Cholelithiasis

　　The etiology of pancreatic calculi is not yet fully understood. According to the results of a large amount of statistical data, cholelithiasis is related to alcohol consumption, with cases of pancreatic calculi occurring more frequently in people who have a long history of drinking and consume large amounts of alcohol, with an average daily alcohol intake of, protein intake of 100g, and fat intake of 90g. In addition, there are also reports that cholelithiasis is related to family history. The etiology of cholelithiasis is also associated with recurrent pancreatitis, biliary tract diseases, hyperparathyroidism, genetic factors, and pancreatic parasitic diseases.

　　Alcohol can stimulate the secretion of pancreatic juice and enzymes, with enzyme secretion exceeding water secretion. High concentrations of enzymes can destroy the epithelial cells of the pancreatic duct, causing an increase in protein and calcium concentrations in the pancreatic juice. Lactoferrin and cholelithin protein (PSP) play an important role in the formation of stones, as they can bind with albumin to form large protein polymers that precipitate. With the progression of the disease, calcium carbonate is added, causing typical calcification and gradually forming stones. In summary, the stasis of pancreatic juice and the change in its composition are important reasons for the formation of cholelithiasis.

　　The complications of cholelithiasis mainly include benign and malignant complications, as detailed below:

　　1. Benign complications

　　Cholelithiasis can lead to chronic inflammatory changes in the pancreatic tissue, causing chronic pancreatitis and pancreatic pseudocysts. When inflammation involves islet cells, diabetes can occur. Other complications include peptic ulcers and liver disease.

　　2. Malignant complications

　　Malignant complications are mainly pancreatic cancer, with an incidence rate of generally 3.6% to 16.7% reported in China and abroad. Some believe that cholelithiasis can lead to recurrent chronic inflammation and cystic fibrosis of the pancreatic tissue, and the long-term effects of the latter can cause genetic mutations in pancreatic cells, ultimately leading to cancer. In terms of age of onset, patients with cholelithiasis and pancreatic cancer are mostly in their 30s to 40s, while general pancreatic cancer is more common in the 50s to 60s, with the former occurring 20 years earlier than the latter.

　　The clinical manifestations of pancreatic calculus can be divided into two types: early and late.

　　One, Early symptoms

　　3, Abdominal pain: It is the most common symptom, with varying degrees of severity, mainly due to the obstruction of the pancreatic duct and the result of pancreatic fibrosis. It often manifests as upper abdominal pain, and if it is alcoholic pancreatic calculus, it often manifests as severe pain, with repeated attacks lasting a long time. Some patients may only have occasional discomfort in the upper abdomen. In cases where the cause is unknown, severe pain is rare, mostly upper abdominal hidden pain or dull pain.

　　1, Weight loss, steatorrhea: It is caused by decreased exocrine function of the pancreas due to calculous chronic pancreatitis. The condition of steatorrhea depends on the extent of pancreatic damage.

　　2, Jaundice: About 1/4 of patients can have jaundice. It is caused by fibrosis and the hard head of the pancreas compressing the lower end of the common bile duct. Jaundice can be persistent or intermittent, with the latter being more common.

　　Two, Late symptoms

　　The late symptoms of pancreatic calculus are mainly manifested as complications brought by progressive chronic pancreatic damage.

　　Changing bad living habits (excessive alcohol consumption), actively and effectively treating the primary disease (biliary disease, hyperthyroidism, parasites, etc.), is the key to preventing this disease. Drinking plenty of water can dilute urine, reduce the concentration of crystals in urine, flush the urinary tract, and is conducive to preventing the formation of calculi and promoting the excretion of stones. Generally, adults should drink more than 2000 milliliters of water or magnetized water per day, which has a certain significance for preventing calculi.

