gallstone pancreatitis
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Etiology
Epidemiology
- 80% of pancreatitis caused by gallstones or alcohol[4]
Pathology
- obstruction of the common pancreatic-bile duct or reflux of bile into the pancreas by obstrution at the ampulla of vater[4]
Clinical manifestations
Diagnostic criteria
- score for risk of retained common bile duct stone (0-5) based on 4 laboratory & ultrasound criteria
- 100% likelihood of retained common bile duct stone if all 5 predictors (4 laboratory + ultrasound, score=5)[1]
- 55% likelihood of retained common bile duct stone if 4 of 5 predictors
- 0% likelihood of retained common bile duct stone if no predictors (score=0)[1]
Laboratory
- elevation of serum transaminases
- serum gamma glutamyl transferase >= 350 U/L*
- serum alkaline phosphatase >= 250 U/L*
- serum total bilirubin in serum >= 3 mg/dL*
- case of gallstone pancreatitis with serum total bilirubin of 1.5 mg/dL
- serum direct bilirubin in serum >= 2 mg/dL*
- serum lipase is elevated
* laboratory predictor of retained common bile duct stone
Diagnostic procedures
- ERCP with sphincterotomy within 24-72 hours in high risk patients (see management)
Radiology
- abdominal ultrasound[4]
- +/- gallstones
- no gallbladder wall thickening or pericholecystic fluid
- dilated common bile duct supports diagnosis of gallstone pancreatitis
- no choledocholelithiasis (case report MKSAP20)[4]
- biliary ultrasound: duct size >= 9 mm predicts retained common bile duct stone
Management
- management by risk score for retained common bile duct stone
- 0: cholecystectomy without intraoperative cholangiography
- 1 or 2: cholecystectomy with intraoperative cholangiography
- 3 or 4: magnetic resonance cholangiopancreatography to select those who require ERCP or intraoperative common bile duct exploration
- 5: ERCP
- cholecystectomy during index hospitalization for mild gallstone pancreatitis[3][4][5]
- same-day admission cholecystectomy reduces complications[4]
- delaying cholecystectomy leads to much higher rates of stone- related complications
- early cholecystectomy associated with a 99% probability of reducing 30-day length of stay, a 93% probability of decreasing need for ERCP, & a 72% probability of increasing complications[5]
More general terms
References
- ↑ Jump up to: 1.0 1.1 1.2 Brett AS Predicting Retained Common Bile Duct Stones in Gallstone Pancreatitis. NEJM Journal Watch. June 18, 2015 Massachusetts Medical Society (subscription needed) http://www.jwatch.org
Sherman JL et al. Validation and improvement of a proposed scoring system to detect retained common bile duct stones in gallstone pancreatitis. Surgery 2015 Jun; 157:1073. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25712200 - ↑ Telem DA, Bowman K, Hwang J et al Selective Management of Patients with Acute Biliary Pancreatitis. J Gastrointest Surg. 2009 Dec;13(12):2183-8 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19779946
- ↑ Jump up to: 3.0 3.1 da Costa DW, Bouwense SA, Schepers NJ et al Same-admission versus interval cholecystectomy for mild gallstone pancreatitis (PONCHO): a multicentre randomised controlled trial. Lancet. 2015 Sep 26;386(10000):1261-8 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26460661
- ↑ Jump up to: 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 Medical Knowledge Self Assessment Program (MKSAP) 17, 18, 19. American College of Physicians, Philadelphia 2015, 2018, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025 - ↑ Jump up to: 5.0 5.1 5.2 Mueck KM, Wei S, Pedroza C et al. Gallstone pancreatitis: Admission versus normal cholecystectomy - a randomized trial (Gallstone PANC trial). Ann Surg 2019 Sep; 270:519. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31415304 https://insights.ovid.com/crossref?an=00000658-201909000-00014
- ↑ NEJM Knowledge+ Gastroenterology