Kurume Medical Journal, 50, 57-61, 2003 Case Report

Effective Extracorporeal Shock Wave Lithotripsy for Pancreatic Duct Stone

YOSHINOBU OKABE, NAOFUMI ONO, HIDEYA SUGA, HIROYASU IJUIN, TAKAHITO KODAMA, KOZABURO NARITA, OSAMU TSURUTA, MICHIO SATA AND ATSUSHI TOYONAGA

Department of Medicine and Division of Gastroenterology and , and Department of , Kurume University School of Medicine, Kurume 830-0011 and tTenyokai Central Hospital, Kagoshima 892-0822, Japan

Summary: A 55-year-old man with alcoholic chronic pancreatitis was hospitalized for further treat- ment of intractable repeated upper abdominal pain. A laboratory data showed normal hepatobiliary enzymes and glucose tolerance test, but abnormal pancreatic enzymes including amylase, lipase, trypsin and elastase I. Pancreatic function diagnostant test was 71 %. Abdominal ultrasound exami- nation and computed tomography showed an approximately 4 mm main pancreatic duct stone and multiple small stones in the surrounding parenchyma, and the findings being compatible with chron- ic pancreatitis. Endoscopic retrograde cholangiopancreatrography revealed that there was a main pancreatic duct stone in the head, and that the caudal pancreatic duct could not be visu- alized due to the impacted stone. In addition, intrapancreatic showed no malignant irreg- ularity, but pancreatitis-induced smooth narrowing. The patient underwent extracorporeal shock wave lithotripsy (ESWL) alone, because endoscopic manipulation for pancreatic stone removal was impossible due to tightly impacted stone with stenosis. Successful ESWL was achieved with the stone disappearance and without any complication. Key words pancreatic duct stone, chronic pancreatitis, extracorporeal shock wave lithotripsy (ESWL)

ments that do not require a , such as oral INTRODUCTION litholysis [3,4], endoscopic lithotripsy [5-7], and In the past, pancreatic duct stones were basically ESWL [8,9], have been actively selected. treated conservatively by diet control, instructing However, oral litholysis often does not com- patients to refrain from drinking alcohol, and admin- pletely dissolve stone, and litholytic agents some- istering analgesics, digestive enzymes and pancreatic times need to be given for long periods of time. As a enzyme inhibitors. recent treatment selection in many institutions, endo- Surgery to remove pancreatic duct stone is mostly scopic lithotripsy or ESWL is performed alone [10] performed by laparotomy, and favorable results have or in combination with other treatments [11,12]. In been reported by many studies [1,2]. this paper, we report one case in whom ESWL However, due to recent advances in medical monotherapy was particularly effective. equipment and technology, minimally invasive treat-

Received for publication January 7, 2003 Correspondence to: Yoshinobu Okabe, Department of Medicine II, Kurume University School of Medicine, 67 Asahi-machi, Kurume 830- 0011, Japan. Tel: 0942-35-3311 (ext. 3714) Fax: 0942-31-7723

Abbreviations: CT, computed tomography; ERCP, endoscopic retrograde cholangiopancreatography; EST, endoscopic sphincterotomy; ESWL, extracorporeal shock wave lithotripsy; MRCP, magnetic resonance cholangiopancreatography; US, ultrasonography. 58 OKABF FT AL.

seen in the surrounding pancreatic parenchyma. CASE REPORT The pancreatic margin was irregular, and parenchy- A 55-year-old man was referred and admitted to mal scans were rough in echogenic appearance. our hospital because of repeated upper abdominal Abdominal computed tomography (CT) showed pain with pancreatic enzyme abnormalities after a main pancreatic duct stone and mild dilatation of drinking a large quantity of alcohol on January 16, the caudal main pancreatic duct as seen in US find- 2002. He has 20 years' history of alcohol consump- tion 2 liter of beer a clay. The patient had a height 162 cm, body weight 61.8 kg, temperature 36.2 C , blood pressure 134/88 mm Hg. no anemic conjunc- tiva and no scleral icterus. Heart and lung were clear to auscultation and percussion. Mild tenderness was detected in the upper , but no tender back was noted. Laboratory studies disclosed normal serum amy- lase 127 U/I, and elevation of lipase 182 U/l, trypsin 900 nag/ml and elastase 1 540 ng/dl. C reactive protein was negative and hepatobiliarv enzyme abnormali- ties were not observed, and levels of various tumor markers were all within normal values (Table 1).

