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Juarez LA, Gupta RR, Ruhnke GW. Gastric varices and splenic vein obstruction during steroid treatment for autoimmune pancreatitis: A case report and literature review. Medicine (Baltimore) 2018; 97:e11940. [PMID: 30142813 PMCID: PMC6112881 DOI: 10.1097/md.0000000000011940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
RATIONALE Few cases of autoimmune pancreatitis (AIP) complicated by gastric varices, in the absence of splenic vein obstruction, have been described in the medical literature. The findings in this case parallel those of 3 previously described cases from Japan and support a pathologic explanation for the evolution of gastric varices in relation to early splenomegaly and the role of steroid therapy for AIP. PATIENT CONCERNS A 50-year-old male with a history of transfusion-requiring erosive gastritis and recently diagnosed AIP on steroid therapy for 2 weeks presented with a 2-day history of lightheadedness, abdominal pain, and melena. DIAGNOSIS Esophagogastroduodenoscopy (EGD) revealed prominent varices in the gastric fundus. An abdominal ultrasound with Doppler demonstrated patency of the splenic, hepatic, and portal veins. Review of previous imaging revealed that the splenic vein and the superior mesenteric vein (SMV) were occluded prior to the diagnosis of AIP and steroid therapy initiation. OUTCOME Following resolution of hemodynamic instability through fluid resuscitation and blood transfusion, the remainder of his hospital course was uneventful. Subsequent to discontinuation of steroid therapy, he developed near total reocclusion of both the splenic vein and SMV. LESSON Early steroid treatment should be considered in patients with uncomplicated AIP to prevent the occlusive vascular complications that are frequently associated with the pathophysiology of this disease process.
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Affiliation(s)
| | - Roop R. Gupta
- Gastroenterology, Department of Internal Medicine, Mercy Hospital and Medical Center
| | - Gregory W. Ruhnke
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL
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Dubravcsik Z, Farkas G, Hegyi P, Hritz I, Kelemen D, Lásztity N, Morvay Z, Oláh A, Pap Á, Párniczky A, Sahin-Tóth M, Szentkereszti Z, Szmola R, Takács T, Tiszlavicz L, Szücs Á, Czakó L. [Autoimmune pancreatitis. Evidence based management guidelines of the Hungarian Pancreatic Study Group]. Orv Hetil 2015; 156:292-307. [PMID: 25662147 DOI: 10.1556/oh.2015.30061] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Autoimmune pancreatitis is a rare disease which can even mimic pancreatic tumor, however, unlike the latter, it requires not surgical but conservative management. Correct diagnosis and differential diagnosis of autoimmune pancreatitis and treatment of these patients requires up-to-date and evidence based management guidelines. The Hungarian Pancreatic Study Group proposed to prepare an evidence based guideline based on the available international guidelines and evidences. The preparatory and consultation task force appointed by the Hungarian Pancreatic Study Group translated and complemented and/or modified the international guidelines if it was necessary. 29 relevant clinical questions in 4 topics were defined (Basics; Diagnosis; Differential diagnostics; Therapy). Evidence was classified according to the UpToDate(®) grading system. The draft of the guidelines was presented and discussed at the consensus meeting on September 12, 2014. All clinial questions were accepted with almost total (more than 95%) agreement. The present guideline is the first evidence based autoimmune pancreatitis guideline in Hungary. The guideline may provide very important and helpful data for tuition of autoimmune pancreatitis, for everyday practice and for establishing proper finance. Therefore, the authors believe that these guidelines will widely become a basic reference in Hungary.
