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

• 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