A 40-year-old female complaining of epigastric pain, was diagnosed with acute pancreatitis and admitted at local hospital. After recovery she was referred to our hospital for further examinations of dilatated common bile duct (CBD) and SOL in the head of pancreas.
MRCP showed dilatated CBD and SOL with low signal intensity on T2-weighted image in the main pancreatic duct (MPD) . EUS revealed 13.3 × 8.3 mm-sized isoechoic SOL with distal acoustic shadowing in the MPD, considered as pancreatic stone. In ERCP, we diagnosed as pancreaticobiliary malformation and found impaction of stone in MPD. So we performed endoscopic sphincterotomy (EST) and placed endoscopic nasal biliary drainage (ENBD) tube and endoscopic pancreatic stent. Biliary juice sampling through ENBD tube contained very high level of pancreastic enzyme (amylase : 16,032 U/L, lipase : 107,964 U/L) . For replacing ENBD tube to internal biliary stent, second ERCP was performed. Then we recognized divided stones and succeeded to remove stones by balloon catheter. Stones were milky white and compatible with protein plug as suspected.