　　The clinical examination methods for pancreatic calculus mainly include laboratory examination and imaging examination, as follows:

　　One, Laboratory examination

　　Testing serum GPT, GOT, cholesterol, triglycerides, etc., may show slight abnormalities, and alkaline phosphatase (AKP) can be elevated in a few patients. To differentiate whether there is concurrent pancreatic cancer, cancer embryonic antigen (CEA) should be detected. The staining of pancreatic cancer tissue with cancer embryonic antigen is moderately positive, and the staining of pancreatic duct epithelial cells is light to moderate positive.

　　Two, X-ray film

　　Pancreatic calculi can be displayed in 3 types on X-ray films:

　　1, Diffuse type: It is a group of calculi of different sizes scattered on the pancreas.

　　2, Solitary type: It is one or more block-like calculi, mostly in the main pancreatic duct.

　　3, Mixed type: Both granular calculi and block-like calculi can be seen on the same X-ray film.

　　Pancreatic calculi are often most abundant in the head of the pancreas, less in the tail, and centrally in the body. Larger calculi cause more severe obstruction of the main pancreatic duct, with the vast majority accompanied by duct obstruction, and complications are also common.

　　Three, Ultrasound and CT scans

　　The sensitivity of pancreatic calculi is above 90%. If combined with positive CT scans, the rate is particularly high. CT scans can improve the detection rate of positive cases in the diagnosis of pancreatic cancer. When pancreatic calculus and concurrent pancreatic cancer are present, calcification of the pancreas, pseudocysts, dilatation of the pancreatic duct, irregular shape of the pancreas, localized enlargement of the pancreas, and disappearance of peripancreatic fat can be seen.

　　Patients with pancreatic calculus should have a light diet, avoiding greasy foods and alcohol. In terms of specific diet, the following aspects should be paid attention to:

　　1. The supply of protein should be 60 grams per day, including an appropriate amount of high-quality protein.

　　2. In cooking methods, more steaming, boiling, braising, stewing, and blanching methods with less oil should be selected.

　　3. The intake of fat should be strictly limited to 20 grams per day, gradually transitioning to 40 grams per day.

　　4. Reduce the use of foods that are prone to bloating, such as radishes, onions, coarse grains, and dried beans. Avoid刺激性食物, such as alcohol and animal internal organs, and duck stuffed with rice, etc.

　　5. More easily digestible carbohydrates, such as brown sugar, sucrose, and honey, should be selected. Since carbohydrates are the main source of energy, more than 300 grams can be given daily. Eat less and more frequently, 4 or 5 times a day, to prevent overeating and overdrinking.

　　The Western medical treatment methods for pancreatic stone disease include non-surgical treatment, surgical treatment, and treatment of complications, as follows:

　　First, non-surgical treatment

　　1. Symptomatic treatment: When symptoms occur, fasting or low-fat diet should be avoided to reduce the stimulation of pancreatic secretion. Maintain water and electrolyte balance. Appropriately use antispasmodic analgesics, pancreatic secretion inhibitors, pancreatic enzyme preparations, and traditional Chinese medicine. Broad-spectrum antibiotics should be used to prevent infection if necessary. For patients without symptoms or only with pancreatic stone disease found by imaging examination, if there is no manifestation of insufficient exocrine and endocrine function, close follow-up can be performed.

　　2. Litholysis therapy: The main purpose of drug treatment is to dissolve the main components of pancreatic stones to restore the patency of the pancreatic duct. Lohse reported that increasing the concentration of sodium chloride, especially citrate, locally in vitro can increase the solubility of pancreatic stones, so citrus acid can be used orally to treat pancreatic calculi in clinical practice. Noda found that the pancreas can secrete a weak organic acid called dimethyl oxazole dione (DMD), which can increase the solubility of calcium carbonate, the main component of pancreatic stones, allowing the formed microstones to dissolve spontaneously, playing a self-protective role. Therefore, he used the derivative of DMD (trimethyl oxazole dione, TMD, originally an antiepileptic drug) as a litholytic agent to treat pancreatic duct stones and achieved certain therapeutic effects.

