Autoimmune pancreatitis associated with a large pancreatic pseudocyst that disappeared after corticosteroid therapy: a case report and literature review

Auto-immune pancreatitis with unusual presentations - A case series

Auto-immune pancreatitis (AIP) is a rare benign disease commonly presented with painless obstructive jaundice and biliary obstruction with rare complications like pseudocyst. We present a case series of two patients of AIP with unusual presentations; one case presented with periorbital swelling, jaundice, and pseudocyst, and the other case presented with abdominal pain and biliary obstruction without jaundice; both showed good response with steroids.

Immunoglobulin G4-related Pleuritis Complicated with Minimal Change Disease

A 70-year-old woman with bilateral pleural effusion and respiratory failure was admitted to our hospital. Nephrotic syndrome due to minimal change disease had been diagnosed four months before admission. Because blood tests and a pleural fluid analysis did not reveal the etiology of her condition, we performed a video-assisted thoracoscopic pleural biopsy. No specific thoracoscopic findings were noted. The pathological findings revealed an increase in immunoglobulin G4 (IgG4)-positive cells; IgG4-related pleuritis was diagnosed. Her pleuritis improved with oral corticosteroid therapy. A further investigation was performed on previous kidney samples; however, the etiology of the nephrotic syndrome was not IgG4-related disease but minimal change disease.

Diagnostic imaging guide for autoimmune pancreatitis

The International Consensus Diagnosis Criteria for autoimmune pancreatitis (AIP) has been published internationally for the diagnosis of AIP. However, since the revisions in 2006 and 2011, the Clinical Diagnostic Criteria for Autoimmune Pancreatitis 2018 have been published. The criteria were revised based the Clinical Diagnostic Criteria 2011, and included descriptions of characteristic imaging findings such as (1) pancreatic enlargement and (2) distinctive narrowing of the main pancreatic duct. In addition, pancreatic duct images obtained by magnetic resonance cholangiopancreatography as well as conventional endoscopic retrograde pancreatography were newly adopted. The guideline explains some characteristic imaging findings, but does not contain descriptions of the imaging methods, such as detailed imaging parameters and optimal timings of dynamic contrast-enhanced computed tomography/magnetic resonance imaging. It is a matter of concern that imaging methods can vary from hospital to hospital. Although other characteristic findings have been reported, these findings were not described in the guideline. The present paper describes the imaging methods for obtaining optimal images and the characteristic imaging findings with the aim of standardizing image quality and improving diagnostic accuracy when radiologists diagnose AIP in actual clinical settings.

Effectiveness of steroid therapy for pancreatic cysts complicating autoimmune pancreatitis and management strategy for cyst-related complications

Objectives: Autoimmune pancreatitis (AIP) sometimes becomes complicated with pancreatic cysts, although their detailed characteristics and management strategy have not been fully determined. We aimed to clarify the efficiency of steroid therapy and the risk factors for cyst formation and cyst-related complications. Methods: One hundred sixty-three AIP patients were retrospectively analyzed for relevant factors of cyst formation. We compared subjects with and without steroids to evaluate drug effectiveness on cyst size change and investigated the factors associated with cyst-related complications. Results: Thirty-two patients (19.6%) had complicating pancreatic cyst formation, and 40 cystic lesions of ≥10 mm in size were detected. Multivariate analysis revealed a drinking habit, abdominal/back pain, and elevated serum amylase to be significantly associated with cyst formation. Steroid-treated cysts became significantly reduced in size in the short-term and disappeared significantly more frequently within 1-year as compared with non-treated ones, which was confirmed by multivariate analysis. Six of 40 cysts exhibited cyst-related complications significantly associated with multilocular morphology and larger size. Conclusions: Steroid therapy is an effective choice for cysts developing in AIP to promote the release of pancreatic juice stasis. Larger lesions with multilocular morphology should be monitored closely for cyst-related complications and be considered strong candidates for steroid therapy.

Autoimmune Pancreatitis Type 1 Associated with a Pancreatic Pseudocyst

Pancreatic cystic lesions comprise diverse entities with different histopathological characteristics. Differential diagnosis is often challenging. Autoimmune pancreatitis (AIP) is usually not considered an underlying pathology in the differential diagnosis of peri-/pancreatic pseudo-/cystic lesions. We report the case of a 73-year-old male with diffuse pancreatic enlargement and an adjacent cystic lesion (60 × 80 mm) on computed tomography scan. Based on these imaging findings and an elevated serum IgG4 concentration, AIP complicated by a pancreatic pseudocyst was diagnosed, and treatment with glucocorticoids was started. Regular follow-ups showed a good response to treatment with regression of the pancreatic pseudocyst and remittent pancreatic swelling.