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Affiliation(s)
| | - Gyula Farkas
- Szegedi Tudományegyetem, Általános Orvostudományi Kar, Szent-Györgyi Albert Klinikai Központ Sebészeti Klinika Szeged
| | - Péter Hegyi
- Szegedi Tudományegyetem, Általános Orvostudományi Kar, Szent-Györgyi Albert Klinikai Központ I. Belgyógyászati Klinika Szeged MTA-SZTE Lendület Gasztroenterológiai Multidiszciplináris Kutatócsoport Szeged
| | - István Hritz
- Bács-Kiskun Megyei Kórház Gasztroenterológia Kecskemét Szegedi Tudományegyetem, Általános Orvostudományi Kar, Szent-Györgyi Albert Klinikai Központ I. Belgyógyászati Klinika Szeged
| | - Dezső Kelemen
- Pécsi Tudományegyetem, Általános Orvostudományi Kar Klinikai Központ, Sebészeti Klinika Pécs
| | | | - Zita Morvay
- Szegedi Tudományegyetem, Általános Orvostudományi Kar, Szent-Györgyi Albert Klinikai Központ Radiológiai Klinika Szeged
| | - Attila Oláh
- Petz Aladár Megyei Oktató Kórház Sebészeti Osztály Győr
| | - Ákos Pap
- Péterfy Sándor utcai Kórház-Rendelőintézet Budapest
| | | | - Miklós Sahin-Tóth
- Boston University Henry M. Goldman School of Dental Medicine Department of Molecular and Cell Biology Boston Massachusetts USA
| | - Zsolt Szentkereszti
- Debreceni Egyetem, Általános Orvostudományi Kar, Orvos- és Egészségtudományi Centrum Sebészeti Klinika Debrecen
| | - Richárd Szmola
- Országos Onkológiai Intézet Intervenciós Gasztroenterológiai Részleg Budapest
| | - Tamás Takács
- Szegedi Tudományegyetem, Általános Orvostudományi Kar, Szent-Györgyi Albert Klinikai Központ I. Belgyógyászati Klinika Szeged
| | - László Tiszlavicz
- Szegedi Tudományegyetem, Általános Orvostudományi Kar, Szent-Györgyi Albert Klinikai Központ Pathologiai Intézet Szeged
| | - Ákos Szücs
- Semmelweis Egyetem, Általános Orvostudományi Kar I. Sebészeti Klinika Budapest
| | - László Czakó
- Szegedi Tudományegyetem, Általános Orvostudományi Kar, Szent-Györgyi Albert Klinikai Központ I. Belgyógyászati Klinika Szeged
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Krones E, Graziadei I, Trauner M, Fickert P. Evolving concepts in primary sclerosing cholangitis. Liver Int 2012; 32:352-69. [PMID: 22097926 DOI: 10.1111/j.1478-3231.2011.02607.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Accepted: 06/27/2011] [Indexed: 02/13/2023]
Abstract
Patients suffering from primary sclerosing cholangitis (PSC) show considerable differences regarding clinical manifestations (i.e. large duct versus small-duct PSC, presence or absence of concomitant inflammatory bowel disease), disease progression, risk for malignancy and response to therapy, raising the question whether PSC may represent a mixed bag of diseases of different aetiologies. The growing list of secondary causes and diseases 'mimicking' or even overlapping with PSC (e.g. IgG4-associated sclerosing cholangitis), which frequently causes problems in clear-cut discrimination from classic PSC and the emerging knowledge about potential disease modifier genes (e.g. variants of CFTR, TGR5 and MDR3) support such a conceptual view. In addition, PSC in children differs significantly from PSC in adults in several aspects resulting in distinct therapeutic concepts. From a clinical perspective, appropriate categorization and careful differential diagnosis are essential for the management of concerned patients. Therefore, the aim of the current review is to summarize current and evolving pathophysiological concepts and to provide up-to-date perspectives including future treatment strategies for PSC.
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Affiliation(s)
- Elisabeth Krones
- Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Narula N, Vasudev M, Marshall JK. IgG₄-related sclerosing disease: a novel mimic of inflammatory bowel disease. Dig Dis Sci 2010; 55:3047-51. [PMID: 20521111 DOI: 10.1007/s10620-010-1287-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Accepted: 05/13/2010] [Indexed: 02/06/2023]
Abstract
High levels of IgG₄-positive plasma cells are commonly seen in autoimmune pancreatitis. It has recently become evident that autoimmune pancreatitis is one component of a larger multi-system disease. IgG₄-positive plasma cells have been identified in many extrapancreatic tissues, including the colon, biliary tract, liver, and lungs, and thus the term "IgG₄-related sclerosing disease" has been proposed. Awareness of IgG₄-related sclerosing disease is important, as it has been shown to mimic other conditions like malignancy. This review discusses IgG₄-related colitis and its potential for mimicking inflammatory bowel disease.
