Diagnosis of autoimmune pancreatitis with intraductal biliary biopsy and treatment of stricture with serial placement of multiple biliary stents

Pancreatitis-related benign biliary strictures: a review of imaging findings and evolving endoscopic management

Biliary strictures can be secondary to a gamut of etiologies, most of which are malignant and the remaining related to a host of benign causes, including pancreatitis. Pancreatitis related benign biliary strictures (BBS) primarily involve the distal common bile duct (CBD) and can be seen in acute and chronic pancreatitis as well as their other forms, including necrotizing, groove, and autoimmune pancreatitis. Patients with pancreatitis related BBS present along a wide clinical spectrum that spans from an asymptomatic state to biliary obstruction, which not uncommonly facilitates additional workup for malignancy and endoscopic evaluation and treatment. Furthermore, the location and appearance of these strictures lends itself to various imitating benign and malignant etiologies. In this article, we will discuss the pathophysiology and clinicoradiologic features of pancreatitis related BBS while providing a review of an approach to their management focusing on endoscopic techniques.

Autoimmune pancreatitis: role of endoscopy in diagnosis and treatment

This review addresses the role of endoscopy in the diagnosis and treatment of autoimmune pancreatitis (AIP) and provides a diagnostic process for patients with suspected AIP. When should AIP be suspected? When can it be diagnosed without endoscopic examination? Which endoscopic approaches are appropriate in suspected AIP, and when? What are the roles of diagnostic endoscopic retrograde pancreatography, endoscopic biopsies, and IgG4 immunostaining? What is the proper use of the steroid trial in the diagnosis of AIP in patients with indeterminate computed tomography imaging? Should biliary stenting be performed in patients with AIP with obstructive jaundice?

IgG4-associated cholangitis

IgG4-associated cholangitis is the hepatobiliary manifestation of a recently characterized inflammatory systemic disease, associated with increased IgG4 serum levels and IgG4-positive lymphoplasmacytic infiltration. Often, patients present with obstructive jaundice, and imaging reveals stenoses of the extrahepatic or intrahepatic bile ducts, often in association with parenchymal pancreatic findings and irregularities of the pancreatic duct. The histologic findings include lymphoplasmacytic infiltrates, on occasion resulting in tumefactive lesions (which can mimic malignancy), obliterative phlebitis, and fibrotic changes. Steroid treatment is the mainstay of management, but relapse is common after discontinuation of therapy or during tapering of steroids and may require further treatment.

Nonneoplastic mimickers of pancreatic neoplasms

CONTEXT

A variety of nonneoplastic conditions may form pancreatic masses that mimic carcinoma. Approximately 5% to 10% of pancreatectomies performed with the clinical diagnosis of pancreatic cancer prove on microscopic evaluation to be pseudotumors.

OBJECTIVES

To illustrate the clinical and pathologic characteristics of the 2 most frequent pseudotumoral inflammatory conditions, autoimmune pancreatitis and paraduodenal pancreatitis, and describe the criteria that may be useful in the differential diagnosis versus pancreatic carcinoma.

DATA SOURCES

Recent literature and the authors' experience with the clinical and pathologic characteristics of autoimmune pancreatitis and paraduodenal pancreatitis.

CONCLUSIONS

The knowledge of the clinical, radiologic, and pathologic findings in both autoimmune pancreatitis and paraduodenal pancreatitis is crucial in making the correct preoperative diagnosis. Autoimmune pancreatitis, which occurs in isolated or syndromic forms, is characterized by a distinctive fibroinflammatory process that can either be limited to the pancreas or extend to the biliary tree. Its correct preoperative identification on biopsy material with ancillary immunohistochemical detection of dense immunoglobulin G4-positive plasma cell infiltration is possible and crucial to prevent major surgery and to treat these patients with steroid therapy. Paraduodenal pancreatitis is a special form of chronic pancreatitis that affects young males with a history of alcohol abuse and predominantly involves the duodenal wall in the region of the minor papilla. Pathogenetically, the anatomical and/or functional obstruction of the papilla minor, resulting from an incomplete involution of the intraduodenal dorsal pancreas, associated with alcohol abuse represents the key factor. Endoscopic drainage of the papilla minor, with decompression of the intraduodenal and dorsal pancreas, might be considered in these patients.