A 30-year-old obese female with a past medical history of cholelithiasis presents to the emergency room with progressive abdominal pain, nausea, and emesis for 2 days. While in the emergency department, she was noted to be afebrile with the following vital signs:
Her laboratory evaluation was notable for:
An abdominal ultrasound shows cholelithiasis without secondary signs of cholecystitis and a common bile duct measuring 5 mm. She is admitted for supportive management and the following day her total bilirubin is 0.6 mg/dL, lipase is 500 U/L, and her pain and nausea are significantly improved.
What is the best next step in management?A. Endoscopic Retrograde Cholangiopancreatography (ERCP)
Correct Answer: B
This patient’s presentation is consistent with mild gallstone pancreatitis. After initial resuscitation, her laboratory test results improved (normalizing total bilirubin and lipase). With no evidence of ongoing biliary obstruction and no signs/symptoms of cholangitis, there is no indication to proceed with further imaging (MRCP) or ERCP. Current recommendations are for laparoscopic cholecystectomy during the same admission for patients who present with gallstone pancreatitis. This is based on the clear reduction in risk for recurrent gallstone-related events and that surgical outcomes do not differ in same admission versus delayed cholecystectomy. There is no evidence to support the use of prophylactic antibiotics in patients with gallstone pancreatitis, regardless of severity. The patient presented in this question has no evidence of ongoing or active infection to warrant antibiotic therapy.