Proposal of the term "gallstone cholangiopancreatitis" to specify gallstone pancreatitis that needs urgent endoscopic retrograde cholangiopancreatography

Abstract

Opie's "pancreatic duct obstruction" and "common channel" theories are generally accepted as explanations of the mechanisms involved in gallstone acute pancreatitis (AP). Common channel elucidates the mechanism of necrotizing pancreatitis due to gallstones. For pancreatic duct obstruction, the clinical picture of most patients with ampullary stone impaction accompanied by biliopancreatic obstruction is dominated by life-threatening acute cholangitis rather than by AP, which clouds the understanding of the severity of gallstone AP. According to the revised Atlanta classification, it is difficult to consider these clinical features as indications of severe pancreatitis. Hence, the term "gallstone cholangiopancreatitis" is suggested to define severe disease complicated by acute cholangitis due to persistent ampullary stone impaction. It incorporates the terms "cholangitis" and "gallstone pancreatitis." "Cholangitis" refers to acute cholangitis due to cholangiovenous reflux through the foci of extensive hepatocyte necrosis reflexed by marked elevation in transaminase levels caused by persistent ampullary obstruction. "Gallstone pancreatitis" refers to elevated pancreatic enzyme levels consequent to pancreatic duct obstruction. This pancreatic lesion is characterized by minimal or mild inflammation. Gallstone cholangiopancreatitis may be valuable in clinical practice for specifying gallstone AP that needs urgent endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy.

Keywords: Acute cholangitis; Endoscopic retrograde cholangiopancreatography; Gallstone hepatitis; Gallstone pancreatitis; Necrotizing pancreatitis; Pathophysiology.

Figure 1

Subdivisions of gallstone pancreatitis with severe disease into gallstone cholangiopancreatitis and gallstone necrotizing pancreatitis. A: Gallstone cholangiopancreatitis with persistent ampullary stone impaction and ascending acute cholangitis complicated with minimal or mild pancreatic inflammation due to biliopancreatic obstruction; B: Gallstone necrotizing pancreatitis caused by the reflux of bile or duodenal contents into the pancreas (P), not complicated by acute biliary tract disease due to the passage of stones. L: Liver; BD: Bile duct; GB: Gallbladder; PD: Main pancreatic duct.

Figure 2

The algorithm for the diagnosis and initial treatment of gallstone pancreatitis. AP: Acute pancreatitis; CECT: Contrast-enhanced computed tomography; CP: Cholangiopancreatitis; ERCP: Endoscopic retrograde cholangiopancreatography; ES: Endoscopic sphincterotomy; NP: Necrotizing pancreatitis.