case_images: PMC8825244_01
case_images: The pancreas is markedly hypoechoic and contains two large rounded hyperechoic shadowing structures (measured at 0.59 cm and 0.66 cm, respectively), identified as pancreatoliths
case_images: 10.1177_2055116921998494-fig1.jpg
case_images: PMC8825244_01_10.1177_2055116921998494-fig1.jpg
case_images: fig1-2055116921998494
case_images: The pancreas contained multiple pancreatoliths (measuring between 0.4 cm and 0.7 cm) located both intraparenchymally and within the pancreatic duct (Figure 1).
case_images: Left lateral abdominal radiograph. Three well-defined rounded mineral opacities are visible caudal to the stomach, in the region of the pancreas. Note the focal lack of serosal detail in the cranial abdomen, just caudal to the liver
case_images: 10.1177_2055116921998494-fig2.jpg
case_images: PMC8825244_01_10.1177_2055116921998494-fig2.jpg
case_images: fig2-2055116921998494
case_images: Abdominal radiography documented the presence of three large mineral opacities in the region of the pancreas (Figure 2).
case_images: Left limb of pancreas at second presentation. Note the marked enlargement of the pancreatic limb, multiple hyperechoic structures within the pancreatic parenchyma and the markedly hyperechoic surrounding mesentery
case_images: 10.1177_2055116921998494-fig3.jpg
case_images: PMC8825244_01_10.1177_2055116921998494-fig3.jpg
case_images: fig3-2055116921998494
case_images: Abdominal ultrasonography documented a markedly enlarged, heterogeneous, hypoechoic pancreas with undulating margins and several pancreatoliths within the parenchyma (Figure 3), surrounded by markedly hyperechoic mesentery.
case_images: The measured tubular anechoic structure is a sagittal image of the pancreatic duct in the right limb of the pancreas. It is markedly dilated, filled with anechoic fluid and to the right of the image there is a large rounded hyperechoic shadowing structure within the pancreatic duct
case_images: 10.1177_2055116921998494-fig4.jpg
case_images: PMC8825244_01_10.1177_2055116921998494-fig4.jpg
case_images: fig4-2055116921998494
case_images: A pancreatolith 0.4 cm in diameter was visible within the duct of the left pancreatic limb and a pancreatolith 0.5 cm in diameter was present within the duct of the right pancreatic limb, which was markedly dilated to 0.41 cm (Figure 4).
case_images: Pancreas. The pancreatic parenchyma is multifocally to coalescing replaced by abundant collagen (fibrosis) (asterisk), which is infiltrated and surrounded by moderate numbers of lymphocytes, plasma cells and viable, non-degenerate neutrophils, which expand the interlobular and intralobular septa. Pancreatic acini within the lobules are markedly reduced in size (atrophy) (arrowhead) and compressed by fibrosis and inflammatory cells. Few pancreatic acini are markedly ectatic (arrow) and contain moderate viable, non-degenerate neutrophils
case_images: 10.1177_2055116921998494-fig5.jpg
case_images: PMC8825244_01_10.1177_2055116921998494-fig5.jpg
case_images: fig5-2055116921998494
case_images: Marked pancreatic acinar atrophy affecting 95% of the pancreatic parenchyma was present and the inter- and intralobular septa of the pancreas were expanded by high numbers of small and medium-sized lymphocytes, plasma cells and neutrophils (Figure 5).
case_images: Liver. The picture shows a portal tract. The portal tract is expanded by moderate numbers of small mature lymphocytes and plasma cells (asterisk), which frequently surround and cross small bile ducts (arrow). The lumen of few bile ducts contains small amount of necrotic debris. Adjacent hepatocytes are mildly swollen and vacuolated (hepatocellular degeneration) (arrowhead)
case_images: 10.1177_2055116921998494-fig6.jpg
case_images: PMC8825244_01_10.1177_2055116921998494-fig6.jpg
case_images: fig6-2055116921998494
case_images: Moderate cholangitis was identified with evidence of biliary ductular proliferation and hyperplasia, portal fibrosis and a lymphoplasmacytic inflammation present in the biliary epithelium and lumen of the bile ducts and expanding the portal tracts (cholangiohepatitis) (Figure 6).  