Pancreatic Lithiasis: Stones in the Pancreatic Duct – Causes, Symptoms, Treatment

Pancreatic lithiasis (pancreatic duct calculi) refers to calculi (stones) within the pancreatic ductal system.

Composition

Calcium carbonate, calcium phosphate, protein plugs, glycoproteins. Often associated with protein precipitation in alkaline pancreatic juice.

Etiology

• Chronic pancreatitis: Most common cause (strictures, stasis, altered secretion).
• Genetic: PRSS1, SPINK1, CFTR mutations.
• Metabolic: Hypercalcemia, hyperparathyroidism.
• Anatomic: Pancreas divisum, ductal strictures.
• Idiopathic.

Clinical Presentation

• Recurrent epigastric pain (radiates to back), postprandial worsening.
• Nausea, vomiting, weight loss, steatorrhea (exocrine insufficiency).
• Diabetes (endocrine insufficiency).
• Obstructive jaundice (if distal CBD compressed).

Diagnosis

• CT abdomen: Calcifications in pancreatic duct/head (high sensitivity).
• MRCP: Ductal anatomy, strictures, stones (non-invasive).
• EUS: High resolution for small stones.
• ERCP: Diagnostic + therapeutic (stone extraction).

Treatment

• Medical: Pain control, pancreatic enzyme replacement, diabetes management, abstinence (alcohol).
• Endoscopic: ERCP with sphincterotomy, stone extraction, lithotripsy (ESHL), stenting.
• Surgical: Pancreaticojejunostomy (Puestow), duodenum-preserving head resection (Beger/Frey), distal pancreatectomy. For refractory pain/complications.

Multidisciplinary management (GI, surgery, pain, nutrition) optimizes outcomes.