Abdominal ultrasound examination (US) showed Fits. 1. Ahdominal ultrasound examination. a: a main pancreatic duct stone in the transitional zone Multiple small stones seen in the pancreas head of the pancreas head. and the main pancreatic duct parenchyma. h: A main pancreatic duct stone 4 mm caudal to the stone was dilated to about 4 nun (Fig. in size (arrow) in the transitional zone of the pan- creas head. The main pancreatic duct caudal to the 1). The pancreatic duct stone was about 4 mm in the tone vbas dilated to about 4 mm. maximum diameter. Smaller pancreatic stones were

TABLE 1. Laboratory data on admissioll

kurume Medical journal Vol. 50. No.1,2,2003 ESWL FOR PANCREATIC DUCT STONE 59

Fig. 2. Contrast enhanced CT. a: A main pancreatic duct stone in the transitional zone of the pancreas head and body. Smaller pancreatic stones were seen in the surrounding pancreatic parenchyma. h: Caudal duct was mildly dilated.

Fig. 3. Magnetic re"onance cholangiopancre- atography (MRCP). MRCP showed a filling defect (arrow) in the main pancreatic duct at the transi- tional zone of pancreas head and body, and the mild dilatation of caudal main pancreatic duct. Fig. 4. Endoscopic retrograde cholangiof ncre- atography (FRCP). ERCP res led an interruption of main pancreatic duct in the transitional zone of ings (Fig. 2). No clear signs of a tumor were noted. the pancreas head and body due to stone impaction. Magnetic resonance cholangiopancreatography The main pancreatic duct caudal to the stone could (MRCP) similarly showed a filling defect in the main not be visualized even by forced injection of con- pancreatic duct, and the mild dilatation of caudal trast medium. The intrapancreatic bile duct appeared main pancreatic duct (Fig. 3). The intrapancreatic bile smooth narrowing. duct appeared smooth but narrowed. Endoscopic retrograde cholangiopancreatrogra- phy (FRCP) revealed a main pancreatic duct stone in um (Fig. 4). the transitional zone of the pancreas head as seen in Furthermore, we could not insert a or US, CT and MRCP, and the caudal duct could not be guide wire deep into the pancreatic duct beyond the visualized even by forced injection of contrast medi- site of stone impaction. No atypical cells were found

Kurume Medical Journal Vol. 50, No. 1,2,2003 o() OKABF FT AL.

