Gallstones account for 35-40% of cases of pancreatitis and the risk increases with diminishing stone size. Bile reflux into the pancreatic duct can form stones there, beyond where they can be visualized by ultrasound. Biliary colic may precede the pancreatitis, but not necessarily. The pain typically reaches maximum intensity quickly but can remain for days.
Alanine aminotransferase (ALT) > 3x normal is highly suggestive of biliary pancreatitis.
Abdominal ultrasound is not sensitive to common bile duct stones but may find dilation.
In the absence of cholangitis, endoscopic ultrasound or MRCP are sensitive tests and permit intervention. Patients who recover are much more likely to develop cholangitis, therefore cholecystectomy is indicated in patients after they recover from gallstone pancreatitis.
Bottom Line: a patient presenting with days of abdominal pain but an absence of gallstones or cholangitis may still suffer from gallstone pancreatitis which requires further intervention, including cholecystectomy.
Answer
References
Portincasa P, Molina E, Garruti G, et al. Critical Care Aspects of Gallstone Disease. The Journal of Critical Care Medicine. 2019;5(1):6-18.
