Acute Biliary Pancreatitis Diagnosed
Acute pancreatitis with gallstones or sludge on ultrasound
All Pathways
GastroenterologyManagement
Acute Biliary Pancreatitis - GI Management (ACG 2024)
Acute Biliary Pancreatitis - GI Management (ACG 2024): Acute Biliary Pancreatitis Diagnosed → Assess severity, start fluids, check for cholangitis → Cho...
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Action Assess severity, start fluids, check for cholangitis
Scores alone do not predict severity. Watch closely for 48 h. Pregnancy, child or after cholecystectomy: not covered; get specialist advice.
- Organ failure or SIRS: monitored bed or ICU
- Severe = organ failure lasting more than 48 h
- Fluids (adult): Hartmann's. Hypovolaemic: 10 mL/kg bolus, repeat while still hypovolaemic. Not hypovolaemic: up to 1.5 mL/kg/h. Reassess often in first 24-48 h
- Heart or kidney disease, older age: smaller volumes; watch for overload. Shock: still resuscitate
- Check bilirubin, LFTs and CBD diameter on ultrasound
- Early oral feeding as tolerated; no prophylactic antibiotics
03Decision Cholangitis present?
Fever or raised inflammatory markers, plus jaundice or abnormal LFTs, plus dilated CBD or stone (Tokyo 2018)
- If Yes
04Warning Cholangitis: antibiotics now, ERCP within 24 h
Do not wait for ERCP to start antibiotics. No ERCP on site: transfer urgently. ERCP fails: percutaneous or EUS-guided drainage.
- Blood cultures, then IV antibiotics now (local guideline)
- Resuscitate. Septic shock: ICU; drain as soon as stable
- ERCP: sphincterotomy and stone extraction; stent if duct not cleared or patient unstable. On anticoagulants or P2Y12 inhibitors, or coagulopathic: stent without sphincterotomy; do not delay drainage
05Decision Mild pancreatitis, no necrosis or collections?
Pain settling, eating, no organ failure
- If Yes
06Action Mild: cholecystectomy this admission
Before discharge. If delayed, about 18% are readmitted with biliary events.
- Laparoscopic; IOC if CBD stone not excluded
- Unfit for surgery (frail, severe comorbidity): ERCP sphincterotomy instead
- Sphincterotomy does not replace cholecystectomy in fit patients
07Outcome Cholecystectomy done, CBD clear
No further biliary intervention needed.
If No08Action Not mild (organ failure, necrosis or collections): plan cholecystectomy timing
Plan timing with surgeon and gastroenterologist.
- Necrosis or collections: manage them first. Operate when collections resolve, or after 6 weeks if they persist
- No necrosis or collections: operate once recovered and inflammation settled; this admission or interval, decided with surgeon
09Outcome Cholecystectomy date planned
Book the date before discharge. Unfit for surgery: discuss ERCP sphincterotomy.
If No10Action No cholangitis: assess CBD stone risk (ASGE 2019)
Do not do urgent ERCP without cholangitis or CBD obstruction.
- High: CBD stone on imaging, OR bilirubin >4 mg/dL (68 micromol/L) AND CBD >6 mm
- Intermediate: abnormal LFTs, age >55 years, or dilated CBD
- Low: none of these
- Recheck bilirubin; rising bilirubin or new cholangitis changes the plan
11Decision CBD stone risk level?
High, intermediate or low (criteria above)
- High
12Action High risk, no cholangitis: ERCP this admission
CBD stone on imaging, or bilirubin >4 mg/dL (68 micromol/L) with dilated CBD. Not urgent without cholangitis.
- Rising bilirubin or new cholangitis: urgent ERCP
- Bilirubin falls to normal and no stone seen: MRCP or EUS first
- Otherwise no MRCP or EUS needed; ERCP before or after cholecystectomy
- Before sphincterotomy: check anticoagulants, antiplatelets, INR and platelets
- Path rejoins step 05Shared downstream outcome
- Intermediate
13Action Intermediate risk: MRCP or EUS first
Abnormal LFTs, age >55 years, or dilated CBD
- MRCP or EUS (local access); or IOC at cholecystectomy
- Stone confirmed: ERCP with sphincterotomy and stone extraction (check anticoagulants first)
- No stone: go to cholecystectomy
- No diagnostic ERCP: higher risk of post-ERCP pancreatitis with normal duct and bilirubin
- Path rejoins step 05Shared downstream outcome
- Low
14Action Low risk: no ERCP
Normal LFTs, CBD not dilated and age 55 years or younger
- No MRCP or ERCP needed
- Laparoscopic cholecystectomy, with IOC if indicated
- Path rejoins step 05Shared downstream outcome
Guideline Source
ACG Guidelines: Management of Acute Pancreatitis (Tenner et al., Am J Gastroenterol 2024)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- SIRS from pancreatitis can mimic cholangitis. If infection is suspected, give antibiotics while the source is confirmed.
- Not covered: pregnancy, children, and patients after cholecystectomy. Get specialist advice.
- Antibiotic choice and doses: follow local guideline (Therapeutic Guidelines in Australia).
- MRCP, EUS and ERCP access varies; transfer may be needed.
Contraindicated Populations
Pregnancy (specialist advice)ChildrenAfter cholecystectomy (specialist advice)
Applicable Regions
AUUSEUGlobal
AU: Hartmann's is the usual lactated crystalloid. Bilirubin is reported in micromol/L (4 mg/dL = 68 micromol/L). Antibiotics per Therapeutic Guidelines.
EU: Similar to IAP/APA 2013 guidance.
US: ACG 2024 and ASGE 2019 choledocholithiasis guideline.
Version 2Next review: 2027-09-30
Next steps
Finish the workflow by opening the most relevant calculator, then convert the session into a live account when you are ready.
Calculator
Glasgow-Blatchford Bleeding Score
Upper GI bleed risk stratification and need for intervention
Open page
Compare
AttendMe.ai vs UpToDate
See how this pathway workflow compares against UpToDate.
Open page
Commercial
Start free
Run the pathway in a live AttendMe account with citations and tracked usage.
Start free
Related Resources
Frequently Asked Questions
What is the Acute Biliary Pancreatitis - GI Management (ACG 2024)?
The Acute Biliary Pancreatitis - GI Management (ACG 2024) is a management clinical algorithm for Gastroenterology. It provides a structured decision tree to guide clinical decision-making, based on ACG Guidelines: Management of Acute Pancreatitis (Tenner et al., Am J Gastroenterol 2024).
What guideline is the Acute Biliary Pancreatitis - GI Management (ACG 2024) based on?
This algorithm is based on ACG Guidelines: Management of Acute Pancreatitis (Tenner et al., Am J Gastroenterol 2024) (DOI: 10.14309/ajg.0000000000002645).
What are the limitations of the Acute Biliary Pancreatitis - GI Management (ACG 2024)?
Known limitations include: SIRS from pancreatitis can mimic cholangitis. If infection is suspected, give antibiotics while the source is confirmed.; Not covered: pregnancy, children, and patients after cholecystectomy. Get specialist advice.; Antibiotic choice and doses: follow local guideline (Therapeutic Guidelines in Australia).; MRCP, EUS and ERCP access varies; transfer may be needed.. Individual patient factors may require deviation from these recommendations.
Get AI-Powered Analysis Alongside This Algorithm
In AttendMe.ai, the Acute Biliary Pancreatitis - GI Management (ACG 2024) appears automatically when your clinical question matches — alongside evidence from 3M+ peer-reviewed articles.
Try AttendMe Free