Pancreatic stones and calcifications

Pancreatic stones were first discovered in 1667 by Graaf. Subsequently, individual observations of pancreolithiasis began to accumulate, and, according to autopsy data, its frequency fluctuates from 0.004 to 0.75% of cases. It should be noted that these differences in pancreolithiasis statistics become understandable if we take into account the main goals of the autopsy study in each specific case: if the underlying disease from which the patient died is determined (for example, myocardial infarction, lung cancer, etc.), then, naturally, the identification of some additional "details" that are of no importance in the lethal outcome of the underlying disease (for example, small stones 1-2-3 mm in diameter in the pancreatic ducts) will not be given such attention. Therefore, pancreatic stones, especially medium and large ones, in patients who died from other diseases not associated with damage to the gland itself, are usually a "autopsy finding", mainly accidental. Clinical statistics, especially with the widespread introduction of X-ray (radiograph!) examination, make it possible to detect pancreolithiasis in a significantly greater number of cases.

The widespread use of ultrasound and CT significantly improves the lifetime diagnostics of pancreolithiasis, especially in patients with pancreatitis or suspected chronic pancreatitis. In chronic pancreatitis, calcium salts are deposited in the parenchyma of the gland (in places of former necrosis), but it is believed that duct stones occur more often. Pancreatic duct stones are often combined with gallstones and, in some cases, bile duct stones. Among the possible variants of chronic pancreatitis, due to frequent calcification of the pancreas in this disease, a special form is distinguished - calcifying pancreatitis. Most often, it occurs with severe alcoholic damage to the pancreas - in 40-50%. Pancreolithiasis is also often observed in hereditary pancreatitis, as well as in pancreatitis associated with hyperparathyroidism.

It is believed that more than half of patients with hereditary pancreatitis have stones in the pancreatic ducts, most often in the large ones, in the head area, and less often in the ducts of the body and tail.

Acute pancreatitis in patients with hyperparathyroidism, according to different authors, occurs in 6.5-19% of cases. Its occurrence is usually explained by blockage of the pancreatic duct by a stone, activation of trypsin under the influence of an increased concentration of calcium in the pancreatic secretion, and vasculitis in the glandular tissue. Pancreatic stones are found, according to different authors, in 25-40% of patients with acute pancreatitis in hyperparathyroidism.

Sometimes calcification occurs both in the parenchyma of the gland (calcificatia pancreatica) and in its ducts simultaneously or almost simultaneously.

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Pathomorphology

Pancreatic stones, as evidenced by specialized medical literature, mainly consist of calcium carbonate and phosphate, to a lesser extent - of magnesium, silicon, aluminum salts. Organic components in the form of protein, cholesterol, duct epithelial particles, leukocytes are always found in the composition of stones. The size of the stones varies - from the size of a grain of sand to the size of a walnut, and in some cases the mass of the stone reaches 60 g. The color of the stones is white, white with a yellowish tint, brown. The shape of the duct stones is also different: they are round, cylindrical, mulberry-like, irregularly shaped, sometimes branching.

Most often, the stones are multiple, and when they are located close to each other, the surface is usually fastened at the points of their contact (as with multiple gallstones).

The presence of stones in the pancreatic ducts to a greater or lesser extent prevents the outflow of pancreatic secretion and causes expansion of their more proximally located sections, and in some cases is the cause of the formation of pancreatic cysts. In addition, from the pressure of the dilated ducts and cysts, atrophy and sclerosis of the surrounding parenchyma of the gland occur, and the pancreatic islets also suffer. All this can be the cause of the progression of excretory and endocrine insufficiency of the pancreas, exacerbations of pancreatitis.

Symptoms

Very rarely, pancreatic stones are asymptomatic, especially since in the vast majority of cases they develop as a complication of pancreatitis, which has its own symptoms. Therefore, the clinical manifestations of pancreatic calculus generally correspond to the symptoms of pancreatitis. The most common symptom of pancreatic stones and calcifications is pain, either constant, excruciating, of a girdle-like nature, or resembling biliary colic (pancreatic colic), attacks of which most often occur when deviating from the normal, habitual regimen and nature of nutrition (dietary errors). In some cases, to relieve such severe attacks of pancreatic colic, it is necessary to administer to the patient not only antispasmodic drugs and non-narcotic analgesics, but even narcotic drugs, which is usually not recommended, since in some cases they cause an increase in the tone of the sphincter of the hepatopancreatic ampulla, thereby contributing to the progression of stagnation of pancreatic juice in the ducts and inflammation of the pancreas. Therefore, if there is an urgent need to relieve such pain, parenteral administration of narcotic drugs is combined with the administration of myotropic antispasmodics (no-shpa, papaverine hydrochloride, etc.) and anticholinergics (atropine sulfate, metacin, gastrocepin, etc.). Almost constant symptoms of pancreatic stones and calcifications are loss of appetite, nausea, belching, rumbling and gurgling sensations in the abdomen, other dyspeptic symptoms, “pancreatogenic” diarrhea, secondary “pancreatogenic” diabetes mellitus.

Course, complications

Pancreatolithiasis usually has a progressive course. With each subsequent attack of pancreatic colic (and even without attacks - as a result of the difficulty of pancreatic juice outflow) pancreatitis progresses, pain and dyspeptic symptoms become more severe, excretory and endocrine pancreatic insufficiency progresses, digestion and absorption disorders in the intestines become even more severe, "pancreatogenic" diarrhea becomes more frequent, exhaustion increases, in some cases up to cachexia, polyhypovitaminosis.

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Diagnostics

Pancreatic duct stones and focal calcifications are easily detected on plain abdominal radiographs, ultrasound, and CT. In plain abdominal radiographs, to detect duct stones, it is necessary to carefully examine the areas corresponding to the usual location of the pancreas to the right of the midline in the epigastric region and left hypochondrium. Stones and areas of calcification of pancreatic tissue of sufficiently large sizes, 0.5-1.0 cm or more, immediately attract the attention of the radiologist, especially if the examination is performed on a patient with a pancreatic disease; at the same time, small duct stones the size of a grain of rice and less often remain unnoticed. Upon careful examination of the radiographs, several “grains” or elongated “seeds” located in the area of the usual location of the pancreas, consisting of calcium salts, can be noted.

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Differential diagnostics

Pancreatic stones are differentiated from stones of the common bile duct (terminal part), kidneys, left adrenal gland (with calcification of its caseous contents in tuberculous lesions), from mesenteric lymph nodes. Radiography of this area of the abdomen in various projections, CT and other modern instrumental research methods allow to specify the localization and size of stones.

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Treatment

In most cases, pancreatic stones and calcifications are treated as in chronic pancreatitis. In case of large duct stones, they can be surgically removed. In some, particularly severe cases, the main duct is "sealed", which results in glandular tissue atrophy, but does not affect the pancreatic islets; symptoms improve somewhat, sometimes significantly. However, patients must subsequently strictly adhere to a diet (5-6 times a day), a diet, and constantly take pancreatic enzyme preparations (pancreatin, panzinorm, pancitrate, festal, etc.) during each meal in fairly large doses (8-12 tablets or more) to ensure normal digestion.