A 48-year-old man with 12 years of alcoholic chronic pancreatitis presents with recurrent severe epigastric pain radiating to the back, weight loss, steatorrhea, and new-onset diabetes mellitus. He stopped drinking 2 years ago but symptoms persist. CT abdomen shows a calcified pancreatic parenchyma, dilated main pancreatic duct (8 mm), and multiple intraductal stones (4–6 mm) impacted in the head region. MRCP confirms ductal obstruction with proximal lithiasis. EUS-FNA excludes malignancy. The structure marked **A** in the diagram represents the first-line endoscopic intervention for this patient's obstructive chronic pancreatitis. Which of the following is the PRIMARY GOAL of the procedure marked **A**?
A. Complete dissolution of all pancreatic stones using chemical lithotripsy agents injected into the duct
B. Prevention of pancreatic cancer development by eliminating the chronic inflammatory microenvironment
C. Ductal decompression and relief of main pancreatic duct obstruction to reduce intraductal pressure and abdominal pain
D. Permanent cure of chronic pancreatitis by removing the entire diseased pancreatic parenchyma
Explanation
Why "Ductal decompression and relief of main pancreatic duct obstruction to reduce intraductal pressure and abdominal pain" is right
The procedure marked A (ERCP with pancreatic sphincterotomy and stone extraction) achieves its therapeutic benefit through ductal decompression. According to ESGE guidelines cited in the clinical anchor, the PRIMARY GOAL of endoscopic intervention in obstructive chronic pancreatitis with main pancreatic duct stones is to relieve ductal obstruction, lower intraductal pressure, and thereby reduce pain and slow parenchymal damage. The procedure involves sphincterotomy to widen the papillary orifice, followed by stone extraction using a Dormia basket or balloon catheter, with stent placement to maintain drainage. This directly addresses the pathophysiology: obstruction raises intraductal pressure, which contributes to pain and accelerates exocrine/endocrine insufficiency. Clinical pain response after ductal clearance is 65–85% at 1–2 years.
Why each distractor is wrong
Complete dissolution of all pancreatic stones using chemical lithotrypsy agents injected into the duct: ERCP does not dissolve stones chemically; it extracts them mechanically. Large stones (>5 mm) often require extracorporeal shock wave lithotripsy (ESWL) for fragmentation before endoscopic extraction. Chemical dissolution is not part of standard ERCP technique.
Permanent cure of chronic pancreatitis by removing the entire diseased pancreatic parenchyma: ERCP is a ductal decompression procedure, not a parenchymal resection. It does not cure chronic pancreatitis; it manages symptoms and complications. Pancreatic resection is reserved for failed endoscopic therapy or coexisting head mass (Frey procedure) or suspected malignancy (Whipple), not as a primary goal of ERCP.
Prevention of pancreatic cancer development by eliminating the chronic inflammatory microenvironment: While chronic pancreatitis carries a 4–5% lifetime risk of pancreatic ductal adenocarcinoma, preventing cancer is not the primary goal of ERCP. The goal is symptom relief and ductal decompression. Cancer surveillance is part of long-term management, but ERCP is not performed primarily for cancer prevention.
High-YieldNEET PG
ERCP is first-line for symptomatic main pancreatic duct stones in the head/body; the goal is ductal decompression, not stone dissolution or cure of pancreatitis.
ESGE Guidelines on Endoscopic Therapy in Chronic Pancreatitis, 2019
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