Multiple Pancreatic Duct Stones

8/13/2019 Multiple Pancreatic Duct Stones

1/31

Digestive Surgery Division


2/31

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. Li L, Zhang S-N. Management of Pancreatic Duct Stone.

Hepatobiliary Pancreat Dis Int. 2008;7(1).

2. Robert J. Lesniak, Mark D. Hohenwalter, Taylor AJ. Spectrum of

Causes of Pancreatic Calcifications. AJR. 2002;178.


3/31

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.


4/31


5/31

The stones then initiate the cycle ofductal obstruction and contribute to pain,

worsening of pancreatic inflammation,

ductal disruption, and deterioration of theexocrine and endocrine function of the

gland.

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

Hill Professional; 2002.


6/31

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. 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.

2. 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.


7/31

Specific clinical manifestation of pancreatic duct stone isabsent in the early stage, thus making it hard to

diagnose.

To confirm the diagnosis, radiological

examinations,ultrasonography, CT, ERCP and MRCP



2. 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.


8/31

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.



2. 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.


9/31

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.



2. 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.


10/31

Drainage by pancreatic ductotomy is generally applicable for

patients with a dilated pancreatic duct 6mm; drainage

include Puestow, modified puestow, and Frey procedures.

1. Li L, Zhang S-N. Management of Pancreatic Duct Stone. Hepatobiliary

Pancreat Dis Int. 2008;7(1).

2. 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.


11/31

The Berger procedure, in which the

pancreatic head is removed but the

duodenum is preserved, and thewhipple 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.


12/31

Pustoew procedure


13/31


14/31


15/31

If the stones are mainly located in the body of the

pancreas (type II), they can be treated with Puestow-Gillesby procedure , or segmental resection, which is

often used in patients with significant dilation of the

pancreatic duct.






3. Chen Y., He Y., Zhao J., Liu Y., Liu Y.F., Cao H.L. ea. The Classificationand Management of Pancreatic Duct Stone. Zhonghua Wai Ke Za Zhi.

2004;42:4.


16/31


17/31

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.






3. Chen Y., He Y., Zhao J., Liu Y., Liu Y.F., Cao H.L. ea. The Classificationand Management of Pancreatic Duct Stone. Zhonghua Wai Ke Za Zhi.

2004;42:4.


18/31


19/31

Medical Record : 372-70-77

Address : Pesing Poglar RT

08/05 Kedaung Kali Angke

Hospital admission : Nov,

13th2012

Consultant : dr. Maria SpB,

KBD

Height : 152 cm

Weight : 43 kg

BMI : 18.3 kg/m SGA : B

TLC : 3185


20/31

Chief Complain :

epigastric pain since 2 months beforeadmission

History of Present Illness :

Since 2 months before admission ,patient experienced epigastric pain

intermittently. Pain doesnt radiate tothe right shoulder and back. Nonausea, no fever, no weight loss, noyellowish skin nor yellowish eyes.There was no pale stool nor darkyellow urine.

History of Past Illness :Diabetes Mellitus on Metformin 2x500mg and glimepiride 1x2 mg since 5years

Family History :

There were no history of diabetesmellitus, hypertension nor allergic of

Physical Examination

Alert , BP : 110/80 mmHg , Pulse 84x/minute, RR 18 x/minute, temp 36,3C

Eyes : sclera wasnt icteric,conjunctive werent anemic

Lung : vesicular on both side, nowheezing, no rhonchi

Heart : heart sound regular, noadditional heart sound

Abdomen :

I : flat

A : bowel sound was presentand

normalP : supple, no tenderness, no

pain on release, nomuscular

rigidity

P : tympany

Extremities : warm, CRT < 2


21/31

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


22/31

USG (13.10.2012)

Multiple stones along pancreatic ductwirsungi extent to CBD

MRCP (23.10.2012)

extra hepatic bilier duct was slightly

dilated. Intrahepatic duct was fine.there was no patological intensity atintraductal bilier, pancreatic ductwas dilated with multiple stonesgreatest dimension 1.5x1.1 cm2

Conclusion : multiple pancreatic ductstone with dilated pancreatic biler.

There was no stone in extahepaticduct.


23/31

Pancreatic Duct Stones

Working Diagnosis

Puestow procedure


24/31


25/31

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.


26/31

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.


27/31

We performed MRCP in this patient in accordance to the

literature; MRCP is the best method of diagnosing

pancreatic duct stone.


28/31

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.


29/31

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.


30/31



2. Robert J. Lesniak, Mark D. Hohenwalter, Taylor AJ. Spectrum of

Causes of Pancreatic Calcifications. AJR. 2002;178.

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

4. 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.

5. Bo-Nan Liu, Tai Ping Zhang, Yu-Pei Zhao, Quan Liao, Meng-HuaDai, Zhan H-X. Pancreatic Duct Stones in Patients with Chronic

Pancreatitis: Surgical Outcomes. Hepatobiliary Pancreat Dis Int.

2010;9(4):5.


31/31

Multiple Pancreatic Duct Stones

Documents

Transcript of Multiple Pancreatic Duct Stones