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BEYOND THE GUIDELINES
Annals of Internal Medicine
How Would You Treat This Patient With Gallstone Pancreatitis?
Grand Rounds Discussion From Beth Israel Deaconess Medical Center
Anjala Tess, MD; Steven D. Freedman, MD, PhD; Tara Kent, MD; and Howard Libman, MD
Acute pancreatitis, a common cause of hospitalization in the United States, is often the
result of biliary tract disease. In 2016, the American Gastroenterological Association
released a guideline that addresses the practical considerations in managing acute
pancreatitis within the first 72 hours after the patient presents. The guideline specifically
recommends goal-directed hydration therapy, early enteral feeding, judicious use of
endoscopic retrograde cholangiopancreatography (ERCP), and gallbladder surgery
during the index admission for patients with mild pancreatitis. The authors discuss their
approach to these interventions in the context of a patient with recurrent acute pancreatitis who chooses to delay surgery until after hospital discharge. They address hydration and timing of surgery, as well as how they would manage the patient's preferences
in the face of existing guidelines.
Ann Intern Med. 2019;170:175-181. doi:10.7326/M18-3536
For author affiliations, see end of text.
M
r. R is a 44-year-old man with a surgical history of
anterior cruciate ligament repair of the left knee
and inguinal herniorrhaphy and an unremarkable medical history. He works as an accountant and does not
smoke tobacco or drink alcohol. In October 2017, he
had a transient episode of abdominal pain associated
with diaphoresis, nausea, and emesis, for which he presented to a local emergency department for evaluation.
ABOUT BEYOND THE GUIDELINES
Beyond the Guidelines is a multimedia feature based on
selected clinical conferences at Beth Israel Deaconess
Medical Center (BIDMC). Each educational feature focuses on the care of a patient who “falls between the
cracks” in available evidence and for whom the optimal
clinical management is unclear. Such situations include
those in which a guideline finds evidence insufficient to
make a recommendation, a patient does not fit criteria
mapped out in recommendations, or different organizations provide conflicting recommendations. Clinical experts provide opinions and comment on how they
would approach the patient's care. Videos of the patient
and conference, the slide presentation, and a CME/
MOC activity accompany each article. For more information, visit www.annals.org/GrandRounds.
Series Editor, Annals: Deborah Cotton, MD, MPH
Series Editor, BIDMC: Risa B. Burns, MD, MPH
Series Assistant Editors: Eileen E. Reynolds, MD; Gerald
W. Smetana, MD; Anjala Tess, MD, Howard Libman, MD
This article is based on the Department of Medicine
Grand Rounds conference held on 27 September 2018.
Annals.org
His physical examination, complete blood count, serum
chemistry panel, liver function tests, and electrocardiogram were not revealing, and no imaging was performed. He was discharged home with a diagnosis of
“acute abdominal pain, resolved.”
In June 2018, Mr. R again developed abdominal
symptoms; this time they were more severe and necessitated admission to a different local hospital. Evaluation revealed a patient in acute distress, with no fever,
clear lungs, and a tender epigastrium. Laboratory studies showed a leukocyte count of 13.7 × 109/L, serum
lipase level above 66.68 μkat/L, and total bilirubin concentration of 37.6 μmol/L (2.2 mg/dL). His blood urea
nitrogen, serum creatinine, and serum calcium levels
were normal. Abdominal ultrasonography of the right
upper quadrant revealed cholelithiasis with some gallbladder wall thickening and trace pericholecystic fluid
but no evidence of biliary dilation. Magnetic resonance
cholangiopancreatography (MRCP) showed acute pancreatitis with a small amount of peripancreatic fluid but
no signs of acute cholecystitis or cholelithiasis. Mr. R
had bowel rest for 2 days, vigorous hydration with intravenous fluid, and symptomatic management with
intravenous hydromorphone and ondansetron. His symptoms improved clinically, and the surgical team recommended cholecystectomy before discharge. However,
Mr. R wanted to return to his own health system for care,
and his surgery was scheduled there for 5 weeks after
discharge. Nevertheless, 4 weeks after the patient was
discharged, he was hospitalized in his own health system
for another bout of acute pancreatitis after eating a fatty
meal, and he underwent immediate cholecystectomy. Although he did well, he wonders whether waiting to have
surgery caused permanent damage to his pancreas.
