Gallstone Pancreatitis

Overview

What is gallstone pancreatitis?

Acute pancreatitis, or inflammation of your pancreas, has several possible causes, but the leading cause is gallstones. Healthcare providers distinguish pancreatitis caused by gallstones from other types of pancreatitis, because the nature of the disease, how it occurs and how it is treated are different. In gallstone pancreatitis, (also called biliary pancreatitis,) a gallstone is blocking the pancreatic duct. The blockage causes inflammation. The gallstone has to pass or be removed to fix gallstone pancreatitis.

What is the pancreas?

The pancreas is an organ in your digestive system that makes digestive enzymes to help break down your food. When food arrives in your small intestine for digestion, chemicals signal your pancreas to release these enzymes. The pancreas delivers the enzymes through a small channel called the pancreatic duct. The pancreatic duct feeds into a larger duct called the common bile duct, which delivers the enzymes, along with bile from your liver and your gallbladder, into the top of your small intestine.

What are gallstones?

Gallstones develop in your gallbladder from crystalized concentrations of bile. Your gallbladder is a storage compartment for bile made by your liver. Bile has several ingredients, and if there is too much of one of them — usually cholesterol, and sometimes bilirubin — the excess turns into a kind of sludge that sits in the bottom of your gallbladder. If your gallbladder doesn’t empty often or thoroughly enough, the sludge remains and becomes concentrated until it eventually clumps and crystalizes into stones.

Is gallstone pancreatitis serious?

Yes. You should always seek immediate treatment for pancreatitis. Your symptoms may be mild to severe, but they will become more severe the longer it goes untreated. Complications also become more serious over time, especially when there is a blockage in the bile ducts. Complicated or severe pancreatitis can be life-threatening.

How common is gallstone pancreatitis?

Gallstones are common, but they don’t always cause problems. In the U.S., an estimated 10% to 15% of people have gallstones, but only .1% of them will have gallstone pancreatitis. Acute pancreatitis overall occurs in about .4% of people in the U.S. Gallstones account for about 35% of these cases. Alcohol use is the second leading cause.

Symptoms and Causes

What causes gallstones?

Gallstones don’t have one direct cause, but several factors may contribute. You may have too much cholesterol in your blood, either due to diet or a metabolic disorder. This can cause cholesterol to accumulate in your bile. You may have too much bilirubin in your blood and in your bile if you have liver disease. You might have a functional disorder that prevents your gallbladder from emptying efficiently. High estrogen can also slow down gallbladder emptying, which is why pregnant people are more at risk.

How do gallstones cause pancreatitis?

Your pancreas and gallbladder are connected to each other by the common bile duct. Usually, bile passes from your gallbladder through the common bile duct on its way to your small intestine. But if you have gallstones, one of them could also pass through.

Gallstones can travel when they are small, but they grow over time as new bile washes over them. A gallstone that once traveled can eventually become stuck in a narrow place. A gallstone can block the pancreatic duct by traveling into it, or cause a blockage outside of it.

The blockage may cause pancreatitis in one of two ways. One theory is that a gallstone that blocks the common bile duct outside of the pancreatic duct may cause bile to backwash into the pancreas. Bile is highly corrosive and irritates the pancreas.

The other theory is that pancreatic enzymes themselves irritate your pancreas when they back up into it. These enzymes, which are meant to break down proteins, carbohydrates and fats in your small intestine, are also highly corrosive. Your small intestine has a thick mucus lining to protect it, but your pancreas doesn’t.

Pancreatic enzymes usually aren’t activated until they reach your small intestine. But a blockage in the pancreatic duct may cause so much pressure to build up in the duct and in the pancreas that the pressure activates the enzymes.

Whatever the mechanism is, we know that there is a cause-and-effect relationship between gallstones in the bile ducts and acute pancreatitis. When you go to the hospital for treatment, removing gallstones from the bile ducts relieves gallstone pancreatitis.

What are the signs and symptoms of gallstone pancreatitis?

Typical symptoms include:

  • Severe abdominal pain. You may feel it on the upper left side, where your pancreas is. It might feel sharp or like squeezing inside. It may also radiate to your chest, shoulder or back.
  • Nausea and vomiting.

More advanced symptoms can include:

What are the possible complications of gallstone pancreatitis?

If your pancreas remains in a state of acute inflammation, the tissues will eventually begin to scar and lose blood supply. This can cause your pancreas to fail. Prolonged inflammation also causes fluid to accumulate in the tissues between your organs (peritonitis). The fluid can continue to spread upwards into your chest, putting pressure on your lungs and heart. The accumulating fluid depletes your blood volume, causing severe dehydration. This causes your kidneys to retain fluid and can eventually lead to hypovolemic shock.

A gallstone stuck in the bile ducts causes a secondary set of problems for the organs connected to the biliary tree. It can cause bile to back up into your liver and gallbladder, causing secondary cholecystitis (gallbladder inflammation) and liver disease. Pressure in the ducts causes them to leak digestive fluids such as bile into your bloodstream. A blockage can also cause bacteria from your small intestine to backwash into the ducts, leading to secondary infection. If the infection leaks into your bloodstream, it can become systemic, leading to septic shock.

Diagnosis and Tests

How is gallstone pancreatitis diagnosed?

If you come to the hospital with typical symptoms, your healthcare provider will give you a blood test to check for pancreatic enzymes. They’ll also look at your liver enzyme levels to see how much your liver has been affected. They’ll follow up with imaging tests to look at your pancreas and get a better idea of how severe your pancreatitis is.

