Chronic alcoholic pancreatitis - is the most common cause of pancreatic calcifications.

      The ducts become obstructed by proteinaceous  plugs that can eventually accumulate calcium carbonate. This obstruction results in  ductal ectasia and periductal fibrosis.

The calculi occur in ducts of all sizes and vary from microscopic to greater than 1 cm in diameter.

   The radiographic appearance is generally that of numerous irregular small calcifications throughout the pancreas .

 The head of the pancreas is usually involved more prominently than the tail. The degree of calcification appears to parallel the course of the disease .

 a)hyperparathyroidism

b) tropical pancreatitis,

c) idiopathic pancreatitis   ,  causes pancreatic calcification.

2) Developmental

Although hereditary pancreatitis is rare, it is a well-known cause of pancreatic calcifications in the pediatric population

1) Hereditary pancreatitis has an autosomal dominant pattern of inheritance with an estimated 80% penetrance

2. It generally manifests itself during childhood with a peak incidence at 5 years old. However, a second peak at 17 years old may be    attributable to the introduction of alcohol in the diet.

3 .Intraductal calcifications occur in approximately 50% of patients. These stones have a characteristic large, rounded appearance

4) Along with hereditary pancreatitis, cystic fibrosis accounts for most of the pancreatic calcifications in children.

     Cystic fibrosis is an autosomal recessive disease , The most common finding on CT is fatty replacement of the pancreas..

 

3) Neoplasms 

a)The most common primary pancreatic tumor, ductal adenocarcinoma, characteristically does not calcify. However, pancreatic carcinoma may develop in a pancreas with underlying chronic calcific pancreatitis . Or, calcifications may develop in the setting of chronic pancreatitis from an obstructing ductal adenocarcinoma .

b)Islet cell tumors are known for the presence of tumoral calcifications A greater percentage of the nonhyperfunctioning variety develop tumoral calcifications. These calcifications tend to be focal, coarse, irregular, and located relatively centrally in a large pancreatic mass . However, insulinoma, which is the most common functioning islet cell tumor, may contain calcifications in up to 20% of cases.
 

c) Intraductal papillary mucinous neoplasms-
Although not commonly seen, dystrophic calcifications may develop in the mucus .

d) Mucinous cystic neoplasms have been previously referred to as mucinous or macrocystic cystadenomas or cystadenocarcinomas-

Calcifications occur in the cyst wall or septa and tend to be curvilinear .

e) Serous cystadenomas, also called microcystic adenomas, are considered a benign pancreatic neoplasm .The pattern of calcification is characteristic of a central calcified scar with calcified septations radiating outward, resulting in a sunburst pattern..

f) Solid and pseudopapillary epithelial neoplasms are rare tumors found almost exclusively in young women. Calcification of these tumors  is common ,. The calcification is characteristically peripheral and frequently punctate.

 

g) Metastases to the pancreas are uncommon. The most common sources are breast, lung, kidney, melanoma, and colon cancer. Calcifications have been reported in cases of metastatic renal cell carcinoma and metastatic colon carcinoma . Another uncommon pancreatic tumor, the pancreatoblastoma, can develop calcifications in 20% of cases .

4) Senescent

Occasionally, intraductal calculi occur in the older population with no identifiable cause, (These idiopathic calculi are rarely seen in patients less than 70 years old, with their incidence increasing with age)

The calculi occur in the peripheral ducts and are generally 1-3 mm. They can cause atrophy and fibrosis of the pancreas as a result of duct obstruction.

1)Plain radiographs- show pancreatic calcification in 25-59% of patients. This feature is pathognomonic for chronic pancreatitis.

2)Ultrasonography- is the first modality to be used in patients presenting with upper abdominal pain, although the direct diagnosis of chronic pancreatitis is not always possible.

 Sonography can help in determining the cause of chronic pancreatitis (eg, alcoholic liver disease, calculus disease) and in assessing the complications of the disease (eg, pseudocysts, ascites, splenic/portal venous obstruction).

-is a noninvasive technique. MRI provides excellent images that may show the changes in the diseased pancreas and the complications of chronic pancreatitis. The use of secretin with MRCP can demonstrate pancreatic exocrine reserve, as well as a "santorinocele" (ie, a dilated Santorini duct seen in pancreas divisum).

4)CT is excellent for imaging of the retroperitoneum, and it is useful in differentiating chronic pancreatitis from pancreatic carcinoma