The problem of acute gallstone pancreatitis is reviewed with respect to pathophysiology, diagnostic approach, and therapeutic strategy. The role of gallstones and anatomic variations of the common bile duct and pancreatic duct are analyzed. The paramount importance of urgent endoscopic retrograde cholangiopancreatography in all cases of suspected acute gallstone pancreatitis is emphasized. Early biliary surgery after recovery from pancreatitis is demonstrated to be the safest strategy to avoid a relapse of the disease and perioperative complications. In patients with common bile duct stones and severe pancreatitis the outcome seems to be improved by immediate endoscopic sphincterotomy and removal of the stones.