Diagnosis: Gallstone (Biliary) Pancreatitis
Pancreatitis with elevated liver function tests and hyperbilirubinemia indicates gallstone pancreatitis until proven otherwise, requiring immediate assessment for biliary obstruction and potential cholangitis. 1, 2
Immediate Diagnostic Workup
Obtain liver function tests and abdominal ultrasound immediately to identify gallstone disease and assess for biliary obstruction. 2, 3 The diagnosis of acute pancreatitis requires at least two of three criteria: (i) abdominal pain consistent with the disease, (ii) serum amylase and/or lipase greater than three times the upper limit of normal, and (iii) characteristic findings from abdominal imaging. 1
Understanding the Elevated LFTs
Elevated LFTs in pancreatitis have poor positive predictive value (only 15-50%) for common bile duct stones (CBDS), as the inflammatory process itself can elevate liver enzymes without actual biliary obstruction. 1 In acute cholecystitis patients, 15-50% show elevated LFTs without CBDS. 1 However, when present with pancreatitis, this pattern strongly suggests biliary etiology requiring further investigation. 3
Gamma-glutamyl transpeptidase (GGT) is the most reliable single LFT with sensitivity of 80.6% and specificity of 75.3% at a cut-off of 224 IU/L, though negative predictive value (91.4%) is more useful than positive predictive value (50%). 1
Severity Stratification (Critical First Step)
Assess severity immediately using clinical impression, APACHE II score in first 24 hours, or C-reactive protein >150 mg/L after 48 hours. 2 Patients with persistent organ failure (cardiovascular, respiratory, and/or renal) have severe acute pancreatitis with mortality rates of 13-35%. 1
Admit all severe cases to HDU or ICU with full monitoring including CVP, arterial blood gases, hourly vital signs, oxygen saturation, and urine output. 2, 1
Management Algorithm Based on Clinical Presentation
If Cholangitis Present (Fever, Jaundice, RUQ Pain)
Perform immediate therapeutic ERCP with sphincterotomy under antibiotic cover - this is a Grade A recommendation with the highest level of evidence. 2, 1, 4 Delaying ERCP in patients with cholangitis leads to increased morbidity and mortality. 2, 3
If Severe Pancreatitis WITHOUT Cholangitis
Perform urgent ERCP within 24-72 hours if the patient has predicted or actual severe pancreatitis with jaundice or dilated common bile duct, or if the patient fails to improve despite intensive resuscitation. 2, 1, 4 The procedure is best performed within the first 72 hours after onset of pain. 1, 4
All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct. 1
If Mild Pancreatitis
Schedule laparoscopic cholecystectomy within 2-4 weeks, preferably during the same hospital admission. 2, 4, 3 Preoperative assessment should include liver biochemistry and ultrasound examination. 4
Supportive Care During Acute Phase
Begin aggressive intravenous hydration immediately unless cardiovascular or renal comorbidities preclude it, most beneficial within the first 12-24 hours. 5
Obtain dynamic CT scanning with non-ionic contrast within 3-10 days of admission to assess for necrosis or peripancreatic fluid collections in patients with severe disease or those failing to improve. 2, 4, 1
Consider prophylactic antibiotics (intravenous cefuroxime) for maximum 14 days in severe acute pancreatitis to prevent local and septic complications, though evidence is conflicting. 2, 4, 1
Start oral feedings immediately in mild pancreatitis if no nausea and vomiting; in severe cases, use enteral nutrition to prevent infectious complications. 5
Definitive Management After Acute Phase
For severe gallstone pancreatitis, delay cholecystectomy until signs of lung injury and systemic disturbance have resolved. 4 For mild cases, perform cholecystectomy within 2-4 weeks during the same hospital admission to prevent recurrent biliary events. 2, 4
Delaying cholecystectomy beyond 2 weeks significantly increases risk of potentially fatal recurrent acute pancreatitis. 2, 3
Critical Pitfalls to Avoid
Never delay ERCP in patients with cholangitis - this is the single most important intervention to prevent mortality. 2, 3
Do not rely on elevated LFTs or bilirubin alone to diagnose CBDS - perform further diagnostic tests (ultrasound, MRCP, or EUS) as 15-50% of pancreatitis patients have elevated LFTs without actual biliary obstruction. 1
Do not discharge patients with gallstone pancreatitis without definitive management plan - all patients should undergo cholecystectomy during the same admission or have a clear plan for definitive treatment within two weeks. 1
For high surgical risk patients who cannot undergo cholecystectomy, ERCP with sphincterotomy alone may be adequate definitive treatment to reduce recurrent pancreatitis risk. 4, 3