© 2019 American College of Physicians 175
BEYOND THE GUIDELINES
MR. R'S STORY
It was in the fall of 2017 that I had my first attack of
pain. I drove myself to the emergency room. They came
back and said to me that everything checked out fine,
and so there was nothing. I honestly thought maybe I
got food poisoning.
The next time it happened was at the beginning of
June 2018. I started to feel pain in the center abdomen.
Five minutes after it started, I broke into a sweat. It really
wasn't a cold sweat anymore—just drenching, dripping
sweat. We went back to the hospital emergency room.
They said that a level of my liver was astronomically high
and that I needed to be admitted for a gallstone attack.
After about 24 to 36 hours, I felt fine. I had no more pain.
I wasn't taking any more medication, and I felt like nothing
ever happened. I was antsy to leave because I was falling
behind at work and could come back for a scheduled surgery. When I asked to leave, the surgeon didn't mention consequences, but he did state that they typically do surgery during the initial stay for gallstone pancreatitis.
The first hospital that I was admitted to was a chaotic experience. I didn't feel comfortable, so I wanted to
get an appointment within my own hospital network. I
ultimately left and scheduled my surgery for July 12 (5
weeks after my admission), but I ended up having another episode in that window. I didn't realize how serious acute pancreatitis can be. I thought it was just part
of the gallstone attack and it's normal.
Had I known I would be admitted or if a family member
were to go to the emergency room now, I would make more
of an effort to go to the hospital that is affiliated with the practice where our primary care doctors are. I would like to know
if any damage was done to my pancreas. That's something
that was never discussed with me.
See the Patient Video (available at Annals.org) to
view the patient telling his story.
CONTEXT, EVIDENCE, AND GUIDELINES
Acute pancreatitis is a common disorder of the
pancreas and has several possible causes. Up to 50% of
episodes are believed to be related to gallstones or
alcohol use, the latter being an independent risk factor
for gallstone disease (1). Other, less common causes
include cancer, drug reactions, and hypertriglyceridemia. Inflammation occurs in both early and late phases,
with the early phase typically lasting about 2 weeks and
the late phase months to years. Acute pancreatitis is
diagnosed on the basis of at least 2 of the following
criteria: upper abdominal or back pain, increased serum lipase and amylase levels (>3 times the upper limit
of normal), and evidence of pancreatic inflammation on
contrast-enhanced computed tomography (CT) or
magnetic resonance imaging (2). Although most cases
of acute pancreatitis are associated with only mild, local
inflammation, up to 20% may cause a systemic inflammatory response resulting in multiorgan failure or
death (2). Treatment strategies for acute pancreatitis
have evolved over time.
The American Gastroenterological Association Institute Clinical Guidelines Committee (3) published a guide176 Annals of Internal Medicine • Vol. 170 No. 3 • 5 February 2019
How Would You Treat This Patient With Gallstone Pancreatitis?
line in 2018 to address the diagnosis and initial treatment
of acute pancreatitis. On the basis of a systematic review
of relevant studies of the first 72 hours to 7 days of illness,
the guideline committee attempted to answer questions
that had not been clearly addressed regarding the effect
of treatment on the occurrence of persistent single- or
multiple-organ failure, the development of pancreatic or
peripancreatic necrosis, and mortality (4). The committee
used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach for collecting and analyzing evidence (3).
Traditional teaching regarding the initial management of acute pancreatitis has advocated aggressive,
unrestricted hydration. Four studies assessed whether
goal-directed therapy would improve outcomes compared with unrestricted hydration and found no difference in the development of peripancreatic necrosis or
in mortality (4). The degree, method, and timing of nutritional support also were examined, because recent
studies have challenged the approach of “resting the
pancreas” with “nothing by mouth” (NPO) during an
acute episode. On the basis of data from several randomized controlled trials, the review found no difference in
morbidity and mortality between patients whose acute
pancreatitis was treated with an NPO approach and those
who received early enteral feeding (4). Moreover, because no differences in critical clinical outcomes were
found between patients randomly assigned to receive
ERCP and those managed conservatively, the routine use
of ERCP in managing acute pancreatitis has been discouraged (4). Lastly, the timing of cholecystectomy remains
controversial, and this issue was addressed for mild pancreatitis only. One randomized controlled trial looked at
surgery during the index admission versus delayed surgery at 1 month (4). Rates of readmission and other biliary
complications were lower in the index admission group,
although the optimal timing of surgery for patients with
more severe pancreatitis remains unclear.
