Immunological diseases of the pancreatico-hepatobiliary system: update on etiopathogenesis and cross-sectional imaging findings

Magnetic resonance imaging findings in autoimmune hepatitis: how frequent and reproducible are they?

Objective

To determine the frequency and interobserver reproducibility of the magnetic resonance imaging (MRI) features considered diagnostic for autoimmune hepatitis.

Materials and Methods

Two abdominal radiologists, blinded to pathology data, reviewed the MRI examinations of 20 patients with autoimmune hepatitis, looking for liver enhancement, lymphadenopathy, portal hypertension, and chronic liver disease. The pattern of liver fibrosis was categorized as reticular, confluent, or mixed. Interobserver agreement was assessed by calculating intraclass correlation coefficients and kappa statistics.

Results

The most common abnormal finding on MRI was surface nodularity (in 85%), followed by liver fibrosis with a reticular pattern (in 80%)-categorized as mild (in 25.0%), moderate (in 43.8%), or severe (in 31.2%)-; heterogeneous liver enhancement (in 65%); splenomegaly (in 60%); caudate lobe enlargement (in 50%); and lymphadenopathy (in 40%). The interobserver agreement was almost perfect for surface nodularity (0.83), ascites (0.89), and liver volume (0.95), whereas it was just slight and fair for the degree of fibrosis and for heterogeneous liver enhancement (0.12 and 0.25, respectively). It was also slight and fair for expanded gallbladder fossa and enlarged preportal space (0.14 and 0.36, respectively), both of which are indicative of chronic liver disease.

Conclusion

The interobserver agreement was satisfactory for surface nodularity (the most prevalent abnormal MRI finding), ascites, liver volume, and splenomegaly. Conversely, it was only slight or fair for common but less objective criteria.

Intrahepatic diffuse periportal enhancement patterns on hepatobiliary phase gadoxetate disodium-enhanced liver MR images: Do they correspond to periportal hyperintense patterns on T2-weighted images?

The purpose of this study was to investigate the findings of diffuse periportal enhancement in the liver on hepatobiliary phase gadoxetate disodium-enhanced magnetic resonance images by comparing with the finding of periportal hyperintensity on T2-weighted images and to reveal their clinical significance.Nineteen consecutive patients with diffuse periportal enhancement on hepatobiliary phase images constituted the study population. The intrahepatic diffuse periportal enhancement finding was assessed on whether it corresponded to periportal hyperintense patterns on T2-weighted images or not in the location, and the cases were classified into 2 groups according to this characteristic. Signal intensities at the periportal areas were also assessed on T1-, T2-, diffusion-weighted and dynamic images. Furthermore, possible associations between these image findings and the final diagnoses were explored.In 7 of the 19 patients, periportal enhancement area corresponded with the periportal hyperintensity area on T2-weighted images. In the remaining 12 patients, the finding of periportal T2-hyperintensity was absent or the periportal enhancement differed from the periportal T2-hyperintensity in the location. Diseases of the former group comprised autoimmune hepatitis, acute exacerbation of chronic hepatitis and acute alcoholic steatohepatitis, and those of the latter group primary sclerosing cholangitis, autoimmune hepatitis-primary biliary cirrhosis overlap syndrome, and liver cirrhosis with miscellaneous etiology.Diffuse periportal enhancement during the hepatobiliary phase did not always correspond to periportal hyperintensity on T2-weighted images. In the classification based on whether enhancement area corresponded or not, each enhancement pattern appeared in different groups of liver diseases. Specifically, the former (corresponding) was associated with active inflammation such as hepatitis and the latter (not corresponding) was predominantly associated with a chronic change such as cirrhosis. Appropriate recognition of these periportal enhancement patterns may contribute to the improved diagnosis of diffuse liver diseases.

Concurrent autoimmune pancreatitis and primary biliary cirrhosis: a rare case report and literature review

Background

Both autoimmune pancreatitis (AIP) and primary biliary cirrhosis (PBC) are related to various diseases. But the concurrence of AIP and PBC is extremely rare, with only 2 cases reported. Here we report the concurrence of AIP and PBC in a Chinese patient for the first time.

Case presentation

A 65-year-old male was admitted to our hospital with jaundice, pruritus, mild abdominal pain and darkening urine. Serum alkaline phosphatase, γ-glutamyltransferase, bilirubin and IgG4 were prominently elevated. The antimitochondrial antibody was positive. Radiological examination revealed diffusive enlargement of the pancreas. Pancreatic biopsy showed lymphoplasmacytic infiltration, fibrosis and abundant IgG4+ plasma cells. The patient was diagnosed with AIP and PBC. Nasobiliary tube was placed to facilitate biliary drainage. A combination therapy of steroid and UDCA was administered and the patient was gradually recovered, during which the patient was complicated with biliary infecion, herpes zoster and pulmonary abscess.

Conclusion

We present this case together with literature evidence to support the concurrence of AIP and PBC, share our experience of using combination therapy with steroid and UDCA, and raise the awareness of infectious complications in immunosuppressed patients.