Gallstone pancreatitis resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vendhan Ramanujam M.B.B.S [2]

Synonyms and keywords: Biliary pancreatitis

Overview

Gallstone pancreatitis is an acute pancreatitis caused by gallstones. Gallstone pancreatitis is suspected when an acute pancreatitis patient with or without previous history of biliary colic or gallbladder related symptoms presents with elevated serum alanine aminotransferase (ALT) levels and evidence of gallstones or common bile duct stones on abdominal ultrasound.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Gallstone pancreatitis may be a life-threatening condition, especially if it presents with suppurative cholangitis and progresses to necrotizing pancreatitis, and it should be treated as such irrespective of the causes.

Common Causes

• Cholelithiasis
• Choledecholithiasis
• Biliary sludge

Management

Shown below is an algorithm depicting the management of gallstone pancreatitis according to the American College of Gastroenterology (ACG) and the Society for Surgery of the Alimentary Tract (SSAT).

Characterize the symptoms: ❑ Severe abdominal pain and/or ❑ Breathing difficulty and/or ❑ Nausea & vomiting and/or ❑ Hiccups sometimes

Examine the patient: ❑ Fever and/or ❑ Hypotension and/or ❑ Cullen's sign and/or ❑ Grey-Turner's sign and/or ❑ Tachypnea and/or ❑ Abdominal distension and/or tenderness

Consider alternative diagnosis: ❑ Gallstones ❑ Dissecting aortic aneurysm ❑ Pancreatic pseudocyst

Hemodynamic stability?

Stable

Unstable

Order Labs: (Urgent) ❑ CBC ❑ Hematocrit ❑ BUN ❑ Creatinine ❑ Amylase ❑ Lipase ❑ Triglyceride ❑ Total bilirubin ❑ Direct bilirubin ❑ Albumin ❑ AST ❑ ALT ❑ Alkaline phosphatase ❑ GGT ❑ Chest X-ray Order imaging studies: (Urgent) Trans abdominal USG (TAUSG)

Stabilize the patient

Diagnostic criteria: Any 2 out of 3 ❑ Abdominal pain consistent with disease ❑ Serum amylase or lipase values > 3 times normal ❑ Consistent findings from abdominal imaging

Acute Pancreatitis

Systemic inflammatory response syndrome? (Urgent)

Yes

No

Risk stratification for organ failure (Marshall scoring) (Urgent)

Lower risk

Higher risk

Admit to medical ward

Admit to ICU (Urgent)

Fluids: (Urgent) ❑ Aggressive hydration at 250-500 ml/hr with Ringer's lactate in first 12-24 hours ❑ Reassess within 6 hours after admission and for next 24-48 hours Analgesics: (Urgent) ❑ Opioids are preferred ❑ Mepridine & morphine may be used as IV drips/pt. controlled analgesia Nutrition: (Urgent) ❑ Immediate oral feeding as soon as pain, vomiting, nausea subside

Fluids: (Urgent) ❑ Initiate with a fluid bolus ❑ Aggressive hydration at 250-500 ml/hr with Ringer's lactate in first 12-24 hours ❑ Reassess within 6 hours after admission and for next 24-48 hours Analgesics: (Urgent) ❑ Opioids are preferred ❑ Mepridine & morphine may be used as IV drips/pt. controlled analgesia Nutrition: (Urgent) ❑ Nasogastric or nasojejunal feeding may be initiated once pain, vomiting, nausea subside ❑ Consider enteral feeding if above not tolerated

❑ ± Previous history of biliary colic or GB related Sx ❑ Elevated ALT ❑ ± Elevated AST ❑ Gallstones detected during TAUSG

Gallstone pancreatitis

Mild

Severe

Good surgical candidates

Bad surgical candidates

❑ Continue resuscitative & supportive care ❑ Early ERCP within 24 hours

❑ Laparoscopic cholecystectomy during index hospitalization ❑ IOC ❑ ± Intra/postoperative ERCP

❑ ERCP with endoscopic sphincterotomy

Presence of infection

Absence of infection

❑ Surgical intervention

Good surgical candidates

Bad surgical candidates

❑ Delayed cholecystectomy

❑ ERCP with endoscopic sphincterotomy

ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; BUN: Blood urea nitrogen; CBC: Complete blood count; ERCP: Endoscopic retrograde cholangiopancreatography; GB: Gallbladder; GGT: Gamma-glutamyl transpeptidase; H/o History of; ICU: Intensive care unit; IOC: Intraoperative cholangiography; IV: Intravenous; Sx: Symptom

Modified Marshall Scoring System

Modified Marshall Scoring System^†

Organ System	0	1	2	3	4
Respiratory PaO2/FiO2	>400	301-400	201-300	101-200	≤101
Renal‡ Creatinine (μmol/l) Creatinine (mg/dl)	≤134 <1.4	134-169 1.4-1.8	170-310 1.9-3.6	311-439 3.6-4.9	>439 >4.9
Cardiovascular Systolic Blood Pressure (mmHg)	>90	<90, fluid responsive	<90, not fluid responsive	<90, pH <7.3	<90, pH <7.2

^† A score of 2 or more in any system defines the presence of organ failure.
^‡ A score for patients with pre-existing chronic renal failure depends on the extent of further deterioration of baseline renal function. No formal correction exists for a baseline creatinine ≥134 μmol/l or ≥1.4 mg/dl.

▸ For non-ventilated patients, the FiO2 can be estimated from below:

Supplemental oxygen (l/min)	FiO2 (%)
Room air	21
2	25
4	30
6–8	40
9–10	50

Grades of Severity

The definitions of severity in acute pancreatitis according to the revised Atlanta classification is as follows.

• Mild acute pancreatitis

▸ No organ failure

▸ No local or systemic complications

• Moderately severe acute pancreatitis

▸ Organ failure that resolves within 48 h (transient organ failure) and/or

▸ Local or systemic complications without persistent organ failure

• Severe acute pancreatitis

▸ Persistent organ failure (>48 h)

– Single organ failure

– Multiple organ failure

Do's

• Refer the patient for prompt cholecystectomy once gallstones are identified as the etiology for pancreatitis in order to prevent recurrent attacks and potential biliary sepsis.
• Perform cholecystectomy before discharging the patient with mild acute pancreatitis due to gallstones in order to prevent the recurrence (strong recommendation, moderate quality of evidence).
• Perform cholecystectomy in mild acute pancreatitis after resolution of abdominal pain and normalization of laboratory values.
• Consider serum triglyceride as the etiology if its >1000 mg/dl in the absence of gallstones and/or history of significant history of alcohol use (conditional recommendation, moderate quality of evidence).

Dont's

• Do not request an ERCP in patients with gallstone pancreatitis who lack laboratory or clinical evidence of ongoing biliary obstruction (strong recommendation, low quality of evidence).