atic duct Stone causes Intrapancreatlc occlusion and increases the ductal pressure. thus leading to exac- erbated pancreatitis. pseudocyst formation, and per- sistent pain. Furthermore, impaired endocrine and exocrine functions of the pancreas can induce or exacerbate pancreatic diabetes, and fatty stool or poor digestibility can cause malnutrition. Ever since Nimura et al. 151 introduced endo- scopic lithotripsy in 1982, it has been considered an effective treatment for pancreatic duct stones [14,15]. As a general rules, endoscopic sphincterotomy (EST) is performed prior to endoscopic lithotripsy. In some patients, endoscopic incision of the orifice of the main pancreatic duct or the accessory papilla is per- formed. Isolating and opening the orifice of the pan- creatic duct facilitates preventions of acute pancre- Fig. 5. Serial ahdominal X-rav. Endoscopic ret- atitis caused by stone impaction and allows access to rogradc pane reatography alter u-catment. The stone in the main pancreatic duct had disappeared, and the the pancreatic duct for such procedures as basket caudal pancreatic duct was visualised. insertion, performing balloon dilatation for ductal stenosis, or stent insertion. In other words. endo- scopic Iithotripsy is an active modality for stone removal and is quick acting. However, severe stenosis by pancreatic fluid cytology, bile juice cytology or and bending of' the pancreatic duct associated with lower bile duct brush cytology. Based on these find- chronic pancreatitis make it difficult to insert a ings, the patient was diagnosed as having alcoholic basket. Endoscopic lithotripsy is also difficult in pancreatitis accompanied by a pancreatic stone patients with multiple stones and constrictions, and impacted in the main pancreatic duct. can cause hemorrhage or perforation [16]. ESWL As for the treatment, ESWL was selected and was first introduced by Sauerbruch et al. [8] in 1987, performed on May 10, 2002 instead of endoscopic and its safety and effectiveness in lithotripsy are well lithotripsy because it was impossible to place the documented. Ohara et al. [10] performed ESWL catheter deep in the main pancreatic duct. monotherapy in 35 patients and reported that pancre- Following ESWL, cndoscopic retrograde pancre- atic duct stones completely disappeared in 25 (72%,) atography showed that the stone had disappeared. and and mostly disappeared in 5 (14%). They also docu- the caudal pancreatic duct was visualised (Fig. 5). mented that complete lithotripsy was achieved in 15 The patient had no ESWL-related complications and (83(( ) of 18 patients without main pancreatic duct have been doing well for one year after discharge. stenosis, but in 5 (42%) of 12 patients with severe main pancreatic duct stenosis. Therefore, the eff ec- tiveness of ESWL appears to be dependent on main DISCUSSION AND CONCLUSION pancreatic duct stenosis, and pancreatic duct stone Chronic pancreatitis is a progressive disease that removal needs to be combined with an appropriate leads to impairment of the endocrine and exocrine endoscopic treatment for such stenosis [10]. functions of the pancreas, and pancreatic duct stone When combining endoscopic and ESWL.. is one of the complications that arise in late or endoscopic therapy is generally performed first ill uncompensated phase. The incidence of pancreatic Europe and America, but ESWL is generally per- duct stone in chronic pancreatitis is reported to be formed first in Japan. No general consensus has been 40% [13]. and the most common form of pancreatic reached on the most effective order for these treat- duct stone is alcoholic, followed by idiopathic- while ments. When ESWL is performed first. a decision as hiliary stones arc rare. From the viewpoint of stone to whether EST should he performed must be made. morphology. the incidence of large stones is higher Therefore. it is necessary to perform endoscopic among idiopathic pancreatic duct stones. while the therapy or ESWL after determining the relationship incidence of small stones is higher among alcoholic between pancreatic duct stone and the main pancre- pancreatic duct stones I 11. The presence of a pancre- atic duct based on CT. MRCP and ERCP findings.

