Acute Biliary Pancreatitis - GI Management (ACG 2024)

Algorithm Steps

1. ▶

   Start

   Acute Biliary Pancreatitis Diagnosed

   Pancreatitis + gallstones/biliary sludge on imaging

   1. ●

      Action

      Assess Severity & Cholangitis

      Key decision points for ERCP

      • BISAP, APACHE II, or Ranson's score
      • Signs of cholangitis: fever, RUQ pain, jaundice (Charcot's)
      • Worsening LFTs (especially bilirubin)
      • CBD dilation on imaging (>6mm or >8mm if post-CCY)
      1. ◆

         Decision

         Concomitant Cholangitis?

         Tokyo Guidelines criteria

         1. ⚠

            Warning

            ⚠️ Urgent/Emergent ERCP

            Within 24 hours (ideally <12h if sepsis)

            • Definite cholangitis = ERCP within 24 hours
            • Severe cholangitis/sepsis = <12 hours
            • Sphincterotomy + stone extraction
            • Biliary stent if unable to clear duct
            1. ◆

               Decision

               Pancreatitis Resolving?

               Pain improving, tolerating diet, normalizing labs

               1. ●

                  Action

                  Same-Admission Cholecystectomy

                  STRONGLY recommended for mild biliary pancreatitis

                  • Reduces recurrent pancreatitis by 75%
                  • Perform before discharge if mild disease
                  • Laparoscopic preferred
                  • IOC to confirm CBD clear
                  • Delay only if severe pancreatitis/local complications
                  1. ✓

                     Outcome

                     Biliary Pancreatitis Resolved

                     CCY done, biliary tract cleared - no further intervention needed

               2. ●

                  Action

                  Severe Pancreatitis - Delayed CCY

                  Wait for local complications to resolve

                  • Delay 6+ weeks if necrosis/collections
                  • Interval cholecystectomy when recovered
                  • High recurrence risk if CCY not done (~30-50%)
                  1. ✓

                     Outcome

                     Outpatient Follow-up

                     Schedule cholecystectomy within 2-6 weeks if not done inpatient

         2. ◆

            Decision

            Persistent CBD Obstruction?

            Elevated bili, dilated CBD without cholangitis

            1. ●

               Action

               CBD Stone Probability Assessment

               Risk stratification for CBD stone

               • High risk: CBD stone on US, cholangitis, bili >4
               • Intermediate: CBD dilation, bili 1.8-4, abnormal LFTs
               • Low risk: normal labs and no CBD dilation
               1. ●

                  Action

                  High Risk → ERCP

                  Direct to ERCP without further imaging

                  • ERCP within 24-72 hours
                  • Sphincterotomy + stone extraction
                  • No need for MRCP/EUS first
               2. ●

                  Action

                  Intermediate Risk → MRCP/EUS

                  Further imaging to confirm CBD stone

                  • MRCP or EUS preferred (non-invasive)
                  • Sensitivity ~95% for CBD stones
                  • ERCP if stone confirmed
                  • Avoid unnecessary ERCP (PEP risk)
               3. ●

                  Action

                  Low Risk → Observe

                  No ERCP, proceed to cholecystectomy

                  • Labs normalizing
                  • No CBD dilation
                  • ERCP NOT indicated for all biliary pancreatitis
                  • IOC at time of cholecystectomy