Digestive Surgery Division

Pancreatic duct stone is a rare disease It is define as stone or calcification in the pancreatic duct. Traditionally, pancreatic calcifications have been largely associated with chronic calcific pancreatitis from alcohol abuse, espcially in western countries.

1. 2.

Li L, Zhang S-N. Management of Pancreatic Duct Stone. Hepatobiliary Pancreat Dis Int. 2008;7(1). Robert J. Lesniak, Mark D. Hohenwalter, Taylor AJ. Spectrum of Causes of Pancreatic Calcifications. AJR. 2002;178.

 Pancreatic stones are composed largely of calcium carbonate crystals trapped in a matrix of fibrillar and other material.

William E. Fisher, Dana K. Andersen, Richard H. Bell Jr., Ashok K. Saluja, Brunicardi FC. Pancreas. McGraw-Hill Professional; 2002.

 Pathogenesis of the disease remains unclear. Some theories associate chronic pancreatitis, pancreatic duct fibrosis, malnutrition, and alcohol abuse. In chronic pancreatitis, pancreatic duct stones usually result from chronic inflammation or altered metabolism. The ducts become obstructed by proteinaceous plugs that can eventually accumulate calcium carbonate, which composes most of the stone.

1. 2.

Li L, Zhang S-N. Management of Pancreatic Duct Stone. Hepatobiliary Pancreat Dis Int. 2008;7(1). Robert J. Lesniak, Mark D. Hohenwalter, Taylor AJ. Spectrum of Causes of Pancreatic Calcifications. AJR. 2002;178.

 The stones then initiate the cycle of ductal obstruction and contribute to pain, worsening of pancreatic inflammation, ductal disruption, and deterioration of the exocrine and endocrine function of the gland.

William E. Fisher, Dana K. Andersen, Richard H. Bell Jr., Ashok K. Saluja, Brunicardi FC. Pancreas. McGrawHill Professional; 2002.

 Depending on the location of the stones:

Type I: stones are in the head of pancreas Type II: in the body of pancreas Type III: in the tail Type IV: in the whole pancreas

1. 2.

Chen Y., He Y., Zhao J., Liu Y., Liu Y.F., Cao H.L. ea. The Classification and Management of Pancreatic Duct Stone. Zhonghua Wai Ke Za Zhi. 2004;42:4. Bo-Nan Liu, Tai Ping Zhang, Yu-Pei Zhao, Quan Liao, Meng-Hua Dai, Zhan H-X. Pancreatic Duct Stones in Patients with Chronic Pancreatitis: Surgical Outcomes. Hepatobiliary Pancreat Dis Int. 2010;9(4):5.

 Specific clinical manifestation of pancreatic duct stone is absent in the early stage, thus making it hard to diagnose. To confirm the diagnosis, radiological examinations,ultrasonography, CT, ERCP and MRCP

1. 2.

Li L, Zhang S-N. Management of Pancreatic Duct Stone. Hepatobiliary Pancreat Dis Int. 2008;7(1). Bo-Nan Liu, Tai Ping Zhang, Yu-Pei Zhao, Quan Liao, Meng-Hua Dai, Zhan H-X. Pancreatic Duct Stones in Patients with Chronic Pancreatitis: Surgical Outcomes. Hepatobiliary Pancreat Dis Int. 2010;9(4):5.

 Because the pathogenesis of pancreatic duct stone is unknown, improvement of symptoms is a major goal Treatments including surgical, endoscopic techniques, laser lithotripsy, ESWL, balloon stenting, and medications The indication for endoscopic treatment were stone number less than 3, stones confined to the head and body of pancreas, absence of restricted pancreatic duct, pancreatic duct stone diameter 10mm, and non compacted.

1. 2.

Li L, Zhang S-N. Management of Pancreatic Duct Stone. Hepatobiliary Pancreat Dis Int. 2008;7(1). Bo-Nan Liu, Tai Ping Zhang, Yu-Pei Zhao, Quan Liao, Meng-Hua Dai, Zhan H-X. Pancreatic Duct Stones in Patients with Chronic Pancreatitis: Surgical Outcomes. Hepatobiliary Pancreat Dis Int. 2010;9(4):5.

 Surgical therapy results in complete or partial relief of the symptoms of the disease Selection of surgical approach should be guided by the size, number, and type of pancreatic duct stone.