　　Since pancreatic juice stasis is also one of the important reasons for the formation of pancreatic stones, some people propose to use pancreatic juice secretion stimulants to increase the secretion of pancreatic juice and reduce its viscosity. This can prevent the formation of protein thrombi on one hand, and flush the thrombi already formed into the intestines on the other hand, which is known as lavage therapy. Such drugs include enteropancreatic enzyme peptide (CCK) or secretin.

　　3. Endoscopic treatment: Utilizing ERCP technology, the Oddi sphincter is incised, and then the catheter is placed into the pancreatic duct to enter a series of treatments, which is a new technology developed in recent years. Stones can be dissolved using litholytic agents through the pancreatic duct catheter, or stones can be retrieved using baskets or balloons. This technology is relatively complex and requires operators to have rich clinical endoscopic experience. When large stones or pancreatic duct stricture causes stones to be difficult to remove, extracorporeal shock wave lithotripsy (ESWL) or spark discharge lithotripsy can be performed first, and the broken stones can be excreted with pancreatic juice. If they still cannot be excreted, endoscopic stone retrieval or dissolution therapy can be performed again. However, whether ESWL and spark discharge cause damage to the pancreatic tissue needs further observation.

　　Some reports have mentioned the placement of a nasopancreatic duct under endoscopy, through which citrate and other appropriate solvents are injected to achieve the purpose of dissolving stones. This method does not cut the Oddi sphincter and can be used repeatedly multiple times with溶石drugs, which has certain advantages and can be tried.

　　2. Surgical Treatment

　　1. Indications:

　　(1) Large stones or impacted stones that cannot be removed by endoscopic treatment.

　　(2) Symptoms are severe, and non-surgical treatment is ineffective.

　　(3) Clinically, cancer cannot be ruled out.

　　2. Surgical Methods:

　　(1) Surgical procedures for pancreatic duct calculi: Depending on the different locations of the stones in the pancreas, different surgical procedures are adopted. Directly incise the pancreatic tissue and pancreatic duct on the surface of the stones, and remove the stones. This method is suitable for stones located at the junction of the body and neck of the pancreas, with no obstruction in the proximal pancreatic duct. Since the pancreatic tissue here is thin, the pancreatic duct is in front, and it is easy to palpate during surgery. After stone removal, the incision can be directly sutured or a Roux-en-Y anastomosis of the pancreatic duct with the jejunum can be performed, using the pancreatic duct wall and jejunal mucosa anastomosis technique.

　　(2) Stone removal through incision of the pancreatic parenchyma: If stones are not palpated during surgery, the pancreatic duct can be incised at the site of expansion of the pancreatic duct, and stones can be removed with a stone forceps or spatula. After that, perform a contrast study to ensure that there are no residual stones and that the proximal pancreatic duct is patent, and then perform a Roux-en-Y anastomosis of the pancreatic duct with the jejunum.

　　(3) Resection of the body and tail of the pancreas: Appropriate for pancreatic duct calculi or实质calcification in the body and tail of the pancreas, followed by a Roux-en-Y anastomosis of the body and tail of the pancreas with the jejunum (Duval procedure).

　　(4) Pancreaticoduodenectomy or total pancreatectomy: Appropriate for pseudolithiasis of the head and body of the pancreas or extensive and diffuse pseudolithiasis of the whole pancreas. However, this procedure is complex, has a large trauma, and has many and severe postoperative complications, so it must be used with caution, especially since total pancreatectomy has been abandoned.

　　3. Surgical Procedures for Complications

　　If a pseudocyst of the pancreas forms, a Roux-en-Y anastomosis of the cyst with the jejunum can be performed. If there is a malignant transformation, it should be treated as pancreatic cancer.

　　3. Treatment of Complications

　　For patients with concurrent diabetes, drug and insulin therapy can be used. For those with concurrent liver disease or peptic ulcer, treatment should be based on the principle of the primary disease.