Published online Feb 21, 2024. doi: 10.3748/wjg.v30.i7.614
Peer-review started: October 18, 2023
First decision: December 11, 2023
Revised: December 16, 2023
Accepted: January 18, 2024
Article in press: January 18, 2024
Published online: February 21, 2024
Processing time: 125 Days and 23.5 Hours
Severe gallstone pancreatitis (GSP) refractory to maximum conservative therapy has wide clinical variations, and its pathophysiology remains controversial. This Editorial aimed to investigate the pathophysiology of severe disease based on Opie’s theories of obstruction, the common channel, and duodenal reflux and describe its types. Severe GSP might be a hybrid disease with pathology polarized between acute cholangitis with mild pancreatitis (biliary type) and necrotizing pancreatitis uncomplicated with biliary tract disease (pancreatic type), in which hepatobiliary and pancreatic lesion severity is inversely related to the presence or absence of impacted ampullary stones. Severe GSP is caused by stones that are persistently impacted at the ampulla with biliopancreatic obstruction (biliary type), and probably, stones that are either temporarily lodged at the duodenal orifice or passed into the duodenum, thereby permitting reflux of bile or possible duodenal contents into the pancreas (pancreas type). When the status of the stones and the presence or absence of impacted ampullary stones with biliopancreatic obstruction are determined, the clinical course and outcome can be pre
Core Tip: Gallstones represent the main cause of acute pancreatitis globally, and awareness of the etiology and pathogenesis of severe disease is mandatory. Based on the present study aimed to clarify the pathophysiology of severe disease from clinicopathological and historical points of view, severe gallstone pancreatitis may be a hybrid disease with pathology polarized between acute cholangitis and necrotizing pancreatitis in which the severity of hepatobiliary and pancreatic lesions is inversely related to the presence or absence of impacted ampullary stones with biliopancreatic obstruction. When the status of the stones is determined, the clinical course and outcome can be predicted.