Gallstone pancreatitis

The majority of patients with acute gallstone pancreatitis have a mild attack and recover without additional treatment. In about 20% of patients, the attack is severe and is associated with a mortality rate of about 20%. Patients with severe pancreatitis require management in a high-dependency or intensive care setting. These patients are best managed in a specialized unit. Antibiotic prophylaxis is advised in patients with necrosis, and imipenem and cefuroxime are recommended. In severe pancreatitis, early enteral nutrition is recommended through a nasojejunal tube. In patients with severe pancreatitis or with cholangitis, urgent endoscopic retrograde cholangiopancreatography within 72 hours is indicated, and when appropriate, a sphincterotomy and clearance of the bile duct is performed. In sterile necrosis, conservative treatment is indicated unless the patient fails to improve or deteriorates, whereupon surgery is considered. If there is infection of pancreatic necrosis or abscess (pancreatic or peripancreatic), surgery is indicated. A symptomatic and persistent pancreatic pseudocyst requires intervention with either endoscopic drainage (transpapillary pancreatic stent, cystgastrostomy, or cystduodenostomy), percutaneous drainage, or surgery. Before discharge, patients should undergo cholecystectomy, or if they are unfit for surgery, endoscopic sphincterotomy and bile duct clearance.