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Dr. Todd Ponsky

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Update Course Rewind: Pediatric Biliary Stones - Preventing Gallstone Pancreatitis 2024

Video Published 2025-07-29 Updated 2026-08-01

Timestops (9)

Global Cat MD along with Cincinnati Children's Hospital

Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hel…

Presentations now fall into three.

Presentations now fall into three. Categories green circle for established practice, blue square for promising newer pra…

This is actually a patient of mine from about 4 months ago.

This is actually a patient of mine from about 4 months ago. This patient, currently undergoing treatment for acute lymph…

According to our live and virtual audience poll

According to our live and virtual audience poll, over 50% opted to start antibiotics and address the elevated liver func…

Gallstone pancreatitis is inflammation of the pancreas trigg…

Gallstone pancreatitis is inflammation of the pancreas triggered by a gallstone obstructing the bile duct, which can als…

Some will say, hey, we're going to wait for a week.

Some will say, hey, we're going to wait for a week. From an ERCP standpoint, unless there's a persistent biliary obstruc…

There's been some studies done to show if you

There's been some studies done to show if you, you wait one day when the patient comes in with acute biliary pancreatiti…

Some stones pass spontaneously, right?

Some stones pass spontaneously, right? We have to use good judgment with that and local resource. You have to factor in …

The timing of cholecystectomy should be based on clinical im…

The timing of cholecystectomy should be based on clinical improvement rather than complete biochemical normalization wit…

Topic Overview

A multidisciplinary panel discusses management of pediatric biliary stones and gallstone pancreatitis, using a case of a 16-year-old with ALL, neutropenia, and acute cholecystitis. The discussants agree that most stones pass spontaneously and that conservative management with antibiotics is appropriate in high-risk patients. For gallstone pancreatitis, early ERCP is reserved for persistent obstruction or cholangitis; cholecystectomy timing is guided by clinical improvement rather than biochemical normalization, with intraoperative cholangiogram available.

Key Takeaways

Most biliary stones pass spontaneously; conservative management with antibiotics is appropriate in high-risk patients. (1:20)
Early ERCP for gallstone pancreatitis is reserved for persistent obstruction or cholangitis, not routine practice. (2:13)
Rising amylase/lipase one day after presentation indicates impacted stone requiring ERCP; declining levels suggest passage. (2:38)
Cholecystectomy timing is guided by clinical improvement, not biochemical normalization; intraop cholangiogram available. (2:25)

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Speaker 1 — host
Em Goddy — host
Speaker 3 — guest
Speaker 4 — guest
Speaker 5 — guest
Speaker 6 — guest

Chapters

0:00Introduction and Case Presentation — Introduction to the update course series and presentation of a 16-year-old ALL patient with cholecystitis, choledocholithiasis, neutropenia, and thrombocytopenia.
0:53Management of Neutropenic Patient with Cholecystitis — Discussion of conservative management approach with antibiotics in a neutropenic, thrombocytopenic patient, resulting in spontaneous stone passage and elective cholecystectomy.
1:40Gallstone Pancreatitis Management — Panel discussion on timing of ERCP and cholecystectomy in gallstone pancreatitis, with emphasis on clinical improvement over biochemical normalization and selective use of ERCP.
3:11Summary and Conclusion — Recap of key management principles for neutropenic patients with cholecystitis and gallstone pancreatitis, emphasizing conservative management and judicious use of interventions.

Key claims

0:53Patient is 16 years old undergoing treatment for acute lymphoblastic leukemia — Speaker 3
0:56Patient is neutropenic with markedly elevated liver function tests and ultrasound findings consistent with acute cholecystitis and choledocholithiasis — Em Goddy
1:13Patient is thrombocytopenic — Speaker 3
1:20Over 50% of audience opted to start antibiotics and address elevated liver function tests — Em Goddy
1:31Patient spontaneously passed the stone and LFTs came back down — Speaker 3
1:34Patient's counts recovered and proceeded to elective cholecystectomy — Speaker 3
1:49Gallstone pancreatitis is inflammation of the pancreas triggered by a gallstone obstructing the bile duct, which can also impede pancreatic drainage — Em Goddy
1:57Blockage prevents pancreatic enzymes from reaching the small intestine, leading them to accumulate and damage the pancreas — Em Goddy
2:06Some surgeons do cholecystectomy within a few days for gallstone pancreatitis, some wait for a week — Speaker 4
2:13From ERCP standpoint, unless there's persistent biliary obstruction or cholangitis, ERCP is not performed right away for gallstone pancreatitis — Speaker 4
2:25When symptoms are improving, proceed to cholecystectomy with intraoperative cholangiogram without waiting for biochemical normalization — Speaker 5
2:38Studies show if amylase and lipase continue to rise one day after presentation with acute biliary pancreatitis, ERCP should be performed because stone is impacted — Speaker 6
2:49Most of the time amylase and lipase will go down, indicating the stone has passed, and can proceed to cholecystectomy — Speaker 6
3:01Most stones can be cleared — Speaker 3
3:03Some stones pass spontaneously — Speaker 3
3:05Good judgment and local resources must be factored into management decisions — Speaker 3

