A rare complication of chronic calcifying pancreatitis

Background: The stricture of ductus choledochus and ductus Wirsungianus caused by the expansion of the calcified tissue is a known complication of chronic calcifying pancreatitis (CCP). Case report: A 61 year-old male patient had a history of acute pancreatitis. His examination in the hospital began in January 2013, because of intense stomach pain, extreme weight loss and weakness. From his laboratory parameters acquired on admission, extremely increased obstructive serum enzyme activity should be highlighted. By abdominal ultrasound, stones in the gallbladder and the common bile duct, some free abdominal fluid and multiple cystic malformation in the pancreatic head and body regions were described. The ultrasound opinion raised the possibility of pancreatic neoplasia. During gastroscopy, in the duodenum polypoid erosions were seen. From biopsy samples, malignancy was not described. Abdominal CT scan described moderate dilatation of the common bile duct and extreme, cystic dilatation of the ductus Wirsungianus. The pancreatic lesions were observed as chronic pancreatitis, but in the head area of the pancreas, malignancy could not be ruled out. The gallbladder was observed to be hydropic, containing small stones in its fundus. ERCP described CCP with gravely disordered outflow. After endoscopic sphincterotomy and progressive dilatation, a 10 F stent was placed in the extreme wide Wirsung duct, and pancreatic fluid aspiration was performed for cytological examination. Then, because of the common bile duct stenosis, a 10 F stent was inserted in the ductus choledochus as well. Endoscopic ultrasound (EUS) using linear head could reach the duodenal bulb, where the large, heterogeneous, partly calcified pancreatic head was clearly visible. Fine needle aspiration cytology sampling (FNA) was performed. The aspiration cytology results have not confirmed malignancy (C2). Three days after the ERCP and endoscopic stent implantation, abdominal CT was performed. Regression of the pancreatic and biliary duct dilatations was described. A month later, abdominal ultrasound described the complete regression of cystic pancreatic duct dilatation. Conclusion: in case of CCP, EUS-FNA has a crucial role among the methods of differential diagnosis. Endoscopic drainage therapy is an appropriate alternative to surgical intervention.