|Year : 2013 | Volume
| Issue : 1 | Page : 14-18
Pancreatic calculi: A case report and review of literature
Mervyn Correia, Dilip Amonkar, Pandarinath Audi, Lalit Banswal, Dattaprasad Samant
Department of General Surgery, Goa Medical College, Bambolim, Goa, India
|Date of Web Publication||13-Sep-2013|
Resicom Elite, Flat C-02, Off Kadamba Depot Road, Alto-Porvorim, Bardez, Goa - 403 521
Source of Support: None, Conflict of Interest: None
Pancreatic ductal calculi are rare and most often associated with chronic pancreatitis. Radiological features of chronic pancreatitis are readily evident in the presence of these calculi. We present the case of a 66-year old woman who presented to our emergency department with severe upper abdominal pain and vomiting. She had been having repeated attacks of similar but milder upper abdominal pain, for which she would visit her general practitioner, and be treated for gastritis. This time however the pain was excruciating and accompanied by vomiting. She was a known diabetic for which she was receiving treatment. Both abdominal ultrasound and contrast enhanced computerized tomography scan of the abdomen revealed an atrophic pancreas, and a dilated pancreatic duct filled with an enormous load of calculi. Laparotomy and the Frey procedure which consists of coring out of the pancreatic head and longitudinal pancreaticojejunostomy were done.
Keywords: Chronic pancreatitis, magnetic resonance cholangio pancreaticography, pain surgical treatment
|How to cite this article:|
Correia M, Amonkar D, Audi P, Banswal L, Samant D. Pancreatic calculi: A case report and review of literature. Saudi Surg J 2013;1:14-8
| Introduction|| |
Pancreatic duct stone disease is rare, but there appears to be a rising trend in its incidence in recent years. Its pathogenesis remains unknown . Abdominal pain remains the most debilitating symptom affecting quality of life apart from diabetes mellitus, steatorrhea and weight loss. Pancreatic ductal calculi are most often associated with chronic pancreatitis although at times the calculi may be intraparenchymal. Radiological features of chronic pancreatitis are readily evident in the presence of these calculi. 
Pancreatic calculi are a feature of chronic pancreatitis (CP).The most common cause of CP in India is alcohol. Other causes of CP are tropical, hereditary or idiopathic. The prevalence of calculi cannot be separated from the prevalence of the etiological factors, the most common being alcohol. , Sarles suggested that all forms of CP are the result of calculous disease irrespective of radiological studies showing the presence or absence of calculi.  However it is generally believed that pancreatic calculi visible on radiography usually occur in the late stages of CP. More recently, abdominal CT scanning has revealed a comparatively larger number of intraductal calculi. 
Currently, surgical intervention is recommended for all patients with pancreatic stones, and while individualising treatment is extremely important, microinvasive surgery is a fast developing option for treating patients with pancreatic calculi.
| Case Report|| |
A 66 year old female patient presented to the emergency department with severe abdominal pain and vomiting. She had similar such attacks of pain but of a much milder nature, for which she would visit her general practitioner and get treated for the same. The pain did radiate to the back and she would feel better if she would sit or bend forward rather than lie in bed.
On examination the patient had tachycardia. There was tenderness and guarding with rigidity in the epigastrium and right hypochondrium. The rest of the abdomen was soft and there were no signs of peritonitis. The patient was first treated conservatively with IV fluids, nil by mouth and antibiotics.
Blood investigations revealed a total count of 11000/cmm and an elevated serum amylase of 356 I.U. The renal and liver function tests were normal.
Plain abdominal film showed areas of calcification in the upper abdomen. Abdominal ultrasound and CECT scan of the abdomen revealed an atrophic pancreas, a dilated pancreatic duct with multiple calculi within [Figure 1] and [Figure 2]. Endoscopic Retrograde Cholangio Pancreaticography and MRCP were not done as CT findings were conclusive.
|Figure 1: CT showing dilated pancreatic duct and huge load of calculi within the duct sysyem|
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|Figure 2: CT image showing pancreatic calculi occupying the entire duct system|
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After stabilizing the patient for a week, a laparotomy was performed and a Frey procedure which consists of coring out of the pancreatic head and longitudinal pancreaticojejunostomy was done. Multiple calculi were extracted from the dilated pancreatic duct and the pancreatiojejunal anastomosis roux-en-y was done in two layers [Figure 3], [Figure 4] and [Figure 5]. Biopsy showed features of CP.
|Figure 3: Intraoperative picture showing stomach, pancreas and transverse colon|
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|Figure 5: Pancreatic duct laid open in preparation for side to side longitudinal pancreaticojejunostomy|
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The post operative course was prolonged but largely uneventful and the patient was discharged on the 21 st day after surgery.
| Discussion|| |
Pancreatic duct stone disease as previously stated is rare. Defined as stone or calcification in the pancreatic duct, the pathogenesis of the disease remains unknown, but many theories are available for its formation. , Chronic pancreatitis, pancreatic duct fibrosis, malnutrition, alcohol abuse, spontaneous pancreatic duct stone, dysthyroid, etc., are associated with the formation of these stones. These conditions cause pancreatic exocrine dysfunction and intraductal proteinaceous deposits which subsequently lead to calcification, thus inducing CP and pancreatic duct stone formation. 
