Pathogenetic factors of acute biliary pancreatitis include persistent or tr
ansient, absolute or relative, obstruction of Vater's ampulla or the main p
ancreatic duct and reflux of bile into the pancreatic ducts or of pancreati
c juice into the bile ducts. There is an increasing incidence of persisting
common bile duct stones in the more severe forms of acute biliary pancreat
itis, in patients who die, and in patients with pancreatic necrosis. All th
ese findings provide a rational basis for the use of early biliary decompre
ssion in patients with acute biliary pancreatitis. Endoscopic sphincterotom
y offers a cost-effective and safe alternative to surgical biliary decompre
ssion with an overall morbidity rate of 8% and mortality rate of 2.4%. Rand
omized clinical trials showed that endoscopic sphincterotomy is useful in p
atients with predicted severe attack of acute biliary pancreatitis and is c
learly indicated in all patients who are jaundiced or who have associated c
holangitis. In addition, the procedure is valid in preventing recurrent att
ack of acute biliary pancreatitis in high risk elderly patients with gallst
ones, unfit for any kind of cholecystectomy.