Kurume Medical Journal Vol. 50, No. 1. 2, 2003 ESWL FOR PANCREATIC DUCT STONE 61 and after considering patient social backgrounds and removed by endoscopic sphincterotomy of the pancreatic facility capabilities. duct. Gastrornterol Endosc 1983; 25:1246-1250. (in Japanese) In the present patient with alcoholic chronic pan- 7. Kiyota K, Mukai S, Nishimura K, Cho E, Kobayashi M creatitis, a small pancreatic stone was found in the et al. Non-surgical removal of pancreatic stones by main pancreatic duct with constriction, and because endoscopic sphincterotomy. Gastroenterol Endosc 1985; it was difficult to endoscopically insert a catheter 27:1349-1354. (in Japanese) into deep area of the pancreas, ESWL was performed 8. Sauerbruch T, Holl J, Sackmann M, Werner R, Wotzka successfully instead of endoscopic lithotripsy. R et al. Disintegration of pancreatic duct stone with Fortunately, the stone was crushed by a single treat- extracorporeal shock wave in a patient with chronic ment with ESWL, but because the main pancreatic pancreatitis. Endoscopy 1987;19:207-208. 9. Ohara H, Gotoh K, Noguchi Y, and Hosino M. duct remained stenotic, the risk of recurrence is high. Fundamental and clinical studies of extracorporeal shock Hence, it will be necessary to have proper food wave lithotripsy for pancreatic duct stones. Jpn J restriction and strictly enforce a cessation of alcohol Gastroenterol 1991; 88:2861-2870. (in Japanese) intake, and if the pancreatic duct stone recurs, ESWL 10. Ohara H, Hoshino M, Okayama Y, and Gotoh K. can be repeated or endoscopic lithotripsy from the Extracorporeal shock wave lithotripsy for patients with EST-treated accessory papilla can be an alternative pancreatic duct stones. KAN . TAN . SUI 1996; to ESWL in our patient. Furthermore, the incidence 33:413- 419. (in Japanese) 11. Hasegawa K, Tanaka K, Hayakumo T, Cho E, Yasuda K of malignant tumor in patient with pancreatic duct et al. Endoscopic treatment of chronic pancreatitis with stone ranges from 2 to 22.2% [2,17,18], and as a ductal stones. J Jpn Panc Soc 2002; 17:39-45. (in result, post-therapeutic monitoring, including pancre- Japanese) atic fluid cytology, will also be necessary. 12. Tanaka K, Nakajima M, Yasuda K, Cho E, Hayakumo T In conclusion, we here described a patient with et al. Endoscopic treatment for pancreatic stones-endo- scopical pancreatic duct . KAN TAN . SUI pancreatic duct stone in whom ESWL monotherapy was significantly effective. 2002; 44:197-206. (in Japanese) 13. Kondou T, Ishiguro H, Nakae Y, Kitagawa M, Naruse T et al. Pathophysiological role of pancreatic stones in REFERENCES chronic pancreatitis. Journal of Biliary Tract & Pancreas 1996;17:981-985. (in Japanese) 1. Kinoshita Y, Nakayama K, Imayama Y, Sou H, Aoki E 14. Akiyama T, Omura R, Nakamura M, Kondou T, Harima et al. Surgical treatment of pancreatolithiasis. Journal of K et al. Endoscopic treatments for pancreatothiasis. Biliary Tract & Pancreas 1996;17:1015-1020. (in Journal of Biliary Tract & Pancreas 1991; 12:1447-1453. Japanese) (in Japanese) 2. Kondou A, and Kawarada Y. Surgical treatment and 15. Yamao K, Nakazawa S, Yoshino J, Inui K, Yamachika H results for pancreatic stone. KAN . TAN . SUI 1996; et al. Endoscopic approach for the pancreatothiasis. 33:437-444. (in Japanese) Journal of Biliary Tract & Pancreas 1994; 15:1111-1116. 3. Vantini I, Piubello W, Maso R, Talamini G, Marchiaro G (in Japanese) et al. Citrate treatment of chronic calcified pancreatitis: 16. Lambert ME, Bettts CD, Hill J, Faragher EB, Martin DE A control trial. Digestion 1983: 28:70. et al. Endoscopic sphincterotomy: The whole truth. Br J 4. Noda A, Hayakawa T, Kondo T, Nagai K, Mizuno R et Surg 1991; 78:473-476. al. Pancreatic stones dissolution with dimethadione 17. Oguchi H, Nagata H, Hirabayashi H, Takeuchi K, (DM0). Nippon Shokakibyo Gakkai Zasshi 1984; Tamura Y et al. A study on the complication of malig- 81:101-107. (in Japanese) nancy in pancreatic lithiasis. Jpn J Gastroenterol 1982; 5. Nimura Y, Yamasa Y, Inui K, and Nakae Y. Endoscopic 79:851-857. (in Japanese) sphincterotomy for the pancreatolithiasis. Gastrornterol 18. Tomioka T, Tajima Y, Onizuka S, Inoue K, Kuroki T et Endosc 1982; 24:1312. [proceeding] (in Japanese) al. Long-term follow-up study of surgical treatment of 6. Inui K, Nakae Y, Nakamura J, Kano J, Sato T et al. A pancreatic stones. Journal of Biliary Tract & Pancreas case of non-calcified pancreatolithiasis which was 1996;17:1027-1030. (in Japanese)

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