monitoring and systems support 1
• Management in, or referral to, a specialist unit is necessary for patients with extensive necrotising pancreatitis or other complications requiring intensive care, interventional radiology, endoscopic procedures, or surgical interventions 1

Endoscopic Management

• Urgent therapeutic ERCP should be performed in patients with gallstone pancreatitis who have:
  • Predicted or actual severe pancreatitis
  • Cholangitis
  • Jaundice
  • Dilated common bile duct 1
• ERCP is best performed within the first 72 hours after the onset of pain 1, 2
• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct 1
• Patients with signs of cholangitis require endoscopic sphincterotomy or duct drainage by stenting to ensure relief of biliary obstruction 1, 2

Surgical Management

• After an attack of mild acute pancreatitis, patients with gallstones should undergo definitive treatment (cholecystectomy) to prevent recurrence 1
• For mild gallstone pancreatitis, cholecystectomy should be performed as soon as the patient has recovered and preferably during the same hospital admission 1
• Definitive treatment should not be delayed more than two weeks after discharge from hospital to avoid the risk of potentially fatal recurrent acute pancreatitis 1, 2
• Cholecystectomy should be delayed in patients with severe acute pancreatitis until signs of lung injury and systemic disturbance have resolved 1
• For patients unfit for surgery, endoscopic sphincterotomy alone provides adequate long-term therapy 2

Management of Complications

• Patients with infected necrosis will require intervention to completely debride all cavities containing necrotic material 1
• All patients with persistent symptoms and greater than 30% pancreatic necrosis, and those with smaller areas of necrosis and clinical suspicion of sepsis, should undergo image-guided fine needle aspiration to obtain material for culture 7-14 days after onset of pancreatitis 1
• The choice of surgical technique for necrosectomy and subsequent postoperative management depends on individual features and locally available expertise 1
• Percutaneous wide-bore drainage may be sufficient for the treatment of infected necrosis in some cases 1

Timing of Interventions

• ERCP timing should be guided by clinical presentation, with urgent ERCP (within 24 hours) for patients with concomitant cholangitis and early ERCP (within 72 hours) for those with high suspicion of persistent common bile duct stones 2
• Cholecystectomy with operative cholangiography should be performed if diagnosis is made at emergency laparotomy 1
• If stones are found in the common bile duct during surgery, these should be removed if possible 1

Potential Complications and Considerations

• ERCP carries significant risks including procedure-induced pancreatitis (3-5%), bleeding (2% with sphincterotomy), cholangitis (1%), and procedure-related mortality (0.4%) 2
• The risk of complications from ERCP increases significantly in elderly patients, with major complication rates reported as high as 19% and mortality rate of 7.9% 1
• Careful patient selection is crucial to ensure the benefits of ERCP outweigh these risks 2

By following these guidelines, the multidisciplinary team can effectively manage patients with pancreatitis due to cholelithiasis, reducing morbidity and mortality through appropriate timing of interventions and proper management of complications.