Gallstones are a common cause of acute pancreatitis. This article reviews acute biliary pancreatitis and includes natural history, noting the serious nature of some cases; pathogenesis, identifying transient obstruction as the primary pathogenetic event; diagnosis, including biochemical parameters and imaging; assessment of severity, underlining the importance of early prognostic signs, organ failure, and local complications; and management. Management is reviewed in detail, giving a historical perspective to the role of surgery, highlighting the role of endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy and paying particular attention to the four prospective randomized clinical trials in suggesting which patients are most likely to benefit from early endoscopic evaluation and therapy. Also discussed are additional clinical situations related to biliary pancreatitis in which endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy play a role. Finally, a suggested endoscopic approach to acute biliary pancreatitis is presented along with an algorithm incorporating severity stratification, principles of endoscopic intervention, and concepts of sterile and infected pancreatic necrosis.