CLINICAL QUESTIONS
To structure a debate between our discussants, we
mutually agreed on the following key questions to consider when applying this guideline to clinical practice in
general and to Mr. R in particular.
1. What approach to fluid management and nutrition
do you recommend?
2. What imaging is appropriate for guiding decision
making for surgery?
3. When would you recommend that surgery be
performed?
DISCUSSION
A Gastroenterologist's Viewpoint (Dr. Steven D.
Freedman)
Question 1: What approach to fluid management and
nutrition do you recommend?
Acute pancreatitis has an extensive range of presentations, and the severity affects both its course and
optimal management (Table 1) (2, 3, 5, 6). Patients with
Annals.org
BEYOND THE GUIDELINES
How Would You Treat This Patient With Gallstone Pancreatitis?
mild pancreatitis generally improve in 2 to 3 days and
can be managed safely on a general medical or surgical floor. Moderate pancreatitis is associated with evidence of transient organ failure lasting less than 48
hours.
In contrast, severe pancreatitis involves permanent
organ failure, including adult respiratory distress syndrome (ARDS), acute kidney injury, or cardiovascular
collapse. For example, a Bedside Index of Severity in
Acute Pancreatitis score of 5 is associated with a 50%
mortality rate (7). These patients are hemodynamically
unstable and require treatment in an intensive care
unit.
My approach is to use severity scoring of acute
pancreatitis to guide fluid requirements. A hematocrit
greater than 0.44 may be an indicator of excess cytokine, including angiopoietin-2, which can lead to a vascular leak and third spacing (8). In patients like Mr. R
who receive vigorous hydration, we must be careful not
to “set it and forget it.” I recommend against starting at
a set volume only to reassess the next day. I use the
following formula to estimate the volume deficit (9):
冉
冊
measured hematocrit − baseline hematocrit
baseline hematocrit
×1∕3 total body weight (kg)
Thus, assuming a baseline hematocrit of 0.40, a
60-kg patient who has a hematocrit of 0.50 on admission has a 5-L deficit. Goal-directed bolus infusions
should be given (10), and the hematocrit reassessed
within 6 hours. I have found that the typical 120-mL/h
intravenous continuous infusion exacerbates fluid deficits and increases risk for acute kidney injury over the
initial 24 to 48 hours, especially given the large fluid
requirements that frequently occur during this time
frame. Conversely, overresuscitation also needs to be
avoided because it can lead to abdominal compartment syndrome and ARDS (11, 12). I agree with the
guideline: In someone with mild to moderate disease, I
recommend goal-directed hydration over 24 to 48
hours that is targeted to clinical parameters, such as
blood pressure or urine output, or biochemical parameters, such as hematocrit. As far as nutrition, the guideline suggests early oral feeding and, if not tolerated,
progression to nasogastric or nasojejunal enteral feeding, with parenteral nutrition as a last resort. In this patient, I would follow the guideline and start goaldirected intravenous hydration, then wait 24 hours
before any oral feeding to see how severe his disease
is. If his symptoms improve, I would recommend oral
feeding. If oral feeding is not tolerated, I would suggest
resting for 48 hours and trying again, proceeding to
enteral feeding only if oral feeding is not tolerated on
the second try.
Table 1. Assessment of Severity of Pancreatitis*
Criteria
Mild
Moderate
Severe
Hematocrit
BISAP score (5)
APACHE II score
Organ failure
>0.44
<3
<8
None
>0.44
>3
≥8
Transient
(<48 h)
>0.44
>3
≥8
Persistent
(>48 h)
APACHE II = Acute Physiology and Chronic Health Evaluation II;
BISAP = Bedside Index of Severity in Acute Pancreatitis.
* Data from references 2, 3, 5, and 6.
and to tell him or her how specific tests will affect management (Table 2) (13). Initially, in deciding whether
the cause of the acute pancreatitis is biliary in origin,
one needs to assess whether there are risk factors for
gallstones, including older age, female sex, obesity, diabetes mellitus, estrogen use, pregnancy, Native American heritage, and rapid weight loss (14). Gallstone
pancreatitis is usually associated with increased levels
of liver enzymes, especially alkaline phosphatase, and
direct bilirubin from transient bile duct obstruction, as
in our patient. If these signs are present, abdominal
ultrasonography of the right upper quadrant should be
performed to assess for gallstones or sludge in the gallbladder. However, sludge is a frequent finding in 20%
to 40% of patients, especially if they have not eaten and
are dehydrated due to vomiting and third spacing of
fluid. The sensitivity of ultrasonography in detecting
gallstones is 84%, with 99% specificity (13). Importantly,
I would consider what to do with these results. Do we
want further testing, or do we assume a biliary origin
regardless of the findings if there is no history of alcohol use? Establishing a reasonable pretest probability is
essential for thoughtful decision making.
