Gallstone-induced acute pancreatitis is a prevalent condition that is associated with an unacceptably high mortality rate. Early endoscopic intervention, including endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy within 24 to 72 h of hospital admission, can be used to remove stones in the common bile duct (CBD) and establish biliary drainage. Anecdotal evidence of its effectiveness led to formal testing in randomized clinical trials. Although the design and results of the four published studies have varied, the overall conclusion is that early endoscopic therapy reduces morbidity and mortality in patients with acute biliary pancreatitis. Benefits are especially apparent in patients who satisfy generally accepted criteria for severe pancreatitis. The author's practice is to undertake endoscopic retrograde cholangiopancreatography in patients with severe or worsening pancreatitis, or in patients with jaundice, cholangitis or dilation of the CBD. Endoscopic sphincterotomy is performed in patients with CBD stones or in patients with biliary pancreatitis and cholelithiasis who are not candidates for cholecystectomy. The roles of newer diagnostic modalities, including magnetic resonance cholangiopancreatography and endoscopic ultrasonography, are not yet clear.
