Successful ERCP with Pancreatic Duct Stent Removal in a 17 Y.O. Male with Chronic Calcific Pancreatitis

Chief Complaints

A 17-year-old male patient with a body mass index (BMI) of 18 presented to the Gastroenterology Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of severe epigastric pain radiating to the back for the past three days. The pain had progressively worsened and was associated with mild nausea. The patient denied vomiting, fever, or jaundice. He had a known history of recurrent episodes of acute pancreatitis with similar symptoms in the past.

The patient had a history of recurrent acute pancreatitis and had previously undergone Endoscopic Retrograde Cholangiopancreatography (ERCP) with pancreatic duct stenting for pancreatic duct obstruction. He had no known history of drug or food allergies and no significant family history of pancreatic or gastrointestinal disorders.

On examination, the patient was conscious, coherent, oriented, and hemodynamically stable. Abdominal examination revealed tenderness over the epigastric region without guarding, rigidity, palpable masses, or organomegaly. There were no clinical features suggestive of jaundice or systemic infection. The remaining systemic examination was normal.

Upon admission to PACE Hospitals, following a detailed clinical assessment, the Gastroenterology team evaluated the patient for recurrent episodes of severe epigastric pain radiating to the back, along with a history of recurrent acute pancreatitis and previous endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic duct stenting.

Clinical evaluation, laboratory investigations, and Magnetic Resonance Cholangiopancreatography (MRCP) were performed to determine the cause of the recurrent symptoms. The investigations revealed chronic calcific pancreatitis with incomplete pancreas divisum, accompanied by pancreatic duct calcifications and mild ductal dilatation. Mildly elevated serum amylase and lipase levels supported ongoing pancreatic inflammation, while liver function tests and complete blood count were within normal limits.

Based on the confirmed diagnosis, the patient was advised to undergo Chronic Calcific Pancreatitis Treatment in Hyderabad, India, along with Incomplete Pancreas Divisum under the expert care of the Gastroenterology Department to restore pancreatic duct drainage, relieve ductal obstruction, and reduce the risk of recurrent pancreatitis episodes.

After a detailed consultation with Dr. Govind Verma, (interventional gastroenterologist, transplant hepatologist, pancreatologist and endosonologist) along with cross consultation with Dr. M. Sudhir, (senior gastroenterologist and hepatologist), a comprehensive evaluation was performed to determine the most appropriate diagnostic and therapeutic approach.

Considering the patient's history of recurrent acute pancreatitis, previous ERCP with pancreatic duct stenting, persistent epigastric pain, and MRCP findings of chronic calcific pancreatitis with incomplete pancreas divisum, further evaluation confirmed pancreatic duct calcifications with mild ductal dilatation, suggestive of impaired pancreatic drainage. Routine laboratory investigations revealed mildly elevated serum amylase and lipase levels, while liver function tests, complete blood count, and other baseline parameters were within normal limits.

Based on the clinical assessment, imaging findings, and laboratory investigations, it was determined that Endoscopic Retrograde Cholangiopancreatography (ERCP) with pancreatic duct stent removal under appropriate anesthesia was the most appropriate and effective management strategy. This approach was chosen to remove the previously placed pancreatic duct stent, evaluate the pancreatic duct, restore pancreatic drainage, relieve ductal obstruction, reduce recurrent pancreatic inflammation, and minimize the risk of future episodes of pancreatitis while preserving pancreatic function.

The patient and his family members were counselled regarding the diagnosis, clinical findings, planned endoscopic procedure, expected benefits, potential risks, and the importance of postoperative care, dietary modifications, and regular follow-up.

Following the decision, the patient was scheduled for Endoscopic Retrograde Cholangiopancreatography (ERCP) with pancreatic duct stent removal in Hyderabad at PACE Hospitals, under the expert care of the Surgical Gastroenterology Department.

The following steps were carried out during the procedure:

• Patient Preparation and Anesthesia: The patient was placed in the left lateral position, and the procedure was performed under appropriate anesthesia with continuous monitoring of vital signs. A therapeutic duodenoscope was gently introduced through the mouth and advanced into the second part of the duodenum to identify the major papilla.

• Pancreatic Duct Cannulation and Stent Identification: The pancreatic duct was selectively cannulated under fluoroscopic guidance. The previously placed pancreatic duct (PD) stent was identified, and pancreatography was performed to assess the ductal anatomy, confirming adequate access to the pancreatic duct.

• Pancreatic Duct Stent Removal: Using endoscopic retrieval devices, the pancreatic duct stent was carefully grasped and removed under direct endoscopic and fluoroscopic visualization. The stent was extracted successfully without causing ductal injury or procedural complications.

• Pancreatic Duct Evaluation: Following stent removal, the pancreatic duct was re-evaluated fluoroscopically to assess ductal patency and identify any residual obstruction, strictures, or calculi. No significant residual obstruction or retained stones were detected, and no additional endoscopic intervention was required.

• Completion of Procedure and Post-Procedure Monitoring: The duodenoscope was withdrawn after confirming satisfactory pancreatic duct drainage and hemostasis. The patient was transferred to the recovery area for observation, with close monitoring for post-ERCP complications such as pancreatitis, bleeding, or perforation before resuming oral intake and subsequent discharge planning.
  

Following ERCP-guided pancreatic duct stent removal, the patient was closely monitored for potential post-procedural complications, including abdominal pain, fever, vomiting, bleeding, or signs of pancreatitis. Supportive treatment was provided to relieve pain, reduce gastric irritation, prevent infection, and maintain adequate hydration. The patient was gradually advanced to oral feeding as tolerated and was advised to follow a low-fat, balanced diet to reduce stress on the pancreas and help prevent recurrent pancreatitis. Continuous assessment of vital signs and abdominal examination ensured an uneventful recovery before discharge.

At discharge, the patient was prescribed medications to prevent post-procedural infection, relieve pain as needed, reduce gastric irritation, and support gastrointestinal healing during recovery. Nutritional supplementation was also advised to help maintain adequate nutritional status and support pancreatic function. The patient was instructed to take all medications as prescribed and to report immediately if symptoms such as worsening abdominal pain, persistent vomiting, fever, or inability to tolerate oral intake developed.

The patient was advised to follow a low-fat, balanced diet, stay well hydrated, and gradually resume normal activities while avoiding strenuous exertion. He was instructed to seek immediate medical attention if he developed severe abdominal pain, persistent vomiting, fever, or jaundice.

The patient was informed to contact the emergency ward at PACE Hospitals in case of any emergency or development of symptoms such as severe or persistent abdominal pain, fever, persistent vomiting, jaundice, inability to tolerate oral intake, or any signs of gastrointestinal bleeding.

The patient was advised to return for a follow-up visit with the Gastroenterologist in Hyderabad at PACE Hospitals after 1 month.

This case highlights the successful management of chronic calcific pancreatitis with incomplete pancreas divisum through timely ERCP-guided pancreatic duct stent removal, resulting in restoration of pancreatic duct drainage and significant symptom relief. A multidisciplinary approach, combined with appropriate postoperative care and long-term lifestyle modifications, helped optimize recovery and reduce the risk of recurrent pancreatitis.