There is generally no role for admission CT, unless
you are looking for other causes of abdominal pain.
Furthermore, it is not helpful to assess necrosis, because necrosis takes time to develop and, if found on
admission, will probably not change management.
Moreover, administration of intravenous contrast material in patients with hypovolemia may precipitate acute
kidney injury.
Magnetic resonance cholangiopancreatography is
potentially helpful for identifying choledocholithiaisis
and for assessing other causes of acute pancreatitis,
such as autoimmune disease. Studies have shown that
27% of patients presenting with gallstone pancreatitis
will have a common bile duct stone on MRCP, with 94%
sensitivity and 98% specificity (15). In patients with
autoimmune pancreatitis, characteristic findings include rim enhancement, diffuse edema or segmental
involvement, and pancreatic duct abnormalities (16).
There is no role for ERCP, unless acute cholangitis from
choledocholithiasis is present (17). Thus, for Mr. R, my
only imaging study would be ultrasonography to confirm the presence of gallstones.
Question 2: What imaging is appropriate for guiding
decision making for surgery?
Question 3: When should surgery be done?
My approach is to obtain imaging only if needed. It
is critical to include the patient in any of these decisions
Results of a recent multicenter randomized controlled trial suggest that cholecystectomy on the index
Annals.org
Annals of Internal Medicine • Vol. 170 No. 3 • 5 February 2019 177
BEYOND THE GUIDELINES
How Would You Treat This Patient With Gallstone Pancreatitis?
Table 2. Utility of Imaging Studies in Assessment of Acute Pancreatitis
Imaging Study
Utility in Assessment
Notes
Ultrasonography
CT
MRCP
Diagnoses cholecystitis, cholelithiasis, sludge, and bile duct dilatation
Confirms pancreatitis; can assess other causes of abdominal pain
Elucidates choledocholithiasis and can show nonbiliary causes,
including autoimmune pancreatitis
Defines and allows for removal of impacted stone with cholangitis
84% sensitivity and 99% specificity for detecting gallstones (13)
Not helpful in assessing necrosis on admission
–
ERCP
No role unless cholangitis is present
CT = computed tomography; ERCP = endoscopic retrograde cholangiopancreatography; MRCP = magnetic resonance cholangiopancreatography.
admission prevents further episodes of gallstone pancreatitis, assuming there are no overt complications of
acute pancreatitis (18). This study randomly assigned
130 patients to have a cholecystectomy either before
discharge or within 27 days after discharge. Three patients (2%) had recurrent pancreatitis after immediate
surgery, versus 12 patients (9%) who underwent surgery later (risk ratio, 0.27 [95% CI, 0.08 to 0.92]; P =
0.03). (There was a 30% rate of endoscopic sphincterotomy in each group, but it is unclear how this affected
outcomes.) However, older literature suggests that
more than 80% of patients will pass the stone on the
index admission (19, 20). Thus, if you do not see gallstones on ultrasonography, it is not clear that cholecystectomy would be of benefit. In addition, if you see only
sludge, cholecystectomy is not clearly indicated. In deciding whether gallstones or sludge is the cause and
whether to pursue a cholecystectomy, you should also
consider whether the patient has known risk factors, as
mentioned earlier.
I agree with the guideline that surgery be performed
on the index admission, but only when the gallbladder is
clearly the culprit. In patients with pancreatitis complications or comorbid conditions, I favor waiting for stabilization. If pancreas divisum is present (Figure), I would not
pursue surgery because the area of pancreas at risk is
quite small. Further, most of the pancreas drains through
the minor papilla, with no connection to the biliary tree
(21). In addition, pancreatitis in these patients probably
has genetic causes, including mutations in the CFTR,
Figure. Pancreas divisum.
