Acute biliary pancreatitis is caused by gallstones obstructing the common bile duct, which causes bile to reflux into the pancreas and induce inflammation. ERCP with sphincterotomy can effectively treat the obstruction but may benefit only patients with severe disease. While same-admission cholecystectomy is recommended after ERCP/sphincterotomy, further studies are needed to determine the optimal timing of cholecystectomy for mild versus severe cases of acute biliary pancreatitis.

1. Acute Biliary Pancreatitis: Pathogenesis and Management Bushra Ibnauf Sulieman, MD MS Consultant, Gastroenterology & Hepatology Department of Medicine King Faisal Specialist Hospital & Research Center - Jeddah

4. Types of Gallstones Feldmans GastroAtlas online; www.gastroatlas.com

6. Gallstone Pathogenesis Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed., page 1069

10. Pigment Stone Pathogenesis Feldmans GastroAtlas online; www.gastroatlas.com

11. Gallstone Risk Factors Am Fam Physician 2000; 62:164-74.

12. Gallstone Complications Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed., page 1074

18. http://www.medinfo.ufl.edu/year2/clinmed/jaundice/slide18.html Diagnosis of ABP

22. Challenge Identifying the patients who will benefit from early endoscopic drainage

23. ERCP and Sphincterotomy

24. ERCP

25. ERCP

26. ERCP – Advanced Transpappilary Balloon dilation Precut Sphincterotomy

28. Major ERCP Complications Consensus Definition Complications of endoscopic biliary sphincterotomy. Freeman, Sherman NEJM 1996 Mild Moderate Severe Pancreatitis Hospital stay 2-3 days 4-10 days 10 days Pseudocyst/intervention Bleeding Hgb drop<3gm No Transfusion Transfusion<4 U No angio/surgery Transfusion >5 U Angio/surgery Perforation Possible or very mild Definite, treated medically Medical Rx>10 days, intervention Infection (Cholangitis) >38C for 24-28 hrs Febrile or septic illness > 3 days hospital Septic shock or surgery

29. Post-ERCP pancreatitis-Risk Factors Multivariate Analysis Risk factors for post-ERCP pancreatitis. Freeman, DiSario GIE 2001 Definite Maybe No Suspected SOD Female sex Biliary sphincterotomy Young Age Acinarization Small CBD Difficult/failed cannulation Trainee involvement SOD manometry Pancreatic sphincterotomy Absence of CBD stone PD injection Lower ERCP volume History of PEP Balloon Dilation Normal Bilirubin Precut sphincterotomy

30. ERCP Bleeding-Risk Factors Multivariate Analysis Risk factors for post-ERCP pancreatitis. Freeman, DiSario GIE 2001

31. Reducing Complications: Cannulation

32. Reducing Complications: Cannulation

33. Complications: Management Pancreatic stent placement Post-sphincterotomy Bleeding hemoclipping

35. Trials of ERCP in ABP Lancet 1988; 2:979-983 N Eng J Med 1993; 328:228-232 N Eng J Med 1997; 336:237-242 Gastroenterology 1995; 108:A380(abstract) ERCP  ES Control Time to ERCP Center Severe pancreatitis ERCP Success Gall-stones Other United Kingdom 1988 59 62 72h Single 44% Glasgow 88% 85% Hong Kong 1993 97 98 24h Single 42% Ranson’s 90% 66% Germany 1997 126 112 72h Pain onset Multiple 14% Glasgow 96% 46% Bili > 5 excl Poland 1995 178 102 24h Single NR NR NR Pooled 460 374 30% 92% 61%

37. Predicted mild pancreatitis P<0.05 Predicted severe pancreatitis Lancet 1988; 2:979-983 N Eng J Med 1993; 328:228-232 Gastroenterology 1995; 108:A380(abstract) N Eng J Med 1997; 336:237-242 Interval between onset of ABP and ES Polish Study

47. Acute Gallstone Pancreatitis Mild Severe Cholecystectomy (same admit) Cholecystectomy (same admit) Discharge ERCP/ES ERCP/ES No planned cholecystectomy Clinical deterioration Emergent Cholangitis Jaundice BD dilated Surgical Contraindication(s) Adapted From - Gastrointest Endosc 2002; 56(6):S170-S174

48. Biliary Sludge Sx’s or complications present Consider cholecystectomy No reversible factor present Reversible factor present (ceftriaxone) Surgical candidate? Nonsurgical therapy (UDCA, cholecystostomy) Sx’s or complications absent Reverse (if possible) , observation Clinical observation Reconsider cholecystectomy if sludge persists or complications develop Yes No

49. SAMA www.sama-sd.org