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Currently studying basic diagnostic procedure and the topic of pancreatitis comes in. The scenario is that the patient has come in with severe nausea and vomiting. It's already been confirmed via blood panel (amalyse and lipase) and urinalysis that the pancreas pancreas is not working correctly and pancreatitis may be present. CT scan is ordered and it is clear via scan the area doesn't look as it should (Just trying to keep this short). In this situation, obviously IV fluids and other nutrients must be administered to dampen the mortality percentage. In this case however, would it be standard to remove the gallbladder without confirming that the gallbladder is the culprit? Just for safe measure? Or should there be more testing done to determine what caused the pancreatitis?

I was told that fifty percent of pancreatic issues are caused by gallbladder disease, although I cannot find any evidence to support this. Is this actually common practice for a GI doctor to do just because pancreatitis is present?

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Gallstones are the most frequent cause of acute pancreatitis. According to the American Gastroenterology Association (see ref below), gallstone related acute pancreatitis represent 35-40% of the cases. Interestingly, only 5% of the patients with gallstones will develop pancreatitis.

Several studies have been conducted to investigate the optimal timing for cholecystectomy in patients with biliary pancreatitis. A recent Cochrane review (which summarises and aggregates the evidence from all the studies) has concluded the folowing:

There is no evidence of increased risk of complications after early laparoscopic cholecystectomy. Early laparoscopic cholecystectomy may shorten the total hospital stay in people with mild acute pancreatitis. If appropriate facilities and expertise are available, early laparoscopic cholecystectomy appears preferable to delayed laparoscopic cholecystectomy in those with mild acute pancreatitis. There is currently no evidence to support or refute early laparoscopic cholecystectomy for people with severe acute pancreatitis. Further randomised controlled trials at low risk of bias are necessary in people with mild acute pancreatitis and severe acute pancreatitis.

But this is not an "upfront" procedure. The etiology of acute pancreatitis needs to be determined first. The AGA has provided some recommendations on the steps which should be undertaken to determine the etiologies for pancreatitis (you can find them in the reference below) such as:

  • History taking should focus on possible risk factors for pancreatitis (previous symptoms, hypertriglyceridemia, the 4 F (female, fat, forty fertile) as RF for choleliathiasis, drug and alcool use, autoimmmune diseases)
  • Appropriate lab and clinical examination
  • Abdominal ultrasound (to detect possible cholelithiasis or choledocholithiasis)
  • EUS (endoscopic ultrasound) or ERCP (endoscopic retrograde cholangiopancreatography): if cause unclear or suspicion of tumor or if high suspicion for cholelithiasis but not visualised in abdominal US

References:

Gurusamy KS. Early versus delayed laparoscopic cholecystectomy for acute gallstone pancreatitis.Cochrane Database Syst Rev. 2013 Sep 2;(9):CD010326. doi: 10.1002/14651858.CD010326.pub2.

Forsmark. AGA Institute Technical Review on Acute Pancreatitis. Gastroenterology. May 2007Volume 132, Issue 5, Pages 2022–2044

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