Common bile duct
Dorsal duct
(of Santorini)
Pancreas
Duodenum
Ventral duct
(of Wirsung)
Reproduced with permission from Chauhan A, Elsayes KM, Sagebiel T,
Bhosale PR. The pancreas. In: Elsayes K, ed. Cross-sectional Imaging
of the Abdomen and Pelvis. New York: Springer; 2015.
178 Annals of Internal Medicine • Vol. 170 No. 3 • 5 February 2019
SPINK1, and PRSS1 genes. For these reasons, I do not
think cholecystectomy would be preventative in these
cases and thus is not warranted (22, 23).
To summarize, I would explain to the patient the
rationale behind early surgery and recommend that it
be performed by a general surgeon before discharge.
If there were complications or if the diagnosis remained
unclear, I would recommend waiting but perhaps involve a hepatobiliary surgeon in the final decision. If the
patient did not feel comfortable with his current surgeon, I would contact his surgeon of choice and arrange an appointment, with a goal of performing cholecystectomy within 4 to 7 days.
A Surgeon's Viewpoint (Dr. Tara Kent)
Question 1: What approach to fluid management do
you recommend?
The guideline recommends goal-directed hydration with ongoing monitoring of volume requirements,
particularly in the first 24 to 48 hours after presentation
with acute pancreatitis (4). As Dr. Freedman outlines, it
is critical to assess the severity of illness to guide expectations regarding the extent of fluid resuscitation.
With respect to adequacy of resuscitation, the
amount should always be guided by the patient's
needs. It is important to give the necessary volume;
however, it is equally important to be vigilant about
changes in clinical status and the need to adjust resuscitation. Careful monitoring of urine output and other
hemodynamic metrics is crucial.
Mr. R had mild pancreatitis; therefore, less volume
was needed to meet his needs. Overresuscitation can
lead to other significant problems, including ARDS or
abdominal compartment syndrome (11, 12), which
complicate the management of pancreatitis and increase mortality. Abdominal compartment syndrome
manifests with multiple organ system failure, as well as
marked abdominal distention and increased bladder
pressure, and requires emergent decompression. Although these complicating factors are unlikely in a patient with mild pancreatitis, it is important to understand the consequences of overresuscitation. Bladder
pressure is an often-misunderstood metric for patients
with severe pancreatitis. It is not relevant for a patient
with stable pancreatitis who is awake, alert, and on a
regular hospital ward—accurate measurement requires
that the patient be supine, intubated, and paralyzed, so
it should be done only in the intensive care unit (24).
I agree with the guideline recommendations for
nutrition in mild pancreatitis, including a trial of early
oral feeding, usually within 1 to 2 days of presentation.
Annals.org
BEYOND THE GUIDELINES
How Would You Treat This Patient With Gallstone Pancreatitis?
Most patients with mild and improving pancreatitis will
be able to resume a diet by this time (25). If intolerance
to oral feeding persists, I suggest that cross-sectional
imaging be considered to ensure that pancreatitis is
not more severe than initially anticipated.
Question 2: What imaging is appropriate for guiding
decision making?
All patients with pancreatitis should undergo abdominal ultrasonography of the right upper quadrant. Given
that gallstones are the most common cause of pancreatitis, it is appropriate to investigate for the presence of cholelithiasis or choledocholithiasis in these patients. In a patient with no other obvious cause of pancreatitis who has
ultrasonography-confirmed cholelithiasis and consistent
laboratory study abnormalities, pancreatitis should be attributed to a biliary cause (26, 27).
I agree that CT is generally not indicated at admission, except when alternative diagnoses are being considered, and is more useful after at least 72 hours, at
the beginning of the late phase of disease. It is not
useful to confirm the diagnosis of acute pancreatitis but
can assess the degree of necrosis in patients who are
not recovering. It can also identify potentially infected
necrosis and the location and character of walled-off
pancreatic necrosis or pseudocyst if an intervention is
planned. Patients with severe pancreatitis undergo frequent radiologic studies. Delaying initial scanning and
modifying the order to a single-phase study may help
reduce the overall effective radiation dose (27, 28).
If abdominal ultrasonography findings are negative
but concern persists as to the cause of pancreatitis,
MRCP can be obtained to evaluate for microlithiasis,
anatomical abnormality, or mass lesion (29). In addition, it is useful for the identification of choledocholithiasis that is equivocal on the basis of ultrasonography
and laboratory findings. Endoscopic ultrasonography
may be useful but should be reserved for cases in
which questions remain after noninterventional assessment. It is more accurate than MRCP in the diagnosis of
microlithiasis. One important change from earlier recommendations is that ERCP is no longer recommended
in patients with acute pancreatitis, unless there is clear
biliary obstruction or cholangitis (17, 30). It is also worth
considering in patients who cannot undergo cholecystectomy and for whom sphincterotomy is desired to
“protect” against recurrent pancreatitis.
