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gallstone pancreatitis

Etiology: - cholilithiasis 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: - pancreatitis - gallstones Laboratory: - elevation of serum transaminases - elevated serum ALT the most clinically useful test in predicting gallstone pancreatitis [4] - level of 350 U/L declining to 98 U/L with hydration in case presentation [4] - elevated serum AST; ALT/AST > 1 (case presentation) [4] - serum gamma glutamyl transferase >= 350 U/L* - serum alkaline phosphatase >= 250 U/L* - serum total bilirubin in serum >= 3 mg/dL* - serum direct bilirubin in serum >= 2 mg/dL* - serum lipase is elevated * laboratory predictor of retained common bile duct stone Special laboratory: - 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 - common bile duct not dilated - no choledocholelithiasis - biliary ultrasound: duct size >= 9 mm predicts retained common bile duct stone Diagnosis: - 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] 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]

General

acute pancreatitis

References

  1. 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: 25712200
  2. 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: 19779946
  3. 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: 26460661
  4. Medical Knowledge Self Assessment Program (MKSAP) 17, 18, 19. American College of Physicians, Philadelphia 2015, 2018, 2021.
  5. 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: 31415304 https://insights.ovid.com/crossref?an=00000658-201909000-00014
  6. NEJM Knowledge+ Gastroenterology