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Affiliation(s)
- Neeraj Narula
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, 1200 Main Street West, Hamilton, Ontario, Canada
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Frulloni L, Scattolini C, Katsotourchi AM, Amodio A, Gabbrielli A, Zamboni G, Benini L, Vantini I. Exocrine and endocrine pancreatic function in 21 patients suffering from autoimmune pancreatitis before and after steroid treatment. Pancreatology 2010; 10:129-33. [PMID: 20460944 DOI: 10.1159/000265945] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2009] [Accepted: 12/02/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIM Autoimmune pancreatitis (AIP) responds rapidly and dramatically to steroid therapy. The aim of this study was to evaluate pancreatic exocrine and endocrine function in patients suffering from AIP both before and after steroid therapy. PATIENTS AND METHODS Fecal elastase 1 and diabetes were evaluated before steroid therapy and within 1 month of its suspension in 21 patients (13 males and 8 females, mean age 43 +/- 16.5 years) diagnosed as having AIP between 2006 and 2008. RESULTS At clinical onset, fecal elastase 1 was 107 +/- 126 microg/g stool. Thirteen patients (62%) showed severe pancreatic insufficiency (<100 microg/g stool), 4 (19%) had mild insufficiency (100-200 microg/g stool), while 4 (19%) had normal pancreatic function (>200 microg/g stool). Before steroids, diabetes was diagnosed in 5 patients (24%), all of whom had very low levels of fecal elastase 1 (<19 microg/g stool). Following steroids, fecal elastase 1 increased in all patients (237 +/- 193 microg/g stool) and observed levels were significantly higher than those seen before steroids (p = 0.001). CONCLUSIONS Patients suffering from AIP display exocrine and/or endocrine pancreatic insufficiency at clinical onset. These insufficiencies improve after steroid therapy.
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Affiliation(s)
- Luca Frulloni
- Department of Biomedical and Surgical Sciences, University of Verona, Verona, Italy.
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Sánchez-Castañón M, de las Heras-Castaño G, López-Hoyos M. Autoimmune pancreatitis: An underdiagnosed autoimmune disease with clinical, imaging and serological features. Autoimmun Rev 2010; 9:237-40. [DOI: 10.1016/j.autrev.2009.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2009] [Accepted: 07/09/2009] [Indexed: 01/06/2023]
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Sahani DV, Sainani NI, Deshpande V, Shaikh MS, Frinkelberg DL, Fernandez-del Castillo C. Autoimmune pancreatitis: disease evolution, staging, response assessment, and CT features that predict response to corticosteroid therapy. Radiology 2008; 250:118-29. [PMID: 19017924 DOI: 10.1148/radiol.2493080279] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To evaluate the evolution of morphologic features of autoimmune pancreatitis (AIP) at computed tomography (CT) and to identify imaging features that can predict AIP response to corticosteroid therapy (CST). MATERIALS AND METHODS This HIPAA-compliant retrospective study had institutional review board approval. From among a cohort of 63 patients with AIP, 15 patients (12 men, three women; mean age, 64.7 years; age range, 30-84 years) who underwent sequential CT examinations before treatment were included to assess the evolution of disease by reviewing pancreatic, peripancreatic, and ductal changes. Of these patients, 13 received CST and underwent posttreatment CT; these CT studies were evaluated to determine if there were imaging features that could predict response to CST. RESULTS The disease evolved from changes of diffuse (14 of 15 patients) or focal (one of 15 patients) parenchymal swelling, peripancreatic stranding (10 of 15 patients), "halo" (nine of 15 patients), pancreatic duct changes (15 of 15 patients), and distal common bile duct narrowing (12 of 15 patients) to either resolution or development of ductal strictures and/or focal masslike swelling. In 13 patients treated with CST, favorable response to treatment was seen in those with diffuse pancreatic and peripancreatic changes. Suboptimal response was seen in patients with ductal stricture formation (two of 13 patients) and in those in whom focal masslike swellings persisted after resolution of diffuse changes (seven of 13 patients). CONCLUSION CT features like diffuse swelling and halo respond favorably to CST and likely reflect an early inflammatory phase, whereas features like ductal strictures and focal masslike swelling are predictive of a suboptimal response and symbolize a late stage with predominance of fibrosis.
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Affiliation(s)
- Dushyant V Sahani
- Department of Radiology, Massachusetts General Hospital-Harvard Medical School, 55 Fruit St, White 270, Boston, MA 02114, USA.