Question 3: When should surgery be done?
In cases of mild gallstone pancreatitis, the patient
should undergo laparoscopic cholecystectomy at the
index presentation or admission, as recommended in
the guideline (4). When surgery is performed at this
time, there are fewer readmissions for recurrent pancreatitis or other gallstone-related disease, and there is
no difference in rates of mortality or conversion to open
surgery (31).
If pancreatitis is moderate or severe and associated
with peripancreatic collections or necrosis, surgery may
be delayed until the patient's overall status is imAnnals.org
proved, systemic findings of pancreatitis have subsided, and fluid collections and necrosis have stabilized
(30). In this group of patients, interval cholecystectomy
is associated with decreased morbidity and mortality
(30, 32). Patients with biliary pancreatitis who have undergone ERCP or sphincterotomy should still have
laparoscopic cholecystectomy, because the sphincterotomy protects against pancreatitis and cholangitis but
not against cholecystitis.
If surgery is delayed, as was the case with Mr. R,
there is a risk for recurrent pancreatitis as well as a risk
for simply losing the patient to follow-up. There may be
logistical considerations in terms of undertaking cholecystectomy at the index admission. These may include
operating room or surgeon availability, patient preferences related to professional or life events, and patient
comorbidity optimization. In general, surgical risks and
the risk for surgical complications must be weighed
against the risk for recurrent, or even more severe, pancreatitis or sequelae if surgery does not occur. To reduce the risk of delay, if pancreatitis is mild and the
patient is an appropriate surgical candidate, surgery
should occur before discharge. For those who decline
surgical intervention at that time, it is important for
practitioners to ensure that these patients truly understand the risks of this decision. Patient and family education is critical, and a clear follow-up plan must be
established.
Even when cholelithiasis, microlithiasis, or sludge is
identified, questions may remain about the cause. For
example, a patient may present with alcohol abuse as
well as cholelithiasis. Even if it is not certain that the
stones are the cause of the acute pancreatitis, if confirmed the patient should be considered for cholecystectomy. Similarly, if there is autoimmune pancreatitis
but also cholelithiasis, the patient should be treated for
autoimmune pancreatitis and also be considered for
cholecystectomy.
SUMMARY
Mr. R presented with biliary colic followed by an
episode of mild gallstone pancreatitis. His symptoms
improved quickly, but his pancreatitis recurred 4 weeks
later, a week before a scheduled cholecystectomy. He
was readmitted, and cholecystectomy was performed.
Both discussants agree that his initial presentation represented mild pancreatitis, given the absence of multiorgan failure and his rapid improvement within 24 to
48 hours. Both also agree with the guideline that goaldirected fluid resuscitation is the best approach to
avoid complications of under- and over-resuscitation.
Dr. Freedman would wait 24 hours to determine the
disease trajectory before starting oral nutrition; if oral
nutrition is not tolerated, he would try it again after another 24 hours. Dr. Kent would start oral nutrition in 24
to 48 hours; however, if the patient does not tolerate it,
she would be concerned about complications of pancreatitis. She would pursue cross-sectional imaging of
the pancreas before an enteral rechallenge. Both discussants agree that routine imaging with CT or MRCP is
Annals of Internal Medicine • Vol. 170 No. 3 • 5 February 2019 179
BEYOND THE GUIDELINES
AUTHOR BIOGRAPHIES
Dr. Tess is Associate Chair for Education in the Department of Medicine at BIDMC, and Program Director for
the Master Program in Healthcare Quality and Safety
and Associate Professor of Medicine at Harvard Medical
School, Boston, Massachusetts.
Dr. Freedman is Director of The Pancreas Center at
BIDMC, and Chief of the Division of Translational Research and Professor of Medicine at Harvard Medical
School, Boston, Massachusetts.
Dr. Kent is Vice Chair for Education, Program Director,
General Surgery Residency Program at BIDMC, and Associate Professor of Surgery at Harvard Medical School,
Boston, Massachusetts.
