[Acute pancreatitis associated with biliary lithiasis].

The physical characteristics of gallstones and anatomical predisposing factors strongly suggest that acute pancreatitis associated with gallstones is due to a transient blockage of the ampulla of Vater by migrating stones. The diagnosis of acute pancreatitis is based on clinical probabilities and is supported by a threefold elevation in serum amylase. In cases of acute biliary pancreatitis the initial serum amylase value is higher and its decline more rapid than in pancreatitis due to other causes. The diagnostic sensitivity and specificity of serum amylase are higher in cases of acute biliary pancreatitis. The early detection of gallstones in acute pancreatitis by standard imaging techniques may be misleading; ultrasonography fails to identify the gallbladder in almost one-third of patients. The reported accuracy of systems for the clinico-biochemical detection of gallstones in acute pancreatitis is 75 percent. Their lack of specificity prohibits their use as the sole means of detecting gallstones, but they may allow the selection of patients who require further investigations. Ranson's multiple laboratory criteria are generally recognized as providing the best early assessment of severity in acute pancreatitis; a modified scoring system is required for patients known to have pancreatitis due to gallstones. The timing of surgery in gallstone pancreatitis is no longer controversial. In patients with benign pancreatitis the time of surgery appears to have little effect on the outcome, whereas in patients with severe pancreatitis early surgery results in a significant increase in morbidity and mortality rates. Surgery should be performed in the first days following hospital admission, soon after the pancreatitis has subsided. Further investigations are warranted before advocating a widespread use of early endoscopic sphincterotomy in the treatment of severe gallstone acute pancreatitis.