1/ Great question and thx for highlighting this @TheLancet RCT re: #ERCP for gallstone pancreatitis @JBortinger! A few reactions below, and I hope that others on #GItwitter will add their thoughts as well..
2/ Historically, urgent ERCP for gallstone pancreatitis has been recommended in only 2 subgroups of patients:
➡️ pts w/ cholangitis (💯) or
➡️ w/ 'predicted severe pancreatitis' (🤔)
➡️ pts w/ cholangitis (💯) or
➡️ w/ 'predicted severe pancreatitis' (🤔)
3/ That 'predicted severe pancreatitis' concept was supported in this 1988 Lancet study (the typesetting looks like it's actually from 1938..). Idea was that a persistent/obstructing stone could worsen pancreatitis outcome...so.. ERCP. 
4/ That 1988 Lancet study used Glasgow criteria to predict who would go on to have 'severe SAP'. But..
1) In 2020, we are still *not great* at predicting which pts will go on to severe SAP
2) VERY rare that during ERCP to actually find impacted stone causing severe acute panc
1) In 2020, we are still *not great* at predicting which pts will go on to severe SAP
2) VERY rare that during ERCP to actually find impacted stone causing severe acute panc
5/ Fast forward to modern ERCP era. Generally everyone agrees that cholangitis deserves early ERCP (gallstone pancreatitis or not). AND... many of us never really bought the need for urgent ERCP in the 'predicted SAP' group, whoever they are..
6/ Fortunately, the Dutch Pancreatitis Study Group is 🔥 (they also did the 2015 PONCHO trial re: CCY timing). This current Lancet paper asks, "excluding cholangitis, is there any benefit to urgent (<24hr) ERCP in patients with predicted SAP*?" (*High APACHE II score, CRP etc)
7/ And the answer: "urgent ERCP with sphincterotomy did not reduce the composite endpoint of major complications or mortality, compared with conservative treatment".
8/ My top level summary:
➡️ Supportive care for gallstone panc (excluding cholangitis)
➡️ LFTs rising? ERCP to remove stone and/or place stent
➡️ LFTs falling? Controversy still: IOC at CCY, or MRCP or EUS to exclude those ball-valving stones which can fool with improving labs.
➡️ Supportive care for gallstone panc (excluding cholangitis)
➡️ LFTs rising? ERCP to remove stone and/or place stent
➡️ LFTs falling? Controversy still: IOC at CCY, or MRCP or EUS to exclude those ball-valving stones which can fool with improving labs.