Dr. Libman is a clinician educator in the Division of General Medicine, BIDMC, and Professor of Medicine Emeritus at Harvard Medical School, Boston, Massachusetts.
not necessary, unless another cause of the pancreatitis
is suspected or there is potential for retained stones or
cholangitis. Dr. Kent advocates abdominal ultrasonography in all patients because of the high likelihood of gallstone disease. Dr. Freedman recommends the same but
questions whether it ultimately changes management.
The guideline states that cholecystectomy should
be performed on the index admission. Dr. Freedman
agrees, but only if gallstones are clearly the cause of
the pancreatitis, no other causes are evident, and no
complications exist. Dr. Kent also agrees with the
guideline but would pursue surgery even with evidence
of microlithiasis or sludge. The discussants concur that
they would have counseled Mr. R, who wanted to have
the operation in his own medical system, regarding the
risks of delaying surgery. They would have also more
actively managed the handoff to his outpatient physicians to expedite scheduling of cholecystectomy within
1 week after discharge.
A transcript of the audience question-and-answer
period is available in the Appendix (available at Annals
.org). To view the entire conference video, including
the question-and-answer session, go to Annals.org.
From Beth Israel Deaconess Medical Center, Boston, Massachusetts (A.T., S.D.F., T.K., H.L.).
Acknowledgment: The authors thank the patient for sharing
his story.
Grant Support: Beyond the Guidelines receives no external
support.
Disclosures: Authors have disclosed no conflicts of interest.
Forms can be viewed at www.acponline.org/authors/icmje
/ConflictOfInterestForms.do?msNum=M18-3536.
180 Annals of Internal Medicine • Vol. 170 No. 3 • 5 February 2019
How Would You Treat This Patient With Gallstone Pancreatitis?
Corresponding Author: Anjala Tess, MD, Division of General
Medicine and Primary Care, Beth Israel Deaconess Medical
Center, E/Yamins 102, 330 Brookline Avenue, Boston, MA
02215; e-mail, atess@bidmc.harvard.edu.
Current author addresses are available at Annals.org.
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Annals of Internal Medicine • Vol. 170 No. 3 • 5 February 2019 181
Current Author Addresses: Drs. Tess, Freedman, Kent, and
Libman: Beth Israel Deaconess Medical Center, 330 Brookline
Avenue, Boston, MA 02215.
APPENDIX: COMMENTS AND QUESTIONS
Dr. Libman: I think Anjala has the first question,
which I believe was posed by our patient.
Dr. Tess: The patient unfortunately could not make
it today, but his concern is that he ended up having
what sounds like 2 episodes of mild pancreatitis. He
wonders if he caused permanent damage to his pancreas because of the delay in having surgery.
Dr. Kent: He probably had biliary colic in the fall
presentation and should have had an evaluation and a
laparoscopic cholecystectomy at that time. We do see
patients with damage to the pancreas as a result of
pancreatitis, with respect to both endocrine and exocrine insufficiency, and typically more in severe pancreatitis. Most likely, this patient will be just fine.
Dr. Freedman: In a patient with no prior pancreatic
disease and no underlying risk factors for chronic pancreatitis, most likely the pancreas will regenerate and
there will be no sequelae as a result of these episodes.
Dr. Eileen Reynolds: Thank you both for terrific presentations. I love that this patient did not want anything
done to him until he talked to his primary care doctor.
Maybe it would have changed things had somebody
from the hospital contacted the primary care doctor
and said, “It really matters that we do this; can you talk
to the patient?” So, my plea is to engage the primary
care doctor in the clinical course. Now, I have a question. For many patients these days, there is a financial
implication to staying within their hospital network. For
this and other reasons, I am wondering whether it was
important enough for this patient to have early surgery
that we should have transferred him to his home network rather than discharging him.
Dr. Freedman: Very important and valid points. I
would have assumed that right after the first admission to the
outside hospital for pancreatitis, the staff there would have
reached out to the primary care doctor and discussed the
situation. I think as far as the financial implications, it is absolutely a valid point and should be discussed with the patient
as well. I think no matter what, if a patient is going to go
through something invasive, he should be comfortable with
the physician who is doing the procedure and the institution
where it is being performed.
Dr. Kent: I think you raise a really good point, and
we should definitely be engaging the primary care physician in discussion. In terms of transferring patients
back to their home facility for surgery, in my experience, that rarely happens, for practical reasons.
