What is the treatment for gallstone pancreatitis?

Treatment of Gallstone Pancreatitis

All patients with mild gallstone pancreatitis should undergo same-admission laparoscopic cholecystectomy as soon as clinically recovered, ideally within 2 weeks and no longer than 4 weeks, as delaying beyond this timeframe increases recurrent biliary events by 56%, including potentially fatal recurrent pancreatitis. 1, 2

Initial Assessment and Severity Stratification

Immediately assess severity using clinical impression, obesity, APACHE II score within the first 24 hours, and C-reactive protein (>150 mg/L) or Glasgow score after 48 hours to determine the urgency and intensity of intervention. 1, 2 Severe pancreatitis is defined by persistent organ failure beyond 48 hours. 2

• Obtain serum lipase (preferred over amylase), liver function tests, triglycerides, and calcium at admission. 2
• Perform immediate abdominal ultrasonography to identify gallstones and assess for common bile duct stones. 2
• Early elevation of serum aminotransferases or bilirubin strongly suggests gallstone etiology. 2

Management Algorithm Based on Severity

Severe Gallstone Pancreatitis

Admit all severe cases 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, 1, 4, 2

Perform urgent therapeutic ERCP with sphincterotomy within 72 hours in patients with: 1, 4, 2

• Cholangitis (fever, rigors, positive blood cultures) - this requires immediate ERCP 3, 1, 2
• Jaundice or increasingly deranged liver function tests 3, 1, 4
• Dilated common bile duct 1, 4
• Failure to improve within 48 hours despite intensive resuscitation 3, 1, 4

Always perform ERCP under antibiotic cover to prevent infection. 3, 4, 2 If using prophylactic antibiotics in severe pancreatitis, intravenous cefuroxime represents a reasonable balance between efficacy and cost, limited to a maximum of 14 days. 3, 1, 4

Obtain dynamic CT scanning with non-ionic contrast within 3-10 days of admission to assess for pancreatic necrosis and peripancreatic fluid collections. 3, 1, 4, 2

Delay cholecystectomy until signs of lung injury and systemic disturbance have resolved in severe cases. 4

Mild Gallstone Pancreatitis

Perform laparoscopic cholecystectomy during the same hospital admission as soon as the patient has recovered clinically, ideally within 2 weeks and no longer than 4 weeks. 1, 4, 2 This is the single most critical intervention to prevent recurrence.

• Preoperative assessment should include liver biochemistry and ultrasound examination of the common bile duct. 3, 1, 4
• The role of routine preoperative ERCP in the absence of CBD dilatation, detected CBD stones, or abnormal liver function tests remains debatable and should be based on local expertise. 3

Supportive Care

• Provide vigorous fluid resuscitation, supplemental oxygen as needed, correction of electrolyte and metabolic abnormalities, and adequate pain control. 2
• In severe pancreatitis requiring nutritional support, use enteral feeding (nasojejunal tube with elemental or semi-elemental formula) rather than parenteral nutrition to protect the gut mucosal barrier and reduce bacterial translocation. 1, 2

Management of Complications

• Sterile necrosis does not usually require therapy and can be closely monitored unless the patient's clinical status deteriorates. 2, 5
• 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. 1, 2

Special Populations

For patients unfit for surgery due to high surgical risk, ERCP with sphincterotomy alone is adequate definitive treatment to prevent recurrence. 1, 4 However, these patients may require closer surveillance as treatment by ES alone may be associated with a higher risk of biliary complications during follow-up compared with cholecystectomy. 6

Critical Pitfalls to Avoid

• Never delay cholecystectomy beyond 2-4 weeks in patients fit for surgery, as this dramatically increases the risk of recurrent biliary events including potentially fatal repeat pancreatitis. 1, 2
• Never delay ERCP in patients with cholangitis or biliary obstruction, as this leads to increased morbidity and mortality. 1, 4, 2
• Never use prophylactic antibiotics routinely in the absence of infection or sepsis; reserve them for severe cases with documented or suspected infection. 5, 7