Treatment Guideline Chart
Acute pancreatitis is inflammation of the pancreas that occurs suddenly.
Abdominal pain is the most prominent symptom of acute pancreatitis.
It is diagnosed by at least two of the following: Characteristic abdominal pain, serum lipase and/or amylase levels ≥3 times the upper limit of normal and characteristic abdominal imaging findings.
Mild acute pancreatitis does not have any organ failure or local or systemic complication.
Moderately severe acute pancreatitis has the presence of local or systemic complication and/or transient organ failure in <48 hours.
Severe acute pancreatitis has single or multiple organ failure persistent in >48 hours.

Management of Gallstone Pancreatitis

Endoscopic Retrograde Cholangiopancreatography (ERCP)

  • ERCP should be performed urgently, ie within 24-48 hours, in severe acute pancreatitis patients with suspected or proven gallstone etiology, or when cholangitis, jaundice, or dilated common bile duct is present
    • However, patients without obstructive jaundice or biliary sepsis may not benefit
    • Magnetic resonance cholangiopancreatography or endoscopic ultrasound may be an option
    • If ERCP is not feasible in unstable patients, consider placing a percutaneous transhepatic gallbladder drainage tube

Endoscopic Sphincterotomy (ES)

  • ES in many cases protects against recurrence of gallstones
  • Should therefore be considered in the following patients, if cholecystectomy cannot be done:
    • Patients who have severe gallstone pancreatitis with significant local and/or systemic complications
    • Patients with a dilated bile duct with or without demonstrated stones and at the same time a gallbladder that contains stones


  • Cholecystectomy, which constitutes definitive management of gallstones, should be done during the same hospital admission, after the patient has recovered from the acute pancreatic illness
  • Indication and appropriate time interval between acute pancreatitis and cholecystectomy will depend on the presence of an ES and severity of the pancreatitis
    • Otherwise healthy patient with mild acute gallstone pancreatitis should undergo definitive surgical management during the index admission
    • Cholecystectomy may be deferred in necrotizing biliary acute pancreatitis until inflammation subsides and fluid collections resolve or stabilize
    • In patients with high surgical risk, ES alone may be sufficient
  • Patients with severe pancreatitis should not be operated on within the 1st 48 hours after admission as there is a higher risk of complications
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