Dr. Mark Zeidel: Has the timing of surgery changed
now that we do it laparoscopically as opposed to an
open procedure? There used to be, I think, a lot of
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concern about doing an open procedure in someone
with active pancreatitis. Is there really a difference? I
know sometimes we have to convert from one procedure to the other.
Dr. Kent: In patients with mild pancreatitis, the gallbladder itself is typically not severely affected. Doing a
laparoscopic cholecystectomy can be more challenging in a patient with moderate or severe pancreatitis if
there are more phlegmons, or peripancreatic fluid extends up toward the gallbladder. However, I do not
believe that we can attribute the change in recommended timing to the fact that laparoscopic cholecystectomy is now the standard of care.
Dr. Elizabeth Kass: If the patient, as he did in this
case, leaves the hospital before having surgery performed, how important is specific dietary advice?
Dr. Freedman: That is a great question. We generally tell patients to be on a lower-fat diet, because fat is
the ultimate stress test on your pancreas and potentially
stimulates gallbladder contraction through cholecystokinin and other signals. I am not sure we have scientific
data to back that up, but it is not unusual for patients to
say, “Oh, I had a fatty meal, and now I'm either having
biliary colic or coming in with pancreatitis.” Hydration is
also important to emphasize. If you get dehydrated, your
gastrointestinal secretions will thicken, which may predispose to recurrent pancreatitis.
Dr. Kent: I agree. We advise patients to have a lowfat diet and to stay well hydrated. We also make sure to
set up a postdischarge phone call with our nurses to
check in with patients on their state of hydration and
eating habits.
Dr. Tess: Interestingly, this patient was following a
low-fat diet, but it was the July 4th weekend and he
stopped and got ice cream. Right after that, he was
readmitted with the second bout of pancreatitis.
Dr. Jessica Berwick: I was wondering how you
counsel patients about the risk for recurrent pancreatitis from remnant duct stones. I know we talked about
the 2% risk for recurrence, but I did not know how
much of that was from stones in the remnant duct versus other causes of pancreatitis.
Dr. Kent: Nowadays, it is less likely that they will
have an ERCP than in the past. Before we do their laparoscopic cholecystectomy, I counsel patients that there
may have been stones that escaped from the gallbladder into the ducts before the surgery and that they can
cause a similar presentation of symptoms, particularly
within the first 2 years after surgery.
Dr. Michael Apstein: Both of you alluded to the role
of defining the etiology clearly, and I think Tara referred to
biliary sludge. I know from studies 20 years ago that elimination of biliary sludge reduced the risk for recurrent
pancreatitis. Do you think biliary sludge is a player in this
process? Do you think that patients who have sludge and
no stones should have a cholecystectomy?
Annals of Internal Medicine • Vol. 170 No. 3 • 5 February 2019
Dr. Freedman: The problem with sludge is that it is
very common, and it is difficult to determine in which
patients it is truly the cause. If you look at everyone
coming in with acute pancreatitis, I think at least 40%
will have sludge, so I generally follow up with the patient. It is important to consider other causes in this
setting, such as autoimmune or medication-induced
pancreatitis.
Dr. Kent: I think we differ a bit on this point. I believe
that there is a decrease in subsequent episodes of pancreatitis in patients with sludge who undergo laparoscopic
cholecystectomy. I would consider surgery in these patients
because, in addition to the pancreatitis, we know that the
cholecystitis impact is still there, even if they passed the
stones and sludge that caused the pancreatitis.
Dr. Daniele Olveczky: As nocturnists, we often admit
patients for ERCP before they undergo cholecystectomy
Annals of Internal Medicine • Vol. 170 No. 3 • 5 February 2019
and wonder how necessary this is, because for many patients, it does not seem to affect their management.
Dr. Freedman: I think if there is clear evidence of
ongoing bile duct obstruction from an impacted stone
or another cause, then ERCP is indicated, especially in
the setting of cholangitis. Otherwise, I think it needs to
be a thoughtful decision making and not just a kneejerk response of “Yes, you should get this invasive test.”
We have a pancreatitis service that coordinates with
surgeons and the ERCP team, and I think that we can
guide management.
Dr. Kent: There are still many reasons why patients
should have ERCP on admission, whether it is for pancreatitis or, more commonly, for choledocholithiasis,
cholangitis, or suspicion of a mass.
Dr. Tess: Thank you to our discussants and to
Dr. Libman for moderating this session.
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