Episode two works through three first-days decisions where the intuitive older instinct turns out to be net harmful. Pancreatic rest with TPN increases infection because an empty lumen lets villi atrophy and gut bacteria translocate into necrotic tissue, so early enteral feeding wins. Universal urgent ERCP was wrong because most triggering stones have already passed, leaving an empty duct and only post-ERCP risk. And interval cholecystectomy costs roughly one in six patients a recurrent biliary event, so same-admission surgery is now standard. The unifying logic: each intervention earns its place against its own complication profile. Topics covered Pancreatic rest versus early enteral feeding The gut barrier and bacterial translocation Feeding rules in mild disease Feeding in predicted severe disease and tube level TPN as the failure path ERCP indications and the passed-stone anatomy The three-patient ERCP decision Same-admission versus interval cholecystectomy Exceptions: severe disease and the non-surgical patient Key decisions Feed early in mild disease, within twenty-four to forty-eight hours, with a low-fat solid diet if the patient is hungry, has bowel sounds, and isn't vomiting, rather than holding NPO until the lipase normalizes. Do not force an early nasojejunal tube on predicted severe patients, since early nasojejunal placement showed no difference in major infection or mortality versus oral intake on demand. When a tube is needed, place a nasogastric tube and start feeding, because nasogastric, nasoduodenal, and nasojejunal feeding are equivalent and standard formulas work as well as elemental ones. Reserve TPN for the patient who truly cannot tolerate enteral feeding for a prolonged period from severe ileus, hemodynamic intolerance, or surgical anatomy. Perform ERCP within twenty-four hours for cholangitis and within twenty-four to seventy-two hours for persistent obstruction, but give no ERCP to mild gallstone pancreatitis without cholangitis or obstruction. Treat the duct, not the pancreas, as the indication for ERCP: a rising bilirubin and dilated duct warrant ERCP regardless of severity score, while a falling ALT and non-dilated duct do not. Do same-admission cholecystectomy within three days of pain resolution for mild gallstone pancreatitis, deferring four to eight weeks only in severe or necrotizing disease and substituting ERCP with biliary sphincterotomy in patients too high-risk for surgery. For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected].

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“What did the council decide on item 42?” — answered with the speaker and the moment.

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