Management of Gallstone Pancreatitis

Timing of Cholecystectomy

For severe gallstone pancreatitis, delay cholecystectomy until the inflammatory process has subsided, as recommended by the American Gastroenterological Association 1
In mild cases, perform cholecystectomy as soon as the patient has recovered, preferably during the same hospital admission, according to the American Gastroenterological Association and the American College of Surgeons 1
A combined approach, involving both sphincterotomy and cholecystectomy, offers the greatest reduction in risk of recurrent events 2

Ongoing assessment on a daily basis is necessary to monitor recovery, as recommended by the American Gastroenterological Association 1
Severity of pancreatitis can be assessed using clinical impression, APACHE II score, Glasgow score, presence of organ failure, and CRP >150 mg/L at 48 hours, with persistent organ failure >48 hours, obesity, signs of sepsis, and clinical deterioration 6-10 days after admission being indicators of severe disease, according to the American Gastroenterological Association 3
Patients with acute pancreatitis should be managed in a High Dependency Unit (HDU) or Intensive Therapy Unit (ITU) setting with full monitoring and systems support 1

Urgent ERCP with sphincterotomy is indicated for patients with failure of condition to improve within 48 hours despite intensive resuscitation, cholangitis, jaundice, dilated common bile duct, and severe predicted or actual pancreatitis, as recommended by the American Gastroenterological Association, the American Society for Gastrointestinal Endoscopy, and the British Society of Gastroenterology 3, 1, 2
Urgent ERCP with biliary sphincterotomy and stone extraction within 72 hours of presentation is recommended for acute biliary pancreatitis, with high-quality evidence and a strong recommendation, and should be performed within 24 hours for patients with severe sepsis or septic shock 2

Diagnosis of pancreatitis requires at least 2 of 3 criteria: characteristic abdominal pain, serum lipase or amylase ≥3 times upper limit of normal, and characteristic findings on imaging, with lipase being the preferred diagnostic enzyme due to its higher sensitivity and specificity than amylase, according to the American Gastroenterological Association 3
C-reactive protein (CRP) >150 mg/L at 48 hours predicts severe disease, and initial ultrasound should be performed to evaluate for gallstones, while contrast-enhanced CT scan should be performed to assess for complications such as necrosis and collections, as recommended by the American College of Gastroenterology 3

Dynamic CT scanning with non-ionic contrast should be performed within 3-10 days of admission to assess the patient's condition 1
Pre-procedural dynamic CT with contrast should be used to identify vascular structures and assess the collection wall, with imaging evaluation assessing the extent of pancreatic necrosis, identifying peripancreatic fluid collections, and evaluating for intervening vessels that may complicate drainage 4, 1, 5, 6

Enteral nutrition is preferred over parenteral nutrition, as it preserves gut mucosa integrity, stimulates intestinal motility, prevents bacterial overgrowth, and increases splanchnic blood flow, with the European Society for Clinical Nutrition and Metabolism and the American Gastroenterological Association recommending its use 3, 7, 8
Nasogastric feeding is effective in ~80% of cases of severe pancreatitis 3
A low-fat, soft oral diet is recommended when reinitiating oral feeding in patients with mild acute pancreatitis, and pancreatic enzyme supplements should be used to maintain weight and increase quality of life, as suggested by the American Gastroenterological Association 9, 7

Antibiotics should be considered for infected pancreatic necrosis, cholangitis, and sepsis, but not routinely recommended for prophylaxis, and delayed diagnosis beyond 48 hours increases morbidity, according to the Infectious Diseases Society of America 3
Bleeding, infection, buried stent syndrome, and biliary stricture are potential complications of LAMS placement, and confirmed infection requires appropriate antibiotics plus formal drainage (percutaneous or operative) 10, 1

For safe LAMS placement in pancreatic collections, the distance between the enteral puncture site and collection should be less than 10 mm, the collection wall should be adequately thick, and significant vascularity in the puncture tract should be avoided to prevent bleeding complications, as recommended by the American Gastroenterological Association 4
Collection characteristics should be determined, including whether the collection is walled-off pancreatic necrosis (WOPN), pseudocyst, mixed collection, and assess for presence of solid debris vs liquid component 10
The American Gastroenterological Association recommends using Color Doppler during the procedure to identify and avoid blood vessels in the puncture path, as significant vascularity increases the risk of bleeding, which can occur in up to 4-8% of cases 10

Opioids should be used as first-line treatment for pain management, as they do not increase the risk of pancreatitis complications and decrease the need for supplementary analgesia, with consideration of gabapentin, pregabentin, nortriptyline, or duloxetine for neuropathic pain, as recommended by the National Comprehensive Cancer Network 11, 12, 13
Multimodal analgesia with paracetamol and NSAIDs/COX-2 inhibitors can be used as adjuncts to opioids for pain management in acute pancreatitis, and mid-thoracic epidural analgesia can be considered for severe cases 14

Lifestyle modifications, including restricting dietary fat, eliminating added sugars, alcohol abstinence, weight loss, and regular physical activity, are recommended to manage insulin resistance and prevent recurrent pancreatitis, with target triglyceride levels less than 500 mg/dL, ideally less than 150 mg/dL 15
Target glucose levels between 150-180 mg/dL during acute illness to avoid hypoglycemia, which can worsen outcomes 16, 17