In discussing these theories many hypotheses have been put forward. The formation of stones must have two basic conditions, change of the pancreatic fluid component and pancreatic duct obstruction. The main causes are as follows: ,,
- Chronic pancreatitis. This has the closest relationship with pancreatic duct stone. The pathological changes of the pancreatic parenchyma in pancreatic duct stone are similar to those in chronic pancreatitis. It is generally accepted that stones are combined with inflammation. CP however, is not always combined with pancreatic duct stone. It is an important factor in stone formation, but they are not causally associated 
- Alcohol abuse. Alcohol can stimulate the excretion of pancreatic enzymes which destroy the pancreatic alveolus and epithelium of the pancreatic duct. Subsequently, the components of the pancreatic fluid change; protein and calcium concentrations increase so that protein emboli are formed, leading to CP and pancreatic duct stone. In the past, alcohol abuse was regarded as the most important cause of pancreatic duct stone. They had a positive correlation. Many experimental studies have demonstrated a direct correlation between stone formation and long term alcohol abuse 
- Biliary disease. The pancreatic duct and the common bile duct have a common opening in the duodenal papilla. Obstruction of the lower segment of the bile duct often leads to obstruction of the effluent duct of the pancreas. Bile reflux into the pancreatic duct may also occur. Changes of enzymes and pathological changes in the pancreas are a consequence. As a result, pancreatic stones and pancreatitis develop. Biliary diseases, which are important causes of stone formation, have a high incidence in China ,
- Idiopathic pancreatic duct stone
- Malnutrition. This may be an important cause of pancreatic duct stone, especially in the young
- Hyperthyroidism; hereditary factors and so on.
Chronic pancreatitis is a progressive inflammatory process of the pancreas. Pancreatic duct stone is difficult to diagnose in its early stage for the absence of specific clinical manifestations. Abdominal pain remains the most debilitating symptom affecting quality of life apart from diabetes mellitus, steatorrhea and weight loss.  These symptoms along with jaundice should lead one to suspect a diagnosis.
To confirm the diagnosis, radiological examinations, ultrasonography, computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance cholangiopancreatography (MRCP) are used. B-mode ultrasonography is still the best method for reexamination and screening. CT scan has a higher detection rate of pancreatic duct stone.  ERCP was the gold standard for diagnosing pancreatic duct stone in the past. It can reveal not only the size, number and position of the stones but also false stones. Furthermore, ERCP-based removal of stones is a critical treatment for pancreatic duct stone.  However ERCP is invasive and does have complications. MRCP has a very high success rate of 98%.  It also has the advantage of being non traumatic and repeatable. MRCP has become the best method for the diagnosis and directing treatment of pancreatic duct stone in recent years. , MRCP can precisely reveal the stricture, dilation, overflow and defects of pancreatic ducts.
The treatment principle is to remove all stones, relieve obstruction, ensure pancreatic fluid drainage, improve exocrine and endocrine function of the pancreas and relieve symptoms. The aim of surgery should be to deal with the pathomechanism of pain in CP, and provide adequate pain relief. By durable and adequate pain relief surgery should contribute to the social and occupational rehabilitation and improvement in quality of life. 
With the development of endoscopic techniques and combined application of the small-diameter endoscope, laser lithotripsy, extracorporeal shock wave lithotripsy (ESWL) , and balloon stenting, the treatment of pancreatic stone has undergone a dramatic change.
Surgical risks are often the major concern in surgical intervention for pancreatic stones, which may be associated with operative morbidity and mortality. At present in cases refractory to endoscopic management, surgical drainage or pancreatic resection is often combined to lower increased intraductal pressure, which is thought to be one of the main causes of pain. The successful relief of the pain benefits the symptomatic patient.
Surgical interventions are broadly grouped under either drainage or resection procedure, and have evolved over time to the third category of combined drainage and resection procedures. If the stones are mainly located in the body of the pancreas, they can be treated with the Pusetow-Gillesby procedure (pancreaticojejunostomy), which is often used in patients with significant dilation of the pancreatic duct. Resection of the tail of the pancreas or combined resection with splenectomy is done if the stones are located in the tail of the pancreas. Sometimes the stones are found in the head or the tail of the main duct of the pancreas. The Frey procedure consists of coring the head of the pancreas combined with a longitudinal pancreaticojejunostomy as described by Parlington and Rochelle, and this procedure avoids transection of the neck above the portal vein. , This was the procedure that we performed on our patient. A Roux-en-y pancreaticojejunal anastomosis was performed. Being simple to perform, it has been widely accepted, and has been modified with varying degree of resection of the head of the pancreas along with the uncinate process known as Hamburgs modification.
| Conclusion|| |
surgical drainage of the pancreatic duct or resection of the pancreas is of symptomatic benefit. By retrospective analysis of the management of patients with pancreatic duct stone, Li et al., have also suggested that surgical therapy is the most curative method for pancreatic duct stone in patients with severe symptoms or suspected pancreatic carcinoma.
Currently, surgical intervention is recommended for all patients with pancreatic stones. Each patient is different and individualizing treatment is emphasized. Microinvasive surgery is a developing new option for a select group of patients with pancreatic calculi.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]