Management of Gallstone Pancreatitis: A Critical Narrative Review of Diagnostic Triage, Biliary Intervention and Definitive Treatment

Abstract

Gallstone pancreatitis is a common acute gastrointestinal emergency in which pancreatic injury and the underlying biliary disorder require related but distinct management decisions. Although advances in supportive treatment and minimally invasive procedures have improved care, uncertainty persists over which patients benefit from urgent endoscopic biliary decompression, when the gallbladder should be removed after complicated attacks, and how to prevent recurrence without exposing patients to unnecessary procedures. This critical narrative review integrates clinical guidelines, randomised trials, diagnostic accuracy research, cohort studies and relevant methodological reviews published principally between 2000 and 24 August 2026. Evidence was selected through targeted scholarly searching and thematic appraisal of study design, risk of bias, applicability and conflicting findings. The analysis separates the early physiological treatment of pancreatitis from three downstream questions: whether acute cholangitis or persistent biliary obstruction is present, whether definitive cholecystectomy is safe during the index admission, and how pancreatic necrosis or peripancreatic collections alter intervention timing. Randomised evidence supports moderately paced, reassessed fluid resuscitation, early oral intake where tolerated and avoidance of routine urgent endoscopic retrograde cholangiopancreatography in gallstone pancreatitis without cholangitis. Same-admission cholecystectomy is strongly supported for clinically improving mild disease, whereas the optimal schedule after moderately severe or necrotising pancreatitis remains less certain because most comparative evidence is observational and phenotypically heterogeneous. Endoscopic sphincterotomy may reduce recurrent pancreatitis when surgery is inappropriate but does not reliably prevent other gallbladder complications. The most consequential unresolved issues concern persistent duct-stone prediction, selection for early surgery following transient organ failure, implementation of evidence-based gallbladder treatment and long-term outcomes after complicated disease. Management is best understood as a series of severity- and anatomy-specific decisions rather than a single intervention pathway.