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Meegan JM, Sidor IF, Steiner JM, Sarran D, Dunn JL. Chronic pancreatitis with secondary diabetes mellitus treated by use of insulin in an adult California sea lion. J Am Vet Med Assoc 2008; 232:1707-12. [DOI: 10.2460/javma.232.11.1707] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
In this review article, we will briefly describe the main characteristics of autoimmune pancreatitis and then we will concentrate on our aim, namely, evaluating the clinical characteristics of patients having recurrence of pain from the disease. In fact, the open question is to evaluate the possible presence of autoimmune pancreatitis in patients with an undefined etiology of acute pancreatitis and for this reason we carried out a search in the literature in order to explore this issue. In cases of recurrent attacks of pain in patients with “diopathic”pancreatitis, we need to keep in mind the possibility that our patients may have autoimmune pancreatitis. Even though the frequency of this disease seems to be quite low, we believe that in the future, by increasing our knowledge on the subject, we will be able to diagnose an ever-increasing number of patients having acute recurrence of pain from autoimmune pancreatitis.
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Abstract
Autoimmune pancreatitis is a form of chronic pancreatitis of presumed autoimmune aetiology. The disease is characterised with clinical, serological, histomorphological and imaging features. Autoimmune pancreatitis is recognised as a T-cell-mediated specific disease with lymphoplasmatic infiltration of pancreatic tissue and pancreatic parenchyma fibrosis. Serum immunoglobulin IgG or IgG4 and antibodies (rheumatoid factor, lactoferrin antibodies, carbonic anhydrase II, etc) are usually increased. But the lack of specific biochemical markers is a major drawback in the diagnosis of autoimmune pancreatitis. The Japan Pancreas Society proposed diagnostic criteria for autoimmune pancreatitis as the presence antibodies, pancreas enlargement and pancreatic duct narrowing, lymphoplasmatic infiltration, response to corticosteroid therapy, and association with other autoimmune diseases such as autoimmune hepatitis, sclerosing cholangitis, primary biliary cirrhosis, sialoadenitis, inflammatory bowel disease and Sjögren syndrome. New criteria (HISORt Criteria) incorporate imaging changes, organ involvement, specific elevation of IgG4 subclass and histopathological markers. Autoimmune pancreatitis could be associated with diabetes mellitus and exocrine pancreatic dysfunction. Clinically, autoimmune pancreatitis is a disease with mild symptoms; severe attacks of abdominal pain are not typical. Typically, pancreatic calcifications and pseudocyst are absent; on the other hand jaundice and/or pancreatic mass are frequent signs, and both make differential diagnosis with pancreatic cancer difficult. From a practical point of view, in an elderly male presenting with obstructive jaundice and pancreatic mass, autoimmune pancreatitis is one of the differential diagnoses to avoid unnecessary surgical therapy.
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Affiliation(s)
- Petr Dite
- Department of Hepatogastroenterology, University Hospital, Jihlavska 20, 625 00 Brno, Czech Republic.
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Song Y, Liu QD, Zhou NX, Zhang WZ, Wang DJ. Diagnosis and management of autoimmune pancreatitis: Experience from China. World J Gastroenterol 2008; 14:601-6. [PMID: 18203294 PMCID: PMC2681153 DOI: 10.3748/wjg.14.601] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the clinical, radiographic and pathologic characteristics, diagnostic and treatment modalities in patients with autoimmune pancreatitis (AIP).
METHODS: In this retrospective study, the data of patients with diagnosed chronic pancreatitis (CP) between 1995 and 2006 in Chinese PLA General Hospital were included to screen for the cases with AIP, according to the following diagnostic criteria: (1) diagnostic histopathologic features, and abound IgG4-positive plasma cells on pancreatic tissues; (2) characteristic imaging on computed tomography and pancreatography, together with increased serum IgG, γ-globulin levels or presence of autoantibodies; (3) response to steroid therapy. The clinical, radiographic and pathologic characteristics, diagnostic and treatment modalities, and outcome of AIP cases were reviewed.
RESULTS: Twenty-five (22 male, 3 female; mean age 54 years, 36-76 years) out of 510 CP patients were diagnosed as AIP, which accounted for 49% (21/43) of CP population undergoing surgical treatment in the same period. The main clinical manifestations included intermittent or progressive jaundice in 18 cases (72%), abdominal pain in 11 (44%), weight loss in 10 (40%), and 3 cases had no symptoms. The imaging features consisted of pancreatic enlargement, especially in the head of pancreas (18 cases), strictures of main pancreatic duct and intrapancreatic bile duct. Massive lymphocytes and plasma cells infiltration in pancreatic tissues were showed on pathology, as well as parenchymal fibrosis. Twenty-three patients were misdiagnosed as pancreaticobiliary malignancy, and 21 patients underwent exploratory laparotomy, the remaining 4 patients dramatically responded to steroid therapy. No pancreatic cancer occurred during a mean 46-mo follow-up period.
