Pancreatic Lithiasis, with a Case Report and Autopsy Findings

Abstract

PANCREATIC lithiasis was first described by Graaf in 1667. It is a rare condition, only 147 case having been reported in the literature so far. The case to be reported now will be the one hundred forty-eighth case. Etiology.—The exact etiology is not known. Stasis of pancreatic secretion apparently does not produce stones. Mann and Giordano have shown. that ligation of both pancreatic ducts in animals does not produce stones. Also a back-flow of bile into the pancreatic ducts will not do it. Most of the stones that have been examined contained calcium carbonate and calcium phosphate. The normal pancreatic secretion does not contain either one. However, chronically inflamed tissues may produce calcium. The assumption, therefore, is that the stones are formed either on account of a chronic inflammatory process in the ducts or due to some chemical alteration in the pancreatic secretion. Pathology.—Pancreatic stones are mostly multiple, and are distributed throughout the pancreas. However, cases have been described with only a solitary stone which then is mostly in the head of the gland. The stones are mostly the size of a cherry stone or slightly larger. Occasionally small gravel-like concretions are found. Sometimes the ducts are incrusted with sand. The largest stones were described by Shupman and Matoni. Shupman's stone measured 2.5 × 0.5 inches and weighed 200 grains. Matoni reports one stone weighing two ounces. The stones are white or grayish-white in appearance and irregular. Seldom are they facetted. They produce a chronic interlobular pan-creatitis and in the late stages a fibrosis of the interstitial tissue. I t is only in the late stages that, due to the fibrosis, the islands of Langerhans are destroyed. Therefore, diabetes does not occur until quite late in the disease. Symptoms.—The most outstanding symptom is pain in the epigastric region. This pain may be either dull and more lasting in character, or colicky and very sharp but of shorter duration. It generally radiates into the back, very often into the left side. Sometimes the pain is agonizing in character, associated with vomiting, cold sweats, and collapse. Some attacks are similar to those due to gallstones. Minnich and Holzmann found fragments of stones in the stools after each attack. Lack of appetite and loss of weight are common. The weight loss is probably due to impairment of the digestion on account of lack of pancreatic secretion, following the atrophy and destruction of the glandular tissue. Jaundice has been found quite frequently, due to (1) stone obstruction of the papilla of Vater, (2) pressure on the bile ducts, or (3) co-existing biliary disease. Diarrhea was present quite often. Sometimes there were fatty stools.