Complications of bile-duct stones: acute cholangitis and pancreatitis

Acute cholangitis and pancreatitis are the most serious complications of gallstones. In particular, the incidence of acute pancreatitis has increased markedly in recent years. We here discuss the clinical features, laboratory and radiological examinations, and treatment for both conditions. Broad-spectrum antibiotics and biliary decompression (preferably by endoscopic means) are essential in cholangitis. In unstable patients, initial stent or nasobiliary drainage is preferred, with stone removal at a later stage.Patients with small gallstones and sludge are particularly at risk for acute pancreatitis. In most cases, diagnosis of gallstone pancreatitis is easily made. In some cases, however, the underlying cause is not evident (acute ‘idiopathic’ pancreatitis). The state-of-the-art diagnostic approach then includes magnetic resonance cholangio-pancreaticography (MRCP), endoscopic ultrasound, and possibly bile collection for microscopic examination for cholesterol crystals, and sphincter of Oddi manometry. Supportive therapy suffices in most gallstone patients with pancreatitis. Although enteral feeding should be instituted early in the case of a prolonged course, the concept of jejunal feeding to avoid pancreatic stimulation has recently been challenged. Antibiotic prophylaxis to prevent infection in patients with an expected severe course has become increasingly controversial. Four randomised controlled studies have evaluated the role of endoscopic retrograde cholangiography (ERCP) with papillotomy in gallstone pancreatitis. Early ERCP appears especially to benefit patients with significant bile-duct obstruction and (imminent) cholangitis. Circumstantial evidence supports ERCP in patients with expected severe pancreatitis but without significant bile-duct obstruction or cholangitis. Elective cholecystectomy is indicated after resolution of the complication, except where there are significant contraindications to surgery.

• endoscopic drainage is the preferred procedure for biliary decompression in acute cholangitis

• ERCP should be performed in acute biliary pancreatitis patients with significant biliary obstruction and/or (imminent) cholangitis; circumstantial evidence supports ERCP in patients with predicted severe pancreatitis but without significant biliary obstruction or cholangitis

• there is no convincing evidence for routine antibiotic prophylaxis in patients with predicted severe pancreatitis but without significant biliary obstruction or cholangitis

• detailed controlled studies are necessary to evaluate the role of nasojejunal versus nasogastric feeding in acute pancreatitis

• the role of probiotics in preventing infection of pancreatic necrosis in acute pancreatitis needs to be further defined

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