What is pancreatitis associated with gallbladder (cholecystic) disease?

From the Guidelines

Patients with acute biliary pancreatitis should undergo cholecystectomy during the initial admission to prevent recurrent episodes and reduce mortality and gallstone-related complications. This approach is supported by moderate quality evidence from a randomized controlled clinical trial 1, which found that cholecystectomy performed during the initial admission was associated with substantial reductions in a composite outcome of mortality and gallstone-related complications. The primary argument in favor of earlier intervention is that patients with biliary pancreatitis who are discharged without a cholecystectomy have a significant risk of recurrent biliary events.

Key points to consider in the management of pancreatitis associated with gallbladder disease include:

• The risk of recurrent biliary events is significant in patients discharged without a cholecystectomy
• Cholecystectomy can prevent recurrent episodes of acute pancreatitis after an index case of biliary or gallstone pancreatitis
• Performing surgery during the initial admission may reduce the risk of mortality and gallstone-related complications, as found in the study by the American Gastroenterological Association 1
• The appropriate timing of cholecystectomy has been the subject of debate, but the current evidence suggests that earlier intervention is beneficial

In terms of treatment, the goal is to manage pain, prevent recurrence, and reduce the risk of complications. This typically involves:

• Hospitalization for pain management with medications and intravenous fluids
• Bowel rest (nothing by mouth)
• Cholecystectomy, usually within the same hospital stay, to prevent recurrence
• Early diagnosis and treatment are crucial to prevent complications such as pancreatic necrosis, infection, and multi-organ failure, as supported by the guidelines from the American Gastroenterological Association 1

From the FDA Drug Label

A few patients developed acute cholecystitis, ascending cholangitis, biliary obstruction, cholestatic hepatitis, or pancreatitis during octreotide acetate injection therapy or following its withdrawal. Pancreatitis is associated with gallbladder (cholecystic) disease, as it has been reported to occur in patients with complications of cholelithiasis, such as those caused by octreotide acetate injection therapy.

• The exact relationship between pancreatitis and gallbladder disease is not explicitly stated in the label. 2

From the Research

Pancreatitis Associated with Gallbladder Disease

• Pancreatitis is often associated with gallbladder (cholecystic) disease, with gallstones being the most common cause of acute pancreatitis in the Western world 3, 4, 5.
• The combination of trans-abdominal ultrasound and elevated serum alanine transaminase can indicate gallstones as the cause of acute pancreatitis 4.
• Patients with severe acute biliary pancreatitis require close clinical monitoring, aggressive fluid resuscitation, and may need endoscopic retrograde cholangiopancreatography (ERCP) or cholecystectomy 3, 5.
• Index cholecystectomy is safe and recommended for patients with gallstone pancreatitis, except in cases with significant local and systemic complications where delayed cholecystectomy may be safer 5.
• The management of patients with pancreatitis associated with gallbladder disease requires a multidisciplinary approach between the surgeon, radiologist, gastroenterologist, and intensivist 3.

Diagnosis and Treatment

• Diagnosis of pancreatitis associated with gallbladder disease requires a high degree of suspicion and clinical acumen, as well as imaging studies such as ultrasound and magnetic resonance cholangiopancreatography 3, 4, 5.
• Treatment involves fluid therapy, enteral nutrition, and monitoring for local and systemic complications, as well as consideration of ERCP or cholecystectomy 3, 5.
• Antibiotics should be used judiciously and are usually warranted only in the presence of infection or sepsis 3, 6.
• The role of antibiotic administration before or after cholecystectomy to decrease morbidity or mortality is less clear, but guidelines recommend against routine use of peri-operative antibiotic agents in low-risk patients undergoing elective laparoscopic cholecystectomy 6.