CONCLUSION: AIP patients always are subjected to mistaken diagnosis of pancreatic cancer and an unnecessary surgical exploration, due to its similarity in clinical features with pancreatic cancer. The differential diagnosis with high index of suspicion of AIP would improve the diagnostic accuracy for AIP.
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Abstract
Abstract
Background
Approximately 2 per cent of pancreatic masses resected for suspected malignancy are found instead to be a form of chronic pancreatitis defined by a characteristic lymphoplasmacytic infiltrate. This condition is now commonly classified as ‘autoimmune pancreatitis’.
Methods
A literature review of autoimmune pancreatitis was performed using Medline and PubMed. The reference lists of identified articles were searched for further relevant publications.
Results
Patients are predominantly 55-65 years old and present with obstructive jaundice, abdominal pain and weight loss. Imaging may show a mass of malignant appearance or pancreatobiliary tree strictures precipitating surgical exploration. Raised serum levels of IgG4 and specific autoantibodies, when combined with particular radiological features and a biopsy negative for malignancy, enable a preoperative diagnosis and successful treatment with steroids.
Conclusion
Autoimmune pancreatitis is not uncommon and steroid treatment can effect a dramatic improvement. Care is needed to ensure that pancreatic cancer is not misdiagnosed.
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Affiliation(s)
- D P Toomey
- Professorial Surgical Unit, University of Dublin, Trinity College, Adelaide and Meath Hospitals-National Children's Hospital, Tallaght, Dublin 24, Ireland
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14
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Abstract
Early-stage chronic pancreatitis may be undetected as a clinical entity. However, it may carry a definite risk for subsequent secondary damage, depending on the etiology of the disease. Therefore, the most important question is whether indeed the patient in question does have early-stage chronic pancreatitis rather than oligosymptomatic advanced-stage chronic pancreatitis. This can be easily determined by appropriate imaging such as abdominal computed tomography. For early changes, endoscopic ultrasound is superior to any other technique. Endosonography may also tell about anatomical obstacles (e.g., papillary stenosis, pancreas divisum) that may be treated to prevent progression of the disease. Treatment options at this stage are endoscopic for the most part. Depending on the etiology and familiar/hereditary background of the given patient, one must look further into molecular markers. Such markers may give an estimate on the progression or dynamics of the disease in the future and include mutations in the cationic (PRSS1) and anionic (PRSS2) trypsinogen genes as well as mutations in the serine protease (SPINK1) or cystic fibrosis (CFTR) genes. Admitted ly, these are not markers of early-stage chronic pancreatitis but must be investigated if and when such pathogenesis is suspected. Further, rare forms of chronic pancreatitis, such as autoimmune pancreatitis, which can be cured by appropriate medical treatment with steroids, must be excluded. Markers for autoimmune pancreatitis are elevated serum IgG, especially IgG4, and autoantibodies to carbonic anhydrase (type II) and lactoferrin. It is noteworthy that these markers, present in almost every Asian patient with autoimmune pancreatitis, are mostly lacking in Caucasian populations of patients with autoimmune pancreatitis.
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Affiliation(s)
- J-Matthias Löhr
- Molecular Gastroenterology Unit (dkfz E180), Department of Medicine II, Medical Faculty Mannheim, University of Heidelberg, Theodor Kutzer Ufer 1-3, D-68167, Mannheim, Germany
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Abstract
Secondary sclerosing cholangitis (SSC) is a disease that is morphologically similar to primary sclerosing cholangitis (PSC) but that originates from a known pathological process. Its clinical and cholangiographic features may mimic PSC, yet its natural history may be more favorable if recognition is prompt and appropriate therapy is introduced. Thus, the diagnosis of PSC requires the exclusion of secondary causes of sclerosing cholangitis and recognition of associated conditions that may potentially imitate its classic cholangiographic features. Well-described causes of SSC include intraductal stone disease, surgical or blunt abdominal trauma, intra-arterial chemotherapy, and recurrent pancreatitis. However, a wide variety of other associations have been reported recently, including autoimmune pancreatitis, portal biliopathy, eosinophillic and/or mast cell cholangitis, hepatic inflammatory pseudotumor, recurrent pyogenic cholangitis, primary immune deficiency, and AIDS-related cholangiopathy. This article offers a comprehensive review of SSC.
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Affiliation(s)
- Rupert Abdalian
- Department of Medicine, University Health Network, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
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