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

A 16-year-old male with acute lymphoblastic leukemia (ALL), neutropenic and thrombocytopenic, presented with right upper quadrant pain, markedly elevated liver function tests, and ultrasound findings consistent with acute cholecystitis and choledocholithiasis.

Over 50% of the live and virtual audience poll opted to start antibiotics and address the elevated liver function tests in the neutropenic thrombocytopenic patient.

Dr. Neff's patient spontaneously passed the stone, LFTs came back down, counts recovered, and the patient proceeded to elective cholecystectomy.

Gallstone pancreatitis is inflammation of the pancreas triggered by a gallstone obstructing the bile duct, which can also impede pancreatic drainage, preventing pancreatic enzymes from reaching the small intestine and leading them to accumulate and damage the pancreas.

Some surgeons will do cholecystectomy within a few days for gallstone pancreatitis, while others will wait for a week.

From an ERCP standpoint, unless there's a persistent biliary obstruction or cholangitis, ERCP is not performed right away for gallstone pancreatitis.

When symptoms are improving in gallstone pancreatitis, cholecystectomy with intraoperative cholangiogram can proceed without waiting for biochemical normalization, coordinating with ERCP availability if needed.

Studies have shown that if amylase and lipase levels go up when a patient comes in with acute biliary pancreatitis and then start going down, the stone has likely passed and the patient can proceed to cholecystectomy.

If amylase and lipase continue to rise one day after presentation with acute biliary pancreatitis, ERCP should be performed because the stone is likely impacted.

Most biliary stones can be cleared, and some stones pass spontaneously, requiring good clinical judgment.

Local resources and what is available must be factored into management decisions for biliary stones.