What are the symptoms and treatment options for a patient with pancreatic stones?

Symptoms and Treatment of Pancreatic Stones

Pancreatic stones primarily cause chronic, severe upper abdominal pain radiating to the back, and treatment depends on stone size: stones ≤5 mm are managed with conventional ERCP, while stones >5 mm require extracorporeal shock wave lithotripsy (ESWL) followed by endoscopic clearance. 1

Clinical Presentation

Symptomatic pancreatic stones manifest with:

• Chronic, severe upper abdominal pain radiating to the back caused by pancreatic duct obstruction, increased intraductal pressure, and inflammation 2, 3
• Recurrent episodes mimicking acute pancreatitis with sudden onset severe pain, often triggered by alcohol or fatty meals 2
• Weight loss and steatorrhea from progressive pancreatic destruction 2
• Diabetes mellitus developing in 38-40% of patients as a long-term sequela 4
• Exocrine pancreatic insufficiency occurring in 30-48% of patients 4

Important caveat: Only symptomatic stones causing obstruction require treatment; asymptomatic stones do not warrant intervention 1, 5

Diagnostic Workup

Essential imaging before any intervention:

• CT scan should be the first-line imaging investigation to visualize pancreatic calcifications, ductal dilation, and atrophy 2, 4
• Pre-procedural MRCP or contrast-enhanced CT is mandatory to map pancreatic duct anatomy, stone location, size, and presence of strictures 5
• Endoscopic ultrasound assists diagnosis when CT/MRI findings are normal or equivocal despite high clinical suspicion 4

Treatment Algorithm Based on Stone Size

Small Stones (≤5 mm)

Conventional ERCP with standard extraction is first-line therapy:

• Endoscopic sphincterotomy, dilation, and balloon/basket retrieval often achieves complete stone clearance without additional interventions 1, 5
• This approach is sufficient in most cases for stones in this size category 1

Large Stones (>5 mm)

ESWL is the preferred initial approach:

• ESWL achieves stone fragmentation in >90% of cases 1, 5
• Subsequent ERCP achieves complete pancreatic duct clearance in more than two-thirds of patients after ESWL fragmentation 1, 5

When ESWL is unavailable or unsuccessful:

• Pancreatoscopy with intraductal lithotripsy (electrohydraulic or laser) is the preferred alternative 1
• Technical success rates reach 88% with acceptable adverse event rates of 12% 1

Surgical Intervention

Surgery should be considered over endoscopic therapy for long-term pain relief in painful obstructive chronic pancreatitis:

• Randomized trials demonstrate higher complete or partial pain relief with early surgery (58%) compared with endotherapy (39%) during 18 months of follow-up 1
• Surgery is a one-time intervention, whereas endoscopic therapy typically requires serial ERCPs over 6-12 months 1
• Despite superior outcomes with surgery, endoscopic intervention remains reasonable for suboptimal operative candidates or those favoring less invasive approaches 1

Management of Coexisting Strictures

Pancreatic duct strictures complicate stone extraction and increase recurrence risk:

• When strictures coexist with stones, prolonged stent therapy for 6-12 months may be necessary for duct remodeling 1
• Strictures are a key risk factor for stone recurrence 1

Medical Management for Pain Control

First-line analgesic approach:

• Nonsteroidal anti-inflammatory drugs and weak opioids such as tramadol are first-line therapy 4
• Trial of pancreatic enzymes and antioxidants (combination of multivitamins, selenium, and methionine) can control symptoms in up to 50% of patients 4
• Advice to discontinue alcohol and smoking is essential 4

Timing Considerations for Gallstone-Related Pancreatitis

If pancreatic stones are associated with gallstone pancreatitis:

• Urgent therapeutic ERCP should be performed within 72 hours after pain onset in patients with predicted or actual severe pancreatitis, cholangitis, jaundice, or dilated common bile duct 6
• Definitive treatment with cholecystectomy should not be delayed more than two weeks after discharge to avoid potentially fatal recurrent acute pancreatitis 6

Common Pitfalls

Key points to avoid treatment failures:

• Patients must be clearly informed that while endoscopic therapy is less invasive, best practice evidence primarily favors surgery for long-term pain relief in obstructive chronic pancreatitis 1
• Antibiotic prophylaxis is recommended before any pancreatic duct intervention 5
• Follow-up imaging should be driven by clinical symptoms rather than routine surveillance 5