• 48 year old male
  • H/O Abdominal pain radiating towards back since 6 month, last episode 15 days back
  • Associated with nausea and low grade fever
  • USG Abdomen – dilated pancreatic duct with calculus within
  • CT Abdomen – Acute pancreatitis with parenchymal calcifications, Dilated MPD with stones
  • EUS- massively dilated MPD (1.7 cm) in the head, body and tail region with a chain of calculi and filled with purulent materials
    • Side branch dilatation, atrophic pancreatic parenchyma in the head and body region
    • Few reactive nodes were seen
  • ERP- Duodenoscopy revealed a bulging ampulla with an impacted large pancreatic duct stone.
    • Precut sphincterotomy followed by selective cannulation of the MPD was achieved
    • Pancreatogram confirmed EUS findings. Pancreatic sphincterotomy was performed
    • MPD was swept with a stone extraction balloon catheter which showed extraction of large amount of purulent material with large stones and necrotic material
    • Two 7 Fr stents were placed in the MPD for free flow of pancreatic juice

Expert Comments

  • Endoscopic therapy alone was found to be successful in 72% of patients with a 68% symptomatic improvement1
  • Endotherapy in conjunction with ESWL has been shown to increase stone clearance rates and to improve long-term outcomes in patients with stone and stricture disease2
  • In one study Kozarek et al were able to show that surgery was avoided in 80% of patients who underwent ESWL. with decrease in narcotic use and reduction in hospitalizations2

Take Home Message

  • Endoscopic ultrasound mapping of pancreas prior to the endotherapeutic intervention provides adequate information regarding plan of management.
  • Endoscopic treatment of such a case of chronic calculous pancreatitis has significantly decreased morbidity due to surgical interventions in addition to decrease in hospital admissions
  • Pancreatic endotherapy has shown significant improvement in the endocrine and exocrine pancreatic insufficiency, evidenced by decrease in the requirement of insulin and switch to the oral hypoglycemic agents from the insulin dependence in our patients.
Endosonography showing Massively dilated MPD with stone and purulent material

Endosonography showing Massively dilated MPD with stone and purulent material

Duodenoscopy showing impacted pancreatic duct stone at the ampulla

Duodenoscopy showing impacted pancreatic duct stone at the ampulla

 

 

 

 

 

 

 

 

 

 

Cannulation of MPD after precut sphincterotomy of the pancreatic orifice

Cannulation of MPD after precut sphincterotomy of the pancreatic orifice

Pancreatogram showing dilated and irregular MPD with large stones

Pancreatogram showing dilated and irregular MPD with large stones

 

 

 

 

 

 

 

 

 

 

Pancreatic ductal clearance with stone extraction balloon catheter

Pancreatic ductal clearance with stone extraction balloon catheter

Placement of two 7 Fr pancreatic duct stents

Placement of two 7 Fr pancreatic duct stents

 

 

 

 

 

 

 

 

 

 

Fluoroscopy showing optimal placement of the pancreatic duct stent

Fluoroscopy showing optimal placement of the pancreatic duct stent

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