For years, gallstones have taken center stage in discussions around biliary pancreatitis, but a large international study now suggests that their smaller cousins—biliary sludge and microlithiasis—may not carry the same long-term burden when it comes to complications.
Patients hospitalized with acute pancreatitis due to biliary sludge or microlithiasis experienced significantly fewer complications than those with gallstone-induced pancreatitis, according to the study.
The analysis included 789 patients from 18 centers across Spain and Mexico who were admitted for a first episode of biliary acute pancreatitis between January 2018 and April 2020. Participants had no prior cholecystectomy which allowed observation of outcomes without early surgical intervention. Based on imaging findings, 515 patients were classified as having gallstone-related pancreatitis, while 274 had pancreatitis caused by biliary sludge or microlithiasis.
Pancreatobiliary complications—such as recurrent pancreatitis, cholecystitis, cholangitis, symptomatic choledocholithiasis, and biliary colic requiring rehospitalization—occurred in 41.7% of the gallstone group compared with 32.1% of the sludge/microlithiasis group (P = .01).
At 24 months, complication-free survival was lower in the gallstone group (46%) compared with the sludge/microlithiasis group (59%) (log-rank P = .0022).
“This provides the basis for a prospective study design to investigate whether patients with evidence of sludge and microlithiasis in the context of acute pancreatitis should always undergo cholecystectomy,” wrote Simon Sirtl of the Department of Medicine II at the LMU University Hospital Munich, with colleagues.
In the gallstone group, older age was associated with a lower risk of complications (hazard ratio [HR] = 0.54, 95% confidence interval [CI] = 0.39–0.74). In the sludge/microlithiasis group, a Charlson comorbidity index of 2 was linked to increased complication risk (HR = 2.07, 95% CI = 1.24–3.46).
Severe pancreatitis occurred more frequently in the gallstone group (7.3% vs 2.5%, P = .01), although the median hospital stay was 6 days for both groups. Initial bilirubin and alanine aminotransferase levels were higher in the gallstone group (bilirubin = 1.56 mg/dL vs 1.01 mg/dL, P < .001; ALT = 126 U/L vs 70 U/L, P < .001).
A lower percentage of patients with sludge/microlithiasis underwent cholecystectomy during follow-up (56.2%) compared with patients who had gallstones (65.8%). Median time to surgery was similar (4.3 vs 4.6 months, P = .41).
Patients with previous biliary surgery, cholangitis, malignancy, or missing imaging data were excluded. Follow-up continued until cholecystectomy, death, or the last clinical encounter prior to April 30, 2020.
The findings raise questions about whether cholecystectomy is necessary in all cases of sludge- or microlithiasis-induced pancreatitis or if conservative measures, such as endoscopic sphincterotomy, may be sufficient in selected patients.
Funding information and author contributions can be found in the original publication. The authors disclosed no conflicts of interest.
Source: Digestive and Liver Disease