Pancreatic Pseudocysts and Parenchymal Necrosis in Patients With Autoimmune Pancreatitis: A Systematic Review

OBJECTIVE

To investigate the prevalence and natural history of pancreatic pseudocysts (PCs) and parenchymal necrosis in autoimmune pancreatitis (AIP).

METHOD

A search using PubMed, Embase, Scopus, and Cochrane was performed. Search terms were AIP, PC, acute fluid collection, and pancreatic necrosis.

RESULTS

Fifteen studies with 17 patients were included. In 8 of 17 patients, PC was noted concurrently with the AIP diagnosis, whereas in the other half, PC appeared months or years after. In 10 of 17 cases, PC appeared as solitary. The location was variable. Pseudocysts were small (<3 cm) in 4 cases and large (>3 cm) in 13 cases. A normal pancreatic duct was observed in 6 of 17 cases, whereas 9 of 17 had pancreatic duct stenosis. Steroids were given to 4 of 4 small and 10 of 13 large PC. All small PC resolved with steroids, whereas only 4 of 10 large PC treated had some response. Most (9/13) of large PC underwent endoscopic or surgical procedures. None of the 17 cases developed necrosis.

CONCLUSIONS

Pseudocysts in AIP are rare. Pancreatic pseudocyst can present in variable number, size, and location. Small PC resolved with steroids. Large PC had poor response to steroids requiring invasive interventions. Necrosis in AIP has not been reported.

Disappearance of multiple pancreatic cysts after prednisolone treatment in a patient with autoimmune pancreatitis

Autoimmune pancreatitis (AIP) with multiple pancreatic cysts is rare. The severe narrowing of the branched pancreatic ducts found in active AIP with a chronic pancreatitis background may have caused pancreatic juice outflow obstruction, resulting in multiple cysts. Oral steroid therapy resolved the stenosis, resulting in disappearance of the cysts.

The Role of Endoscopic Ultrasound-guided Drainage for Autoimmune Pancreatitis-associated Pancreatic Cysts: A Report of Five Cases and a Literature Review

Objective Autoimmune pancreatitis (AIP) has been recognized as a benign disease, which that shows a prompt response to corticosteroid treatment (CST). It was previously believed to not be associated with cyst formation; however, a few cases of AIP-associated pancreatic cyst (PC) have been reported. Some cases were reported to have been effectively treated by CST, while others were refractory to CST. Many of the patients received interventional treatment. Until now, there has been no consensus on the therapeutic strategies for AIP-associated PC. The aim of the present study is to describe a therapeutic strategy for this condition. Methods We conducted a retrospective study of 5 cases of AIP-associated PC that were treated by endoscopic ultrasonography-guided pancreatic fluid collection drainage (ESPD) or CST at Tokyo Medical University Hospital between March 2012 and October 2016, analyzed the therapeutic outcomes, and performed a literature review. Results The initial treatments included CST (n=2) and ESPD (n=3). All of the PCs disappeared after treatment In 1 of the patients who received CST case and 3 of the patients who received ESPD; however, the PC did not disappear in one of the patients who received CST (corticosteroid maintenance therapy), even after the dose of corticosteroids was increased; ESPD was eventually performed and the PC disappeared. There were no procedure-related complaints. Conclusion We propose that CST be administered as the first-line treatment for AIP-associated PC, particularly in cases of PC without a history of CST. However, ESPD can be applied to treat cases of corticosteroid refractory PC.

Autoimmune pancreatitis complicated by an infected pseudocyst

A 53-year-old man was admitted due to upper abdominal pain. He had been diagnosed with autoimmune pancreatitis (AIP) 4 years previously and had been taking steroids for maintenance therapy since that time. Abdominal computed tomography revealed multiple pseudocysts in the head of the pancreas and a dilated pancreatic duct with mottled calcifications around the pseudocyst. Despite the continuation of steroid therapy for 4 months, the size of the pseudocyst increased further and diffuse calcifications developed throughout the pancreas. He was readmitted due to severe abdominal pain and a high fever, and endoscopic drainage of the pancreatic pseudocyst was performed. Two months after the internal drainage, the pseudocyst disappeared and his symptoms subsided. There are few reports concerning AIP complicated by the formation of pseudocysts. We report this case to emphasize that AIP can be complicated by the development of pseudocysts with progression to chronic pancreatitis, accompanied by multiple calcifications.