Acute pancreatitis is an inflammatory condition of the exocrine pancreas that is a common indication for hospital admission and has had an increasing incidence in the last few decades. The diagnosis of acute pancreatitis requires the satisfaction of two out of three criteria: (1) abdominal pain radiating to the back, (2) serum lipase or amylase levels three or more times the upper limit of the normal level, and (3) findings indicating pancreatitis obtained via a computed tomography (CT) scan or magnetic resonance imaging (MRI). The different etiologies include gallstones, autoimmune disorders, alcohol abuse, smoking, hypertriglyceridemia, obesity, drugs, and post-endoscope retrograde cholangiopancreatography (ERCP). The initial investigation includes serum amylase and lipase analysis, a lipid panel including triglycerides, analysis of immunoglobulins, a full blood count, electrolyte analysis, a hemoglobin A1c test, a complete metabolic panel, and transabdominal ultrasound. The initial therapy includes oxygen supplementation, the provision of intravenous fluids, pain control, and a nutrition regime. Early oral feeding is encouraged if tolerated; if not, liquid supplement provision or enteral tube feeding within 48 h of admission has shown better outcomes. Some complications of acute pancreatitis are necrosis, infection, insulin resistance leading to diabetes mellitus, and pancreatic exocrine insufficiency requiring enzyme supplementation. Patients need to attend regular follow-ups and abstain from alcohol and smoking (if warranted) to prevent the recurrence of acute pancreatitis. The mortality rate of acute pancreatitis has decreased in the past few decades because of better management skills, but the recent rise in acute pancreatitis episodes is concerning. Sustained endeavors through clinical trials are required to establish a broad variety of drugs that can be used for acute pancreatitis episodes.

Endoscopic retrograde cholangiopancreatography (ERCP), introduced in 1968, remains the gold standard for managing pancreatobiliary disorders, achieving success rates of nearly 95% in patients with normal anatomy. However, modern surgical interventions, such as Roux-en-Y gastric bypass (RYGB), hepaticojejunostomy, pancreaticoduodenectomy (Whipple procedure), and Billroth II gastrectomy, result in surgically altered anatomies (SAA), complicating biliary interventions due to anatomical distortions, including long afferent limbs and sharp intestinal angulations. Device-assisted enteroscopy-based ERCP (DAE-ERCP), including double-balloon, single-balloon, and spiral enteroscopy, has improved access in SAA, especially RYGB patients, with technical success rates as high as 95%; however, it remains technically demanding and time-intensive. Laparoscopy-assisted ERCP demonstrates a higher technical success rate (>95%), but carries increased invasiveness, prolonged procedure times, and higher adverse event rates, limiting its routine use. Endoscopic ultrasound-guided biliary drainage, comprising rendezvous technique, transmural drainage such as choledochoduodenostomy (CDS) and hepaticogastrostomy (HGS), and antegrade interventions, has emerged as a reliable alternative, showing superior technical success and lower complication rates compared with percutaneous transhepatic biliary drainage. Specifically, EUS-guided transmural techniques (HGS, CDS) offer effective internal drainage in anatomies where conventional approaches fail. The recently developed EUS-directed transgastric ERCP procedure, utilizing lumen-apposing metal stents to create temporary gastro-gastric or jejuno-gastric fistulas, has revolutionized biliary interventions in RYGB, achieving high technical and clinical success rates. Novel and hybrid approaches, including magnetic compression anastomosis, artificial intelligence-assisted navigation, and biodegradable stents, continue to enhance therapeutic possibilities, underscoring an evolving multidisciplinary landscape for biliary interventions in surgically altered anatomy.