Endoscopic Management of Severe Gallstone Pancreatitis

Abstract

Endoscopy plays an important role as a diagnostic and therapeutic tool in patients with acute gallstone pancreatitis. Endoscopic ultrasound (EUS) is considered the most sensitive and specific test for the diagnosis of choledocholithiasis, and it has been shown to be superior to magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP), particularly for detection of small bile duct stones. The role of EUS as a primary tool for the evaluation of patients with gallstone pancreatitis has been restricted because it has limited availability of both equipment and experienced operators, and although it is minimally invasive it typically requires patient sedation. Nevertheless, EUS has excellent accuracy for detection of common bile duct (CBD) stones and can be considered as a first-line test in institutions with available expertise. The role of early (24–72 h from presentation) ERCP with endoscopic sphincterotomy (ES) in patients with gallstone pancreatitis has been evaluated in a number of randomized controlled studies and an even greater number of meta-analyses, but still remains to be firmly defined. Early ERCP with ES appears indicated in patients with active cholangitis, documented CBD stones, and high likelihood for CBD stones. Patients with intermediate likelihood for CBD stone should be evaluated with EUS or MRCP or intraoperative cholangiogram (IOC). Patients with low likelihood of CBD stones can directly go to laparoscopic cholecystectomy without IOC. Further research is needed to provide standardized criteria for the diagnosis of acute gallstone pancreatitis, cholangitis, and biliary obstruction to better define the likelihood of retained bile duct stones.