Cases discussed

0:5316-year-old with ALL, neutropenia, thrombocytopenia presenting with acute cholecystitis and choledocholithiasis

Points of disagreement

2:06Timing of cholecystectomy in gallstone pancreatitis
- Speaker 4: Some surgeons do cholecystectomy within a few days, some wait for a week
- Speaker 5: Proceed to cholecystectomy when symptoms are improving, without waiting for biochemical normalization

Open questions

What is the optimal timing for cholecystectomy in gallstone pancreatitis when symptoms are improving but biochemical markers are not fully normalized?
How should management be adjusted based on local resource availability for ERCP and advanced biliary interventions?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Gallstone Pancreatitis in Children: When to Intervene and When to Wait

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Teaching arc · AI-written, human-reviewed

The central teaching here is that most pediatric gallstone pancreatitis resolves without procedural intervention, and the skill lies in identifying the minority who need urgent ERCP versus the majority who benefit from strategic patience.

Understand the natural history. Gallstone pancreatitis occurs when a stone obstructs the bile duct at the ampulla, impeding pancreatic drainage 1:49. Pancreatic enzymes accumulate and autodigest the gland 1:57. The critical insight is that most stones causing pancreatitis are small enough to pass spontaneously 3:03. The obstruction is often transient — the stone migrates through or dislodges before you ever see the patient. This means the majority of cases are self-limited if you give them time. The discussants emphasize that most stones can be cleared without intervention 3:01, and the default posture should be observation unless specific criteria for escalation appear.

Trend the enzymes to distinguish impacted from passed stones. The single most useful decision rule presented: measure amylase and lipase one day after presentation 2:38. If levels continue to rise, the stone is impacted and ERCP is indicated 2:38. If levels fall, the stone has passed and you proceed to cholecystectomy 2:49. This is not about waiting for complete biochemical normalization — it is about determining whether the obstruction persists. Rising enzymes a day after presentation signal a stone that will not pass on its own. Falling enzymes signal that the acute event is over and the remaining task is removing the gallbladder to prevent recurrence.

Reserve early ERCP for persistent obstruction or cholangitis. Unless biliary obstruction persists or cholangitis develops, ERCP is not performed immediately for gallstone pancreatitis 2:13. The threshold for urgent intervention is not pancreatitis itself but evidence that the biliary tree remains obstructed or infected. This restraint matters because ERCP carries procedural risk — post-ERCP pancreatitis, bleeding, perforation — and most patients do not need it. The discussants frame ERCP as a coordinated backup during cholecystectomy rather than a first-line maneuver 2:25. You plan for it, but you do not default to it.

Operate on clinical improvement, not biochemical perfection. Once symptoms improve, proceed to cholecystectomy with intraoperative cholangiogram without waiting for enzymes to normalize 2:25. The error here is delaying surgery for laboratory aesthetics. If the patient feels better, is eating, and has falling inflammatory markers, the acute inflammation is resolving and the window for safe cholecystectomy is open. Waiting longer increases the risk of recurrent pancreatitis from residual stones. The intraoperative cholangiogram confirms duct clearance; if a stone is seen, ERCP follows immediately in a coordinated fashion 2:25.

Adjust for host factors and local resources. The neutropenic, thrombocytopenic patient with cholecystitis and choledocholithiasis illustrates the principle of strategic delay 0:53 0:56 1:13. Initial management was antibiotics and observation 1:20. The stone passed spontaneously, liver function tests normalized, and cholecystectomy was deferred until counts recovered 1:31 1:34. The teaching point is not that you always wait — it is that you weigh the risk of immediate surgery against the likelihood of spontaneous resolution when the patient's physiology makes intervention high-risk. The discussants stress that local resources must factor into these decisions 3:05. If you lack immediate ERCP capability or pediatric anesthesia support for a high-risk patient, conservative management becomes more attractive when the clinical trajectory suggests the stone may pass.

