In a prospective, randomized, multicenter study from Germany, 238 patients were assigned to early ERCP and possible papillotomy or conservative treatment of acute biliary pancreatitis. Randomization occurred within 72 h after the onset of pancreatitis symptoms. In the invasive treatment group, 121 of 126 patients successfully underwent ERCP. Papillotomy with extraction of bile duct stones was successful in 57 of 58 patients with choiedocholithiasis. The overall 3-month mortality rate and the mortality directly related to the biliary pancreatitis was not different in the two groups. The complication rate was similar in the two groups, but the invasive treatment group had a higher incidence of more severe and pulmonary complications. Jaundice occurred more frequently in the conservative treatment group, and 22 of the 112 in this group eventually required ERCP.