1. 2.

Li L, Zhang S-N. Management of Pancreatic Duct Stone. Hepatobiliary Pancreat Dis Int. 2008;7(1). Bo-Nan Liu, Tai Ping Zhang, Yu-Pei Zhao, Quan Liao, Meng-Hua Dai, Zhan H-X. Pancreatic Duct Stones in Patients with Chronic Pancreatitis: Surgical Outcomes. Hepatobiliary Pancreat Dis Int. 2010;9(4):5.

 Drainage by pancreatic ductotomy is generally applicable for patients with a dilated pancreatic duct 6mm; drainage include Puestow, modified puestow, and Frey procedures.

1. 2.

Li L, Zhang S-N. Management of Pancreatic Duct Stone. Hepatobiliary Pancreat Dis Int. 2008;7(1). Bo-Nan Liu, Tai Ping Zhang, Yu-Pei Zhao, Quan Liao, Meng-Hua Dai, Zhan H-X. Pancreatic Duct Stones in Patients with Chronic Pancreatitis: Surgical Outcomes. Hepatobiliary Pancreat Dis Int. 2010;9(4):5.

 The Berger procedure, in which the pancreatic head is removed but the duodenum is preserved, and the whipple procedure are suitable for type I stones
Chen Y., He Y., Zhao J., Liu Y., Liu Y.F., Cao H.L. ea. The Classification and Management of Pancreatic Duct Stone. Zhonghua Wai Ke Za Zhi. 2004;42:4.

Pustoew procedure

 If the stones are mainly located in the body of the pancreas (type II), they can be treated with PuestowGillesby procedure , or segmental resection, which is often used in patients with significant dilation of the pancreatic duct.

1. 2.

3.

Li L, Zhang S-N. Management of Pancreatic Duct Stone. Hepatobiliary Pancreat Dis Int. 2008;7(1). Bo-Nan Liu, Tai Ping Zhang, Yu-Pei Zhao, Quan Liao, Meng-Hua Dai, Zhan H-X. Pancreatic Duct Stones in Patients with Chronic Pancreatitis: Surgical Outcomes. Hepatobiliary Pancreat Dis Int. 2010;9(4):5. Chen Y., He Y., Zhao J., Liu Y., Liu Y.F., Cao H.L. ea. The Classification and Management of Pancreatic Duct Stone. Zhonghua Wai Ke Za Zhi. 2004;42:4.

 Resection of the tail of the pancreas (distal pancreatectomy) or combined resection with splenectomy is done if the stones are located in the tail of the pancreas (type III).

1. 2.

3.

Li L, Zhang S-N. Management of Pancreatic Duct Stone. Hepatobiliary Pancreat Dis Int. 2008;7(1). Bo-Nan Liu, Tai Ping Zhang, Yu-Pei Zhao, Quan Liao, Meng-Hua Dai, Zhan H-X. Pancreatic Duct Stones in Patients with Chronic Pancreatitis: Surgical Outcomes. Hepatobiliary Pancreat Dis Int. 2010;9(4):5. Chen Y., He Y., Zhao J., Liu Y., Liu Y.F., Cao H.L. ea. The Classification and Management of Pancreatic Duct Stone. Zhonghua Wai Ke Za Zhi. 2004;42:4.

 For type IV stones (stones in whole pancreas) , alternative to drainage is subtotal pancreatectomy, which allows 95% removal of the pancreas, preserving only a thin layer of pancreatic tissue attached to the duodenum.

1. 2.

3.

Li L, Zhang S-N. Management of Pancreatic Duct Stone. Hepatobiliary Pancreat Dis Int. 2008;7(1). Bo-Nan Liu, Tai Ping Zhang, Yu-Pei Zhao, Quan Liao, Meng-Hua Dai, Zhan H-X. Pancreatic Duct Stones in Patients with Chronic Pancreatitis: Surgical Outcomes. Hepatobiliary Pancreat Dis Int. 2010;9(4):5. Chen Y., He Y., Zhao J., Liu Y., Liu Y.F., Cao H.L. ea. The Classification and Management of Pancreatic Duct Stone. Zhonghua Wai Ke Za Zhi. 2004;42:4.

