Pancreatic duct calculi: pathophysiology and management

PURPOSE OF REVIEW: Pancreatic ductal calculi (PDC) are a defining feature of chronic pancreatitis and contribute significantly to morbidity through pain and ductal obstruction. This review provides a timely update on the evolving understanding of PDC pathogenesis and highlights current and emerging strategies for their management. RECENT FINDINGS: Stone formation in chronic pancreatitis is multifactorial, involving altered pancreatic juice composition, reduced lithostatic proteins, genetic predispositions, and environmental risk factors such as alcohol and smoking. Advances in endoscopic techniques, particularly the combination of extracorporeal shock wave lithotripsy (ESWL) and endoscopic retrograde cholangiopancreatography (ERCP), have improved ductal clearance and symptom control. Pancreatoscopy-guided lithotripsy is gaining traction in complex cases. Surgical options such as longitudinal pancreatojejunostomy and head resection remain vital in patients with extensive disease or failed endoscopic therapy, with evidence supporting superior long-term pain relief when performed early. SUMMARY: Management of PDC requires a multidisciplinary, personalized approach. Endoscopic therapy is the first-line intervention in most cases, while surgery offers durable benefits in select patients. Future directions include identifying biomarkers for early intervention, refining patient selection, and exploring pharmacological strategies to prevent stone formation and recurrence.