Management of Pancreatic Calculi: An Update

Abstract

Pancreatolithiasis, or pancreatic calculi (PC), is a sequel of chronic pancreatitis (CP) and may occur in the main ducts, side branches or parenchyma. Calculi are the end result, irrespective of the etiology of CP. PC contains an inner nidus surrounded by successive layers of calcium carbonate. These calculi obstruct the pancreatic ducts and produce ductal hypertension, which leads to pain, the cardinal feature of CP. Both endoscopic therapy and surgery aim to clear these calculi and decrease ductal hypertension. In small PC, endoscopic retrograde cholangiopancreatography (ERCP) followed by sphincterotomy and extraction is the treatment of choice. Large calculi require fragmentation by extracorporeal shock wave lithotripsy (ESWL) prior to their extraction or spontaneous expulsion. In properly selected cases, ESWL followed by ERCP is the standard of care for the management of large PC. Long-term outcomes following ESWL have demonstrated good pain relief in approximately 60% of patients. However, ESWL has limitations. Per oral pancreatoscopy and intraductal lithotripsy represent techniques in evolution, and in current practice their use is limited to centers with considerable expertise. Surgery should be offered to all patients with extensive PC, associated multiple ductal strictures or following failed endotherapy.

Keywords: Cholangiopancreatography, endoscopic retrograde; Chronic, pancreatitis; Extracorporeal shockwave lithotripsy; Pancreatic calculi.

Fig. 1

Pancreatic calculi. (A) Calculi in head. (B) Calculi in head and body. (C) Calculi in head, body and tail.

Fig. 2

Protocol for extracorporeal shockwave lithotripsy of large pancreatic duct calculi. US, ultrasound; EUS, endoscopic ultrasound; MRCP, magnetic resonance cholangiopancreatography; ERCP, endoscopic retrograde cholangiopancreatography; ESWL, extracorporeal shock wave lithotripsy; EPS, endoscopic pancreatic sphincterotomy; PD, pancreatic duct; NPT, nasopancreatic tube.

Fig. 3

Extracorporeal shock wave lithotripsy (ESWL) for large pancreatic calculi. (A) Large calculi in main pancreatic duct with proximal stricture. Pre-ESWL. (B) Post-ESWL calculi pulverized. (C) Fragments cleared and stent placed.

Fig. 4

Extracorporeal shock wave lithotripsy for large pancreatic calculi (experience at the Asian Institute of Gastroenterology, India).

Fig. 5

Algorithm for the management of pancreatic calculi. ERCP, endoscopic retrograde cholangiopancreatography; ESWL, extracorporeal shock wave lithotripsy.