Stones and calcifications of the pancreas

The first stone in the pancreas was discovered in 1667 by Graaf. Later, individual observations of pancreolithiasis began to accumulate, while, according to autopsy data, its frequency ranged from 0.004 to 0.75% of cases. It should be noted that these differences in the statistics of pancreatitis are made clear by taking into account the main objectives of the sectional study in each case: if the underlying disease from which the patient died (for example, myocardial infarction, lung cancer, etc.) is determined, then, naturally, some additional "details" that have no significance in the lethal outcome of the underlying disease (for example, small concrements 1-2-3 mm in diameter in the pancreatic ducts) will not be given such attention. Therefore, pancreas stones, especially of medium and large sizes, in patients who died from other diseases not associated with the lesion of the gland itself, are usually a "sectional finding," mostly random. Clinical statistics, especially with the widespread introduction of an x-ray (X-ray diffraction!) Study, can detect pancreatitis in a much larger number of cases.

The extensive use of ultrasound and CT significantly improves intravital diagnosis of pancreatitis, especially in patients with pancreatitis or with 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 stones of the ductal system occur more often. Stones of the pancreatic ducts are often combined with gallstones and in some cases - bile ducts. Among the possible variants of chronic pancreatitis, due to the frequent calcification of the pancreas, a special form is formed in this disease - calcific pancreatitis. Most often it occurs with severe alcohol damage of the pancreas - in 40-50%. Pancreatitis 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 find stones in the ducts of the pancreas, more often in large, in the head region, less often in the body and tail ducts.

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

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

[1], [2], [3], [4]

Pathomorphology

Stones of the pancreas, as evidenced by special medical literature, mainly consist of calcium carbonate and phosphate, to a lesser extent - from magnesium, silicon, aluminum salts. In the composition of stones, organic components are always found in the form of protein, cholesterol, particles of duct epithelium, leukocytes. 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 tinge, and brown. The shape of the duct stones is also different: they are round, cylindrical, of the form of mulberry, of irregular shape, sometimes branching.

Most often, the stones are plural, and at their close location in the places of their contact, the surface is usually fascist (as in multiple gallstones stones).

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

Symptoms

Very rarely, pancreas stones are asymptomatic, especially in the vast majority of cases they develop as a complication of pancreatitis, which has its symptoms. Therefore, clinical manifestations of calculosis of the pancreas basically correspond to the symptoms of pancreatitis. The most common symptom of stones and calcifications of the pancreas are pains, or persistent, painful, shingles, or resembling bile colic (pancreatic colic), which attacks most often occur in a deviation from normal, habitual regimen and eating patterns (nutritional errors). In a number of cases, for the relief of such severe attacks of pancreatic colic, it is necessary to inject not only spasmolytic drugs and non-narcotic analgesics, but even narcotic drugs, which is usually not recommended, since they in some cases cause an increase in the sphincter tone of the hepatic pancreatic ampoule, thereby contributing to progression of stagnation of pancreatic juice in the ducts and inflammation of the pancreas. Therefore, if there is an extreme need to stop such pains, parenteral administration of narcotic drugs is combined with the introduction of myotropic antispasmodics (no-sppa, papaverine hydrochloride, etc.) and anticholinergic agents (atropine sulfate, metacin, gastropepine, etc.). Almost constant symptoms of stones and calcifications of the pancreas are loss of appetite, nausea, belching, rumbling and abdominal pain, other dyspeptic symptoms, "pancreatogenic" diarrhea, secondary "pancreatic" 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 outflow of pancreatic juice), pancreatitis progresses, pain and dyspeptic phenomena become more severe, excretory and endocrine insufficiency of the pancreas progresses, digestion and absorption in the intestine becomes even worse, "Pancreatogenic" diarrhea, exhaustion is increasing, in some cases up to cachexia, polyhypovitaminosis.

[5], [6], [7], [8]

Diagnostics

Stones of ducts and focal calcifications of pancreatic tissue are well revealed on the survey radiographs of the abdominal cavity, with ultrasound and CT. On the survey radiographs of the upper abdominal cavity for the detection of concrements of ducts, it is necessary to carefully consider the zones corresponding to the normal location of the pancreas to the right of the midline in the epigastric region and the left hypochondrium. Stones and areas of calcification of pancreatic tissue sufficiently large, 0.5-1.0 cm or more, immediately attract the attention of the radiologist, especially if the study is conducted to a patient with pancreatic disease; at the same time small concrements of ducts the size of rice grains and less often remain unnoticed. Upon close examination of the radiographs, several "grains" or elongated "grains" can be noted, located in the zone of the usual location of the pancreas, consisting of calcium salts.

[9], [10], [11], [12], [13], [14], [15],

Differential diagnostics

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

[16], [17], [18], [19], [20]

Treatment

In most cases, stones and calcifications of the pancreas are treated, as in chronic pancreatitis. With large duct stones, surgical removal is possible. In isolated cases, especially severe cases, the main duct is "sealed", at the same time atrophy of the gland tissue occurs, but pancreatic islets do not suffer; the symptoms improve somewhat, sometimes considerably. However, patients subsequently need to very strictly adhere to the diet (5-6 times a day), diet and constantly take pancreatic enzyme preparations (pancreatin, panzinorm, pancitrat, festal, etc.) during each meal in fairly large doses (8-12 tablets and more) to ensure normal digestion.