The point the discussants most emphasized: Most stones pass, most pancreatitis resolves, and the art is recognizing the minority who need intervention rather than reflexively escalating care in all cases 3:01 3:03. The default is observation with close monitoring. The triggers for escalation are rising enzymes at one day, persistent obstruction, or cholangitis. Everything else waits.

Takeaways from this story

Rising amylase/lipase one day after presentation signals impacted stone requiring ERCP; falling levels mean stone passed, proceed to cholecystectomy.
Early ERCP is reserved for persistent biliary obstruction or cholangitis, not pancreatitis alone — most stones pass spontaneously.
Operate when symptoms improve, not when labs normalize — delaying for biochemical perfection increases recurrent pancreatitis risk.
In neutropenic/thrombocytopenic patients, conservative management allows spontaneous stone passage and deferred cholecystectomy after count recovery.

Keywords

acute lymphoblastic leukemia ALL neutropenia thrombocytopenia acute cholecystitis choledocholithiasis gallstone pancreatitis biliary obstruction cholangitis cholecystectomy ERCP intraoperative cholangiogram ultrasound antibiotics Cincinnati Children's Hospital Medical Center

Hashtags

#pediatricbiliarystones #gallstonepancreatitis #pediatriccholecystectomy #pediatriccholangitis #globalcastmd #cincinnatichildrens #pediatricSurgery #ERCP #Choledocholithiasis #PediatricGastroenterology

Transcript

Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello pediatric surgery family. I'm Em Goddy from Cincinnati Children's Hospital Medical Center. In this video series, we'll be recapping the sessions and sharing the key highlights from our 12th annual update course in pediatric surgery, which was held in August 2024. This year we introduced a new approach to classify practice changing ideas at our update course. Presentations now fall into three. Categories green circle for established practice, blue square for promising newer practice, and black diamond for early adopter practice only. In this video, Doctors David Vitale, Luke Neff, and Jeff Ponsky will talk about how to prevent gallstone pancreatitis in pediatric biliary stone cases. This session is classified as a green circle for established practice. This is a 16 year old. This is actually a patient of mine from about 4 months ago. This patient, currently undergoing treatment for acute lymphoblastic leukemia, or ALL, presents with right upper quadrant pain. He's neutropenic, has markedly elevated liver function tests, and ultrasound findings that are consistent with acute cholecystitis and choleticchootiasis. So now we have a little bit more of a different situation with the neutropenia. Thrombocytopenic patient, what are we going to do? According to our live and virtual audience poll, over 50% opted to start antibiotics and address the elevated liver function tests, and that's the exact approach Doctor Neff took. And he spontaneously passed the stone, LFTs came back down. We were able to get him, his counts recovered and get him to elective cholecystectomy. And I want to bring up one other scenario too for the audience, which is gallstone pancreatitis, which I think is a little bit different than our conventional show up with a stone in the duct. Gallstone pancreatitis is inflammation of the pancreas triggered by a gallstone obstructing the bile duct, which can also impede pancreatic drainage. This blockage prevents pancreatic enzymes from reaching the small intestine, leading them to accumulate and then. the pancreas. So the question is, how would you manage this patient? In my experience, some surgeon will go in and say, hey, we're going to do the cholecystectomy within a few days. Some will say, hey, we're going to wait for a week. From an ERCP standpoint, unless there's a persistent biliary obstruction or cholangitis, we're not jumping in to go do this case right away. So I just want to hear from folks about gallstone pancreatitis. When things are improving. We don't need to see biochemical normalization, but when the symptoms are improving, we go right to cholecystectomy with intraoperative cholangiogram and coordinate with you just in case there might be a need for an ERCP. There's been some studies done to show if you, you wait one day when the patient comes in with acute biliary pancreatitis, if the amylase lipase go up. Then you do the ERCP because you got it, you have it impacted, but most of the time it will go right down. And if it starts going down, they pass the stone and you can go to cholecystectomy. So this is just from my standpoint. Most stones can be cleared. Some stones pass spontaneously, right? We have to use good judgment with that and local resource. You have to factor in what you have available to you. In summary, in neutropenic and thrombocytopenic patients with cholecystitis and choleticcholitisis, initial conservative management with antibiotics can be effective, particularly when spontaneous stone passage occurs. For gallstone pancreatitis, early ERCP is typically reserved for cases with persistent biliary obstruction or cholangitis, as many patients improve without intervention. The timing of cholecystectomy should be based on clinical improvement rather than complete biochemical normalization with intraoperative cholangiogram and ERCP coordinated as needed. Thank you for watching this video. Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.

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