 Medical Record : 372-70-77 Address : Pesing Poglar RT 08/05 Kedaung Kali Angke Hospital admission : Nov, 13th 2012 Consultant : dr. Maria SpB, KBD Height : 152 cm Weight : 43 kg BMI : 18.3 kg/m SGA : B TLC : 3185

 Chief Complain : epigastric pain since 2 months before admission History of Present Illness : Since 2 months before admission , patient experienced epigastric pain intermittently. Pain doesnt radiate to the right shoulder and back. No nausea, no fever, no weight loss, no yellowish skin nor yellowish eyes. There was no pale stool nor dark yellow urine. History of Past Illness : Diabetes Mellitus on Metformin 2x500 mg and glimepiride 1x2 mg since 5 years Family History : There were no history of diabetes mellitus, hypertension nor allergic of

Physical Examination Alert , BP : 110/80 mmHg , Pulse 84 x/minute, RR 18 x/minute, temp 36,3 C Eyes : sclera wasnt icteric ,conjunctive werent anemic Lung : vesicular on both side, no wheezing, no rhonchi Heart : heart sound regular, no additional heart sound Abdomen : I : flat A : bowel sound was present and normal P : supple, no tenderness, no pain on release, no muscular rigidity P : tympany Extremities : warm, CRT < 2

 Lab (17 /11/2012)

CBC : 14,2/42,5/9.100/288.000 PT/APTT 11.8(11.7)/37.6(32.3) Diff count : 1/0/58/35/6 SGOT/SGPT : 19/18 Ur/Cr : 27/0.7 Albumin :4,3 Random Blood Sugar (RBS) : 72 HBA1C : 9,2 (normal <6), Amilase : 4 , Lipase : 9

 USG (13.10.2012)

Multiple stones along pancreatic duct wirsungi extent to CBD

MRCP (23.10.2012)

extra hepatic bilier duct was slightly dilated. Intrahepatic duct was fine. there was no patological intensity at intraductal bilier, pancreatic duct was dilated with multiple stones greatest dimension 1.5x1.1 cm2 Conclusion : multiple pancreatic duct stone with dilated pancreatic biler. There was no stone in extahepatic duct.

Working Diagnosis
Pancreatic Duct Stones

Puestow procedure

 Pancreatic duct stone is not a common disease because there are no significant clinical manifestation in its early stage, thus making it hard to be diagnosed. Our case demonstrated a woman, 40 years old with a vague clinical symptom of intermittent epigastric pain for two months, and there were no significant finding on physical examination. This correlates to the literature review.

 Although the pathogenesis of pancreatic duct stone remains unclear, chronic pancreatitis has been associated with the formation of the stones. However, we do not find any signs of chronic pancreatitis in our case.

 We performed MRCP in this patient in accordance to the literature; MRCP is the best method of diagnosing pancreatic duct stone.

 While performing the Peustow procedure on this patient we found that there were pancreatic duct stones in the head, tail and body of the pancreas. This classifies type IV pancreatic duct stones, which are usually treated with drainage of the pancreatic duct by means of Puestow, modified puestow, and Frey procedures. We did Peustow procedure in this patient.

 We presented a case of pancreatic duct stones without chronic pancreatitis in a 40 years old woman with no specific findings from anamnesis and physical examination. Diagnosis was made by MRCP and Peustow procedure was performed with good results. Patients was dicharged 7 days after the operation with no complication.

1. 2. 3. 4.

5.

Li L, Zhang S-N. Management of Pancreatic Duct Stone. Hepatobiliary Pancreat Dis Int. 2008;7(1). Robert J. Lesniak, Mark D. Hohenwalter, Taylor AJ. Spectrum of Causes of Pancreatic Calcifications. AJR. 2002;178. William E. Fisher, Dana K. Andersen, Richard H. Bell Jr., Ashok K. Saluja, Brunicardi FC. Pancreas. McGraw-Hill Professional; 2002. Chen Y., He Y., Zhao J., Liu Y., Liu Y.F., Cao H.L. ea. The Classification and Management of Pancreatic Duct Stone. Zhonghua Wai Ke Za Zhi. 2004;42:4. Bo-Nan Liu, Tai Ping Zhang, Yu-Pei Zhao, Quan Liao, Meng-Hua Dai, Zhan H-X. Pancreatic Duct Stones in Patients with Chronic Pancreatitis: Surgical Outcomes. Hepatobiliary Pancreat Dis Int. 2010;9(4):5.