Pancreatic stone formation is a serious complication of chronic pancreatitis. While endoscopic retrograde cholangiopancreatography (ERCP) and extracorporeal shock wave lithotripsy (ESWL) are the mainstays of treatment, surgery may be required in select cases. In this paper, we present a patient with chronic pancreatitis who developed a large pancreatic stone, necessitating surgical intervention. Since abdominal pain is a cardinal symptom of chronic pancreatitis, pancreatic stone formation may not be detected until later in the disease course. This can lead to a delayed diagnosis and the subsequent need for surgery, even though the condition could have been more easily managed with ERCP or ESWL if detected earlier. Through this report, we hope to raise awareness of pancreatic stones in patients with chronic pancreatitis.

A 34-year-old patient with chronic pancreatitis presented to our outpatient clinic with abdominal pain. The results of blood laboratory tests were within the normal range. Main pancreatic duct dilation was present on abdominal ultrasonography. Computed tomography revealed near-total atrophy of the pancreatic parenchyma, along with main pancreatic duct dilatation and an 85-mm-long solitary stone within the main pancreatic duct (Fig. 1–4). Due to abdominal pain refractory to medical treatment and the long-term malignancy risk in the near-totally atrophic pancreas, the decision was made to perform surgery based on a multidisciplinary team meeting. Total pancreatectomy was carried out, and a 30 × 85 mm pancreatic stone filling the main pancreatic duct was found in the specimen (Fig. 5). Ethical approval was not required. Written informed consent was obtained from the patient for the publication of this case report with any accompanying images.

Figure 1. Computed tomography imaging showing atrophic pancreatic parenchyma and stone formation in the main pancreatic duct.

Figure 2. Dilated Wirsung duct in the atrophic pancreatic parenchyma on non-contrast computed tomography and fat-suppressed transverse relaxation time-weighted imaging.

Figure 3. Hyperdense image of the pancreatic stone in the main pancreatic duct in axial and coronal images (non-contrast computed tomography, bone window).

Figure 4. Signal void due to a pancreatic stone in the Wirsung duct (coronal transverse relaxation time-weighted imaging).

Figure 5. Surgical specimen showing atrophic pancreatic parenchyma and stone formation in the main pancreatic duct.

Pancreatic stone formation is one of the most important complications of chronic pancreatitis. Stone formation may be overlooked until it reaches a prominent size as pain is a cardinal symptom of both chronic pancreatitis and pancreatic stones. ERCP and ESWL are the main treatment options for pancreatic stone extraction.¹ A surgical approach might be necessary in a few select cases.² A study comparing endoscopic versus surgical drainage of the pancreatic duct in patients with chronic pancreatitis revealed that surgery was more effective than the endoscopic approach.³ Chronic pancreatitis is recognized as a risk factor for pancreatic cancer and is associated with a nearly eight-fold increase in pancreatic cancer risk 5 years after diagnosis.⁴ According to an international consensus guideline, intractable pain, local complications of adjacent organs, and suspicion of a malignant lesion are indications for surgery in patients with chronic pancreatitis.⁵

Chronic pancreatitis is a clinical entity that results in long-term complications regardless of the underlying etiology. Pancreatolithiasis is a serious complication of chronic pancreatitis and should be suspected in chronic pancreatitis patients with refractory abdominal pain. A case-based clinical approach is necessary for the management of pancreatic stones.

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