Pancreatic Stone (Pancreatic Lithiasis)
Pancreatic stones, also known as pancreatic calculi or pancreatic lithiasis, are hardened deposits of calcium carbonate that form within the pancreatic ducts. They are most commonly a consequence of chronic pancreatitis where repeated inflammation leads to protein plug formation that gradually calcifies over time. The stones obstruct the flow of pancreatic juice, causing ductal hypertension, progressive glandular damage and debilitating pain. The condition predominantly affects middle-aged individuals with a history of alcohol misuse or underlying metabolic disorders.
Symptoms
The clinical presentation of pancreatic stones is largely driven by ductal obstruction and glandular dysfunction. Patients typically suffer from recurrent or persistent upper abdominal pain radiating to the back often described as deep, boring and unrelenting which is the hallmark symptom. As the condition advances, exocrine insufficiency develops leading to steatorrhoea (pale, greasy, foul-smelling stools), malabsorption and significant weight loss. Endocrine dysfunction may also emerge, resulting in pancreatogenic diabetes mellitus due to progressive destruction of insulin-producing cells. Nausea, vomiting, and episodes of acute-on-chronic pancreatitis flares are also commonly reported.
Diagnosis
The diagnostic workup aims to confirm stone burden, assess ductal anatomy and evaluate residual pancreatic function. Plain abdominal X-ray may reveal coarse calcifications in the pancreatic region, though cross-sectional imaging is far more informative. CT scan of the abdomen is the most reliable tool for identifying stone number, size, and location within the ductal system. MRCP (Magnetic Resonance Cholangiopancreatography) provides detailed non-invasive mapping of the entire pancreatic duct and is essential for surgical planning. Endoscopic Ultrasound (EUS) offers high-resolution assessment of small stones and ductal changes. Faecal elastase and serum lipase tests evaluate residual exocrine function, while fasting glucose and HbA1c assess endocrine status.
Treatment
Management is directed at relieving ductal obstruction, controlling pain, and preserving residual pancreatic function. For stones located in the head of the pancreas with a dilated main pancreatic duct, Extracorporeal Shock Wave Lithotripsy (ESWL) is the first-line non-surgical approach using targeted shock waves to fragment stones followed by Endoscopic Retrograde Cholangiopancreatography (ERCP) to extract the fragmented debris and place a ductal stent to maintain drainage. When endoscopic management fails or the ductal anatomy is complex, surgery becomes necessary. The Lateral Pancreaticojejunostomy (Puestow procedure) is the most commonly performed operation, in which the pancreatic duct is opened longitudinally and anastomosed to a loop of jejunum, providing durable decompression and long-term pain relief. In cases complicated by an inflammatory head mass, Whipple's procedure (pancreaticoduodenectomy) may be required. Alongside intervention, patients require pancreatic enzyme replacement therapy (PERT) for malabsorption and insulin therapy if pancreatogenic diabetes has developed. Strict abstinence from alcohol and smoking is essential to slow disease progression.