Management of biliary acute pancreatitis

Area of Science:

• Gastroenterology and Hepatology
• Surgical Gastroenterology
• Abdominal Imaging

Background:

• Acute pancreatitis is a common condition, with a significant proportion attributed to biliary causes.
• Early elevation of alanine amino-transferases and gallstones on ultrasound suggest a biliary origin.
• Pregnancy presents unique challenges in diagnosing and managing cholelithiasis-induced pancreatitis.

Purpose of the Study:

• To outline the diagnostic approach for acute pancreatitis, emphasizing biliary etiology.
• To detail the management strategies for acute biliary pancreatitis based on severity.
• To discuss specific considerations for acute pancreatitis during pregnancy.

Main Methods:

• Clinical suspicion based on elevated liver enzymes within 48 hours.
• Confirmation via transabdominal ultrasound for gallstones.
• Abdominal computed-tomography (CT) scan for further assessment around day five, with serial imaging as needed.
• Severity assessment using systemic inflammatory response syndrome (SIRS) and organ failure criteria.

Main Results:

• Mild acute pancreatitis: In-hospital cholecystectomy before oral feeding.
• Moderately severe and severe acute pancreatitis: Resuscitation, early enteral feeding, complication management, and interval cholecystectomy.
• Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy indicated for angiocholitis or persistent common bile duct stones.

Conclusions:

• Management of acute biliary pancreatitis is stratified by severity, balancing early intervention with critical care.
• Cholecystectomy is recommended during the hospital stay for mild cases, while severe cases require a staged approach.
• Prompt ERCP is crucial for associated angiocholitis or common bile duct stones, with potential for simultaneous treatment during cholecystectomy.