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Crowning Pancreatic Stone in a Pediatric Patient

Mackey, Kimberly A.; Fishman, Douglas S.

Journal of Pediatric Gastroenterology and Nutrition: November 2013 - Volume 57 - Issue 5 - p e27
doi: 10.1097/MPG.0b013e318258c124
Image of the Month

Texas Children's Hospital; Baylor College of Medicine, Houston, TX.

Address correspondence and reprint requests to Douglas S. Fishman, MD, Texas Children's Hospital, Baylor College of Medicine, Houston, TX 77030 (e-mail:

Submissions for the Image of the Month should include high-quality TIF endoscopic images of unusual or informative findings. In addition, 1 or 2 other associated photographs, such as radiological or pathological images, can be submitted. A brief description of no more than 200 words should accompany the images. Submissions are to be made online at, and will undergo peer review by members of the NASPGHAN Endoscopy and Procedures Committee, as well as by the Journal.

The authors report no conflicts of interest.

A 14-year-old girl with recurrent pancreatitis secondary to cystic fibrosis–related disease (CFTR; L997F homozygous) was hospitalized for abdominal pain and obstructive jaundice. Her laboratory results at presentation were aspartate aminotransferase 449 IU/L, alanine transaminase 509 IU/L, γ-glutamyl transpeptidase 138 IU/L, alkaline phosphatase 113 IU/L, albumin 4.6 mg/dL, unconjugated bilirubin 1.3 mg/dL, conjugated bilirubin 0.0 mg/dL, amylase 573 U/L, and lipase 3911 U/L. Laboratory examination the following morning were alanine transaminase 645, γ-glutamyl transpeptidase 175, alkaline phosphatase 169, and conjugated bilirubin 1.3 mg/dL. Ultrasound showed a dilated common bile duct and pancreatic duct (PD) without earlier evidence of gallstones or choledocholithiasis.

Endoscopic retrograde cholangiopancreatography revealed a crowning pancreatic stone at the ampulla (Fig. 1) and multiple large stones within the PD (Fig. 2), but without stones in the common bile duct. Her PD was uniformly dilated up to 12 mm and had a dilated biliary system up to 15 mm. Biliary and pancreatic sphincterotomies were performed. The pancreatic stones were soft and removed by a 2.5-cm wire basket (Boston Scientific, Natick, MA) followed by placement of a 7-F 7-cm Geneen pancreatic stent (Wilson-Cook, Winston-Salem, NC). Patient had staged stent therapy during the following year and has since reported only 1 episode of pain in the previous 6 months, without evidence of acute pancreatitis or ductal obstruction during a 3-year follow-up period.





Mutations in CFTR are strongly linked to chronic pancreatitis, and a CFTR mutation can be identified in 19% of idiopathic pancreatitis patients (1,2). Obstructing pancreatic stones are an atypical cause of obstructive jaundice in children.

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1. Sharer N, Schwarz M, Malone G, et al. Mutations of the cystic fibrosis gene in patients with chronic pancreatitis. N Engl J Med 1998; 339:645–652.
2. Choudari CP, Imperiale TF, Sherman S, et al. Risk of pancreatitis with mutation of the cystic fibrosis gene. Am J Gastroenterol 2004; 99:1358–1363.
© 2013 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,