Editing Acute pancreatitis (section)

== '''Gallstone pancreatitis''' ==

=== Indications for ERCP: ===

** Cholangitis
*** Cholangitis = fever + any of: CBD stones OR dilated CBD OR progressive cholestasis (bili >40). If cholangitis is suspected, aim ERCP within 24 hours.
** Persistent CBD obstruction
*** Dilated CBD
*** Obstructing stone in CBD on MRCP (consider at 72 hours)
*** Increasing LFTs without cholangitis (do MRCP first - usually do it after 24-48 hours - give them a chance to improve on their own - could be just pancreatic head oedema)
* Urgent ERCP doesn't make a difference in patients with severe acute gallstone pancreatitis if they don't have cholangitis or significant cholestasis - might as well treat conservatively and take out GB after a few days if possible - Lancet article. Cholangitis will happen more often in conservatively-managed patients, but just do an ERCP at that point.
* ERCP and sphincterotomy effectively prevents recurrent biliary pancreatitis and is especially useful in elderly patients (according to Schein)
[[File:GSP algorithm.png|right|frameless|530x530px]]

=== Cholecystectomy ===

** If no cholecystectomy is done, there's a 25% risk of recurrence
** Cholecystectomy in ALL medically fit patients once pancreatitis settled - during index admission if mild. Traditionally this has meant once pain and LFTs have normalised, but evidence is now suggesting we can do it at 48 hours or even earlier
** Unclear at this time what the best thing to do is with moderate or severe pancreatitis - retrospective data says slightly higher risk profile if done during index admission, but no good evidence
** Usual practice is, if complicated or severe disease, wait until all inflammation has resolved, and all pockets of fluid resolve or stabilise

=== In pregnant patients: ===

** Can lead to complications: preterm labour, prematurity, in utero fetal death
** First trimester is worst - low rate of term pregnancies, high rate of recurrence in same pregnancy - aim conservative treatment then lap chole
** Second trimester - safest time to operate - can operate +/- ERCP
** Third trimester - conservative treatment +/- ERCP, aim lap chole post-partum