The incidence of pancreatitis associated with biliary tract disease is high in certain parts of the world, including Israel. Sometimes, pancreatitis is the first or only manifestation of gallstone disease. However, this may be accompanied by a normal oral or intravenous cholangiogram. Between 1968 and 1980, 173 patients with acute pancreatitis were treated at the Hadassah University Medical Center in Jerusalem. One hundred and two patients (59%) suffered from proven biliary tract disease. In 36 of these 102 patients, repeat preoperative oral and intravenous cholecystograms failed to demonstrate disease in the biliary system. All were referred to surgery on the basis of a high index of suspicion only. At surgery, acute or chronic cholecystitis were found in all cases; gallstones were found in 32 and some degree of pancreatitis in 32. Operative cholangiography demonstrated a common entrance of the ductus choledochus and the pancreatic duct with reflux of contrast material into the pancreatic duct in at least 52.8% of the cases. In 14 patients (38.9%), palpation and cholangiography did not reveal stones and only bile aspiration and filtration through gauze demonstrated many tiny stones. All patients underwent cholecystectomy, and 11 additionally had a common duct exploration. The follow-up period ranged from 2 to 12 years (mean 7 years) with no signs or symptoms of recurrent pancreatitis or biliary tract disease. It has become our practice to attempt proving gallbladder disease radiographically in all cases of recurrent pancreatitis with no other known etiologic background. Failing this, surgical exploration of the biliary system is undertaken.(ABSTRACT TRUNCATED AT 250 WORDS)