Typical Case 5:Spontaneous Expulsion of Stones A...
Fig.13.15 （a）Endoscopy showed the minor papilla on the descending duodenum.（b）ERCP demonstrated the accessory pancreatic duct well，distortion and deformation in the pancreatic head，irregular dilatation in the pancreatic body and tail，and filling defects in the pancreatic duct.（c）X-ray demonstrated successfully placement of a naso-pancreatic duct via the guidewire
Fig.13.16 （a）Endoscopy showed the stricture near the minor papilla being dilated by bougienage.（b）Endoscopy showed stent placement in the accessory pancreatic duct（8.5 Fr，7 cm）
Fig.13.17 （a）X-ray demonstrated the stricture in the pancreatic head，and irregular dilatation in the pancreatic body and tail.（b）X-ray demonstrated that the stent had successfully passed the stricture of the accessory pancreatic duct
Fig.131.8 CT before the surgery revealed a large number of patchy high-density shadows in the pancreas，and gallbladder distended
Fig.13.19 CT in our hospital revealed fewer patchy high-density shadows in the pancreas and no visualization of the gallbladder
Brief history:a 26-year-old woman complained of recurrent upper abdominal pain for 5 years.In 2007，she presented with paroxysmal epigastric colic radiating to the back concurrently with chills，fever and vomiting under no obvious precipitating causes.Cholecystectomy+pancreatolithotomy + pancreatojejunostomy was performed according to the diagnosis of cholecystitis and chronic pancreatitis with pancreatic stones in the local hospital（Fig.13.18）.After the surgery，similar symptoms occurred annually with subsequent hospitalization each time.In October 2011，CT revealed chronic pancreatitis，diffuse and multiple high-density shadows in the pancreas，and main pancreatic duct dilatation in the body and tail.Therefore，the patient was admitted to our department for further management on 28 January，2012.
Physical examination:soft abdomen without tenderness or rebound tenderness，an 8-cm surgical scar in the upper abdominal.
Laboratory parameters: total bilirubin 21.6 pmol/L，direct bilirubin 9.2 pmol/L，serum amylase 220 U/L，anti-cardiolipin antibody 20.4 RU/mL，normal ranges of blood lipid and HbAlc，a weakly positive result of anti-mitochondrial antibody，negative results of CEA，CA 19-9 and IgG4.
CT:fewer patchy high-density shadows in the pancreas and no visualization of the gallbladder（Fig.13.19）.
Fig.13.20 （a）Endoscopy showed the major papilla on the descending duodenum.（b）Endoscopy showed a 5-cm incision in the major papilla after EPT
Fig.13.21 ERCP demonstrated contrast medium into enteric cavity after injection and no visualization of the biliary and pancreatic ducts(https://www.daowen.com)
Diagnosis:chronic pancreatitis with pancreatic stones，post-cholecystectomy+pancreatolithotomy+pancreatojejunostomy.
Treatment process:ESWL was performed on 30 January，3 February，6 February，7 February and 8 February respectively，followed by ERCP+EPT on 9 February（Figs.13.20 and 13.21）.Stones were collected from the stools 1 week later（Fig.13.22）.
Fig.13.22 The photograph presented pancreatic stones of various shapes and sizes collected from the stools after ESWL and ERCP