Acute biliary pancreatitis is the sudden inflammation of the pancreas, triggered by a blockage from the biliary system. The most frequent cause is a gallstone that moves from the gallbladder into the bile ducts. The condition is serious and requires prompt medical evaluation and treatment to manage inflammation and prevent complications.
The Biliary System and Pancreatic Connection
The pancreas is an organ located behind the stomach that produces enzymes for digestion and hormones that regulate blood sugar. The biliary system, consisting of the gallbladder and bile ducts, produces, stores, and releases bile to help digest fats. A specific tube, the common bile duct, carries bile from the liver and gallbladder, and it merges with the pancreatic duct, which carries digestive enzymes from the pancreas.
This shared channel, known as the ampulla of Vater, empties into the first part of the small intestine. Acute biliary pancreatitis occurs when a gallstone travels out of the gallbladder and becomes lodged in this common pathway. The risk of a stone causing this issue is often inversely proportional to its size, as smaller stones can more easily enter and obstruct the narrow ducts.
This physical obstruction creates a backup, preventing both bile and pancreatic fluids from flowing into the intestine. The blockage increases pressure within the pancreatic duct and can lead to the reflux of bile into it. This backup triggers the abnormal activation of digestive enzymes while they are still inside the pancreas, causing them to start digesting the organ itself and leading to inflammation and cellular damage.
Symptoms and Diagnosis
The most prominent symptom of acute biliary pancreatitis is a sudden, severe, and persistent pain in the upper abdomen. This pain is often a steady sensation that can radiate to the back, developing quickly and remaining constant. Nausea, vomiting, fever, and a rapid pulse frequently accompany the pain.
In some instances, symptoms of jaundice may appear, including yellowing of the skin and eyes, dark urine, and pale stools. These occur if the gallstone blocks the flow of bile, causing bilirubin to build up in the bloodstream. The abdomen may also become tender and swollen, and leaning forward may provide some relief from the pain.
Diagnosing this condition involves clinical evaluation, blood tests, and imaging. A diagnosis is confirmed when a patient meets at least two of three criteria: characteristic upper abdominal pain, blood levels of pancreatic enzymes at least three times the normal limit, and imaging findings consistent with pancreatitis. Blood tests measure amylase and lipase, which are released in large amounts when the pancreas is inflamed.
Imaging studies are used to confirm the inflammation and identify the underlying cause. An abdominal ultrasound is the first imaging test performed, as it is effective at detecting gallstones and can show pancreatic inflammation. If the diagnosis is uncertain or complications are suspected, a contrast-enhanced computed tomography (CT) scan may be ordered for a more detailed view.
Treatment Protocols
Upon hospital admission, the initial focus is supportive care to stabilize the patient. This involves bowel rest, meaning the patient cannot eat or drink, which allows the pancreas to recover. Intravenous (IV) fluids are given to prevent dehydration, and medication is provided to control the severe abdominal pain.
Once the patient is stabilized, the next step is to address the gallstone causing the obstruction. This is often done with a procedure called Endoscopic Retrograde Cholangiopancreatography (ERCP). A doctor uses a long, flexible tube with a camera (an endoscope) passed down the throat and into the small intestine to reach the opening of the bile and pancreatic ducts.
Through the endoscope, a physician can inject a special dye into the ducts to make them visible on X-rays. Tiny tools can then be passed through the endoscope to perform a sphincterotomy, a small cut in the muscle at the opening of the ducts. This procedure helps remove the stone and restore the normal flow of bile and pancreatic juices.
The timing of ERCP depends on the severity of the pancreatitis. If a bile duct infection is also present, an urgent ERCP is recommended within 24 hours. For severe cases with ongoing obstruction but no infection, ERCP may be performed within 72 hours. In milder cases, the procedure can be done electively after the inflammation subsides.
Recovery and Preventing Recurrence
After the acute inflammation resolves, the focus shifts to preventing recurrence. The most effective prevention is the surgical removal of the gallbladder, a procedure known as a cholecystectomy. This is the definitive treatment for acute biliary pancreatitis. Removing the gallbladder eliminates the source of stone formation, significantly reducing the risk of future blockages.
The timing of the cholecystectomy depends on the severity of the initial attack. For patients with a mild case, the surgery is often performed during the same hospital stay or within two weeks. In severe cases with complications like pancreatic necrosis (tissue death), surgery is delayed for several weeks to allow the inflammation to fully resolve.
During recovery, a temporary low-fat diet may be recommended. After a cholecystectomy, the digestive system can continue to function well without the gallbladder, and most people can return to a normal diet. Without the removal of the gallbladder, the risk of another episode of pancreatitis remains high.