An abdominal ultrasound can find gallstones in the ducts. A CT scan can provide more detail of the pancreas if necessary. Sometimes the gallstone that caused the original blockage that started your pancreatitis has already passed on its own by the time you seek treatment. But if there are other gallstones around, they’ll know that was the cause.

Management and Treatment

How is gallstone pancreatitis treated?

If you are in a severe state, you’ll be taken to intensive care. Most cases (80%) will be milder and will begin with supportive care. This is the only treatment for pancreatitis itself.

Supportive care

Treatment begins with:

  • IV fluids. Most people will be dehydrated and need to rebuild their blood volume. Your healthcare team will install an intravenous catheter to a vein in your arm or hand to deliver continuous fluids, including electrolytes.
  • Pain relief. Most people will need strong pain relief, either by injection or through their IV.
  • Bowel rest. You’ll probably need to stop eating until your pancreas calms down. Activating your digestive system signals your pancreas to release more enzymes and your liver and gallbladder to release more bile. This adds to the pressure in your bile ducts and makes your condition worse.
  • Nutritional support. Depending on how severe your case is and how long you are expected to stay in the hospital, your healthcare team may simply add some glucose to your IV fluids to give you energy, or they may give you nutrition through a nasogastric tube or through your IV.

Additional treatments may include:

  • Nausea medication.
  • Oxygen support.
  • Antibiotics (if there is an infection detected).
  • A nasogastric (NG) tube passed through your nose into your stomach to drain fluids.
  • A urinary catheter to drain your urine and measure your urine output.

You’ll stay in supportive care until your pancreas begins to calm down. In milder cases, this takes a few days. Supportive care may help you naturally pass a stone if it hasn’t yet caused serious complications.

Gallstone interventions

Sooner or later, any gallstone stuck in your ducts will have to be removed. It may be an immediate emergency procedure, or it may come after supportive care, depending on your condition. Even if the original stone that caused the blockage has passed, all other stones will have to be removed too.

You may have one or both of the following procedures:

  • ERCP. ERCP stands for Endoscopic retrograde cholangiopancreatography. It’s an internal exam that also gives your healthcare provider access to fix things that they find along the way. Using a combination of X-rays and an endoscope, the ERCP test explores the bile ducts. The endoscope — a long tube with a lighted camera at the end — is inserted through your throat into your stomach. Then a second tube is passed through the first tube into your bile ducts. Your healthcare provider will be able to see these ducts through fluoroscopic X-ray technology. They can insert tools through the tubes to remove gallstones and place stents to relieve blockages.
  • Gallbladder removal. Once gallstones have brought you to the hospital, the chance of them causing trouble again is too high to risk. Gallbladder removal is the only treatment for gallstones that cause problems, and it’s a safe and effective one. It can usually be done through minimally invasive surgery. A laparoscopic cholecystectomy removes your gallbladder through a few small incisions, using the aid of a laparoscope, a tiny camera inserted through one of the incisions. Some people may require traditional open surgery depending on their condition.

Prevention

Can gallstone pancreatitis be prevented?

If you’ve had signs or symptoms of gallstones in the past, that’s a warning. You should definitely find out if you have them and have them removed if you do. The red flag is a symptom called biliary colic. It’s an ache in the right side of your abdomen under your right rib cage, where your gallbladder is. You might feel it after eating, and it might give you nausea. Biliary colic that comes and goes indicates a partial or occasional blockage in your gallbladder or bile ducts. It might come and go as your gallbladder contracts and relaxes. This could easily turn into something more serious.

Outlook / Prognosis

How long does gallstone pancreatitis last?

It usually won’t resolve on its own, but if you have a relatively mild and uncomplicated case, a few days of supportive care in the hospital should do it. However, you may still need to have a blockage removed.

How long does it take to recover from treatment?

Most people will need a cholecystectomy, and recovery time will depend on what kind you have. It takes about two weeks to recover from laparoscopic surgery. If you have open surgery, it takes six to eight weeks.

What is the prognosis for people admitted to the hospital with gallstone pancreatitis?

If you don’t have a severe or complicated case, you can expect to recover completely. Gallbladder removal is considered a minor surgery with few complications. Your digestive system can continue to function well without your gallbladder.

About 20% of cases are severe or complicated. The damage already done in these cases is hard to undo. Despite intensive care, up to 25% of these cases may be fatal. Those who survive will be in the hospital for many weeks before they recover.

A note from Cleveland Clinic

If you don’t know that you have gallstones, and many people don’t, you may be surprised and bewildered by the sudden onset of gallstone pancreatitis. The pain can be severe and seem to come out of nowhere. If you think you might have gallstones, it’s a good idea to find out in advance.

Pay attention to symptoms of abdominal pain and nausea that come and go, especially after you eat. This is the warning sign of biliary colic. Always take pain seriously and seek medical attention to find out what’s causing it. The sooner you seek treatment for pancreatitis, the better your outcome will be.

Last reviewed by a Cleveland Clinic medical professional on 05/03/2022.

References

  • American College of Gastroenterology. Gallstone Pancreatitis. (https://gi.org/topics/gallstone-pancreatitis/) Accessed 5/3/2022.
  • Hazem ZM. Acute biliary pancreatitis: diagnosis and treatment. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2841412/) Saudi J Gastroenterol. 2009;15(3):147-155. Accessed 5/3/2022.
  • NHS inform. Acute pancreatitis. (https://www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-gastrointestinal-tract/acute-pancreatitis) Accessed 5/3/2022.

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