Description:

• A 17 yrs/ F was referred to us for the favor of endoscopic evaluation of etiology of recurrent acute pancreatitis and the current status of chronic pancreatitis.

• Endoscopic Ultrasound (EUS) revealed dilated main pancreatic duct (MPD) with stones impacted in the head of pancreas region with upstream dilatation of pancreatic duct without parenchymal calcification.

• In view of these findings ERCP was considered and pancreatic sphincterotomy was performed followed by stone extraction and pancreatic ductal clearance. A 7 fr pancreatic stent was placed to ensure free flow of pancreatic juice.

• This patient underwent few sessions of endotherapy and now for the last 8 years follow up she is asymptomatic.

Expert Comments

In this case as we can see, patient who had recurrent episodes of acute pancreatitis, ultimately developed chronic pancreatitis with stones in the main pancreatic duct. EUS showed dilated MPD with few soft stones which were removed after pancreatic sphincterotomy and balloon sphincteroplasty.

Thus in patients with predominant ductal disease with dilated ducts and soft stones, these patients are the ideal candidates for endotherapy. One has to exercise caution that not all patients with chronic pancreatitis will benefit from endotherapy. Therefore, at our hospital The World Gastroenterology Institute, we feel that with the help of EUS we can map the pancreas and evaluate the exact status of the disease. We can then decide which patient will benefit from endotherapy and which patients should go for other treatment options such as medical treatment or surgery.

Furthermore, I would like to add that since I pioneered pancreato-biliary EUS in India, we have seen that patients who have had more than 2 (two) episodes of acute pancreatitis would benefit from evaluation with EUS to look for etiology of acute pancreatitis which could be small stones in Gall bladder or CBD. EUS will also allow to rule out congenital ductal anomaly such as Pancreas Divisum in most cases. Hence, it is a protocol at our unit that patients with h/o acute pancreatitis without definitive etiology will be subjected to EUS first prior to any further interventions.

Image:

1. Dilated MPD with two stones seen. CBD appeared normal on Endoscopic Ultrasound ( EUS )

2. Pancreatic sphincterotomy after cannulation in process

 

3. Dilated MPD seen with few stones on pancreatogram- ERP 

4. Balloon sphincteroplasty of pancreatic sphincter to facilitate stone extraction

5. Pancreatic ductal stone extraction performed with stone extraction balloon catheters and dormia basket.

6. A 7 fr pancreatic stent placed in the MPD to ensure free flow pancreatic juice.