What is the management of acute gallstone pancreatitis?

Management of Acute Gallstone Pancreatitis

All patients with mild gallstone pancreatitis should undergo laparoscopic cholecystectomy within 2 weeks and preferably during the same hospital admission to prevent potentially fatal recurrent pancreatitis. 1, 2

Initial Assessment and Resuscitation

Severity stratification is the critical first step that determines all subsequent management decisions. 1

• Assess severity using clinical impression, obesity, APACHE II score in the first 24 hours, and C-reactive protein >150 mg/L or Glasgow score ≥3 after 48 hours. 3
• Begin aggressive intravenous hydration immediately in all patients unless cardiovascular or renal comorbidities preclude it, with maximal benefit occurring within the first 12-24 hours. 4
• Admit patients with persisting organ failure or systemic inflammatory response syndrome to an intensive care unit or high dependency unit with full monitoring including CVP, arterial blood gases, hourly vital signs, oxygen saturation, and urine output. 3, 5

Management Algorithm Based on Severity

Mild Gallstone Pancreatitis (No Organ Failure)

Perform same-admission cholecystectomy as soon as the patient has recovered clinically, ideally within 2 weeks and no longer than 4 weeks. 3, 2

• Delaying cholecystectomy beyond 2 weeks increases the risk of recurrent biliary events by 56%, including potentially fatal recurrent pancreatitis. 2, 6
• Preoperative assessment should include liver biochemistry and ultrasound examination of the common bile duct. 3, 5
• Routine preoperative ERCP in the absence of CBD dilatation, detected stones, or abnormal liver function tests carries intrinsic risks (3-5% procedure-induced pancreatitis, 2% bleeding, 1% cholangitis, 0.4% mortality) that outweigh benefits. 5
• Intraoperative cholangiography should be performed if doubt exists about CBD stones. 3

Severe Gallstone Pancreatitis (Organ Failure Present)

Urgent therapeutic ERCP with sphincterotomy must be performed within 72 hours of symptom onset in patients with cholangitis, jaundice, dilated common bile duct, or failure to improve within 48 hours despite intensive resuscitation. 3, 1, 2

• Immediate ERCP (within 24 hours) is required when cholangitis is present, indicated by fever, rigors, positive blood cultures, and deranged liver function tests. 3, 5, 4
• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct. 3
• ERCP must always be performed under antibiotic cover. 3, 5
• Delay cholecystectomy until signs of lung injury and systemic disturbance have resolved and the inflammatory process has subsided, making the procedure technically safer. 1, 2, 5

Imaging

• Obtain dynamic CT scanning with non-ionic contrast within 3-10 days of admission to assess for pancreatic necrosis and peripancreatic fluid collections in patients with severe pancreatitis or those not improving clinically. 1, 5
• Ultrasound of the gallbladder is the first-line imaging modality to identify gallstones. 2

Nutritional Support

• In mild pancreatitis, start oral feedings immediately if there is no nausea and vomiting. 4
• In severe pancreatitis requiring nutritional support, use the enteral route (nasogastric feeding is effective in 80% of cases) rather than parenteral nutrition to protect the gut mucosal barrier and reduce bacterial translocation. 3, 5

Antibiotic Prophylaxis

The evidence on prophylactic antibiotics is conflicting and there is no consensus. 3

• If antibiotic prophylaxis is used in severe acute pancreatitis, limit it to a maximum of 14 days. 3
• Intravenous cefuroxime represents a reasonable balance between efficacy and cost. 5
• Antibiotics are warranted when infection or sepsis is present. 7

Management of Complications

• Patients with infected pancreatic necrosis require intervention to completely debride all cavities containing necrotic material, preferably delayed for 4 weeks to allow wall formation around the necrosis. 2, 4
• Image-guided fine needle aspiration should be performed in patients with persistent symptoms and >30% pancreatic necrosis, or those with smaller areas of necrosis and clinical suspicion of sepsis. 3
• Asymptomatic pancreatic or extrapancreatic necrosis and pseudocysts do not warrant intervention regardless of size or location. 4

Special Populations

For patients unfit for surgery due to high surgical risk, ERCP with sphincterotomy alone is adequate definitive treatment to prevent recurrence. 1, 2

Critical Pitfalls to Avoid

• Failing to perform cholecystectomy during the same admission or within 2 weeks dramatically increases recurrent pancreatitis risk. 2, 5
• Failing to perform ERCP in patients with cholangitis or biliary obstruction leads to increased morbidity and mortality. 1, 2
• Performing routine ERCP in mild cases without specific indications exposes patients to unnecessary procedural risks. 5
• Delaying cholecystectomy beyond 4 weeks significantly increases recurrent biliary events. 5