Dissolution of Pancreatic Lithiasis by Direct Citrate Application into the Pancreatic Duct in Two Patients with Chronic Idiopathic Pancreatitis

Abstract

Several experimental and clinical studies have shown that citrates are useful in dissolving calcifications and proteic plug in pancreatic ducts both of alcoholic etiology and in patients with chronic pancreatitis. Until now, using citrates to dissolve stones in clinical studies was performed orally with satisfactory medium-term results, including control of abdominal pain and eradication of shadows on X-rays. Laboratory studies have shown that these concretions dissolve quickly when such compounds are applied directly. This paper reports 2 women aged 27 and 40 with histories of chronic abdominal pain, and who, by abdominal X-ray and endoscopic retrograde cholangiopancreatography (ERCP), were shown to have multiple calcifications in the main and accessory pancreatic ducts. In both patients, endoscopic sphincterotomy of the bile and pancreatic segments of the sphincter of Oddi and introduction of a nasopancreatic catheter and intraductal infusion of citrates were performed. Radiological controls showed fragmentation and disappearance of calcifications. Clinically, there was complete absence of abdominal pain in the first week following the procedure. This is the first human study of intraductal administration of citrates to dissolve pancreatic lithiasis with highly favorable results.

Chronic Pancreatitis with Spontaneously Disappearing Calcifications

“…The disappearance of calcifications classically occurs in association with ductal drainage procedures, such as the Puestow procedure, either due to active removal of stones or postoperative passage of stones through pancreaticojejunostomy. Studies have also shown associations with intraductal citrate administration as well as oral trimethadione administration 6,7. Spontaneous disappearances, as described in this case, are uncommon.…”

“…However, a spontaneous decrease in pancreatic calcifications has only rarely been described 4 , 5. More recently, although not spontaneous, the disappearance has been demonstrated to occur following intraductal citrate administration as well as after oral trimethadione administration 6 , 7…”

Recovery of ΔF508-CFTR Function by Citrate

“…Low citrate in other tissues such as kidney again decreases extracellular hyaluronan required for Ca 2+ complexation and solubilization, causing lithiasis in cystic fibrosis patients [ 39 , 40 , 41 , 42 ]. Patients thus remain in a vicious cycle, unless they are treated by citrate as a food additive for stone solubilization [ 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 ]. Citrate is freely available in the supermarket and also a nutritional additive for treatment of lithiasis.…”

Acidic and Basic Solutions Dissolve Protein Plugs Made of Lithostathine Complicating Choledochal Cyst/Pancreaticobiliary Maljunction

“…A promising clinical application of these results for choledochal cysts is the direct dissolution of protein plugs through a biliary drainage tube using these organic acids. Güitrón et al reported an effective application of citric acid directly injected into the pancreatic duct for the dissolution of pancreatic stones [13]. The use of citric acid is also considered safe for children with choledochal cysts.…”