The observation that necrotizing pancreatitis and gallstones can be associated is more than 300 years old [1]. Since the beginning of our century, numerous investigations have addressed the question as to how gallstones cause pancreatitis. Despite this effort and many excellent clinical and experimental studies, few pathophysiological issues in gastroenterology have remained so controversial and even fewer have found advocates with such incompatible views and uncompromising convictions. We will review the past and present theories regarding the pathophysiology of gallstone-induced pancreatitis and outline the therapeutic consequences implied by these concepts.