1
|
Girish MI, Dahale AS, Banerjee D, Bhate P, Karad A. Auto-immune pancreatitis with unusual presentations - A case series. J Family Med Prim Care 2024; 13:1106-1110. [PMID: 38736800 PMCID: PMC11086809 DOI: 10.4103/jfmpc.jfmpc_1931_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 05/28/2023] [Accepted: 06/09/2023] [Indexed: 05/14/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Muppa Indrakeela Girish
- Department of Medical Gastroenterology, ”Dr. D.Y Patil Medical College, Hospital and Research Centre, Pimpri, Pune, Dr. D.Y Patil Vidyapeeth Pune”, Maharashtra, India
| | - Amol S. Dahale
- Department of Medical Gastroenterology, ”Dr. D.Y Patil Medical College, Hospital and Research Centre, Pimpri, Pune, Dr. D.Y Patil Vidyapeeth Pune”, Maharashtra, India
| | - Debabrata Banerjee
- Department of Medical Gastroenterology, ”Dr. D.Y Patil Medical College, Hospital and Research Centre, Pimpri, Pune, Dr. D.Y Patil Vidyapeeth Pune”, Maharashtra, India
| | - Prasad Bhate
- Department of Medical Gastroenterology, ”Dr. D.Y Patil Medical College, Hospital and Research Centre, Pimpri, Pune, Dr. D.Y Patil Vidyapeeth Pune”, Maharashtra, India
| | - Abhijeet Karad
- Department of Medical Gastroenterology, ”Dr. D.Y Patil Medical College, Hospital and Research Centre, Pimpri, Pune, Dr. D.Y Patil Vidyapeeth Pune”, Maharashtra, India
| |
Collapse
|
2
|
Kubota K, Oguchi T, Fujimori N, Yamada K, Naitoh I, Okabe Y, Iwasaki E, Masamune A, Ikeura T, Kamisawa T, Inoue D, Kumagi T, Ogura T, Kodama Y, Katanuma A, Hirano K, Inui K, Isayama H, Sakagami J, Nishino T, Kanno A, Kurita Y, Okazaki K, Nakamura S. Steroid therapy has an acceptable role as the initial treatment in autoimmune pancreatitis patients with pancreatic cyst formation: Based on a Japanese nationwide study. J Hepatobiliary Pancreat Sci 2023; 30:664-677. [PMID: 35950952 DOI: 10.1002/jhbp.1227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/14/2022] [Accepted: 08/07/2022] [Indexed: 05/26/2023]
Abstract
BACKGROUND We attempted to determine the indications and limitations of steroid therapy as the first-line therapy in patients with autoimmune pancreatitis (AIP) with cyst formation (ACF). METHODS This Japanese multicenter survey was conducted to examine the merits/demerits of steroid treatment as the initial therapy for ACF. RESULTS Data of a total of 115 patients with ACF were analyzed. Complete remission was achieved in 86% (86/100) of patients who had received steroid treatment, but only 33.3% (5/15) of patients who had not received steroids. Relapse after the remission (n = 86) occurred in 7.6% (6/86) of patients who had received steroid therapy, but 40% (2/5) of patients who had not received steroid therapy. Multivariate analysis identified adoption of the wait and watch approach without steroid treatment (odds ratio = 0.126, P < .001) as a significant and independent negative predictor of remission of ACF. As for predictors of relapse, the presence of varix (odds ratio = 5.83, P = .036) was identified as an independent risk factor. CONCLUSION Steroid therapy plays an important role as first-line therapy in AIP patients with pancreatic cyst formation, however, varix formation, besides the diameter of the cyst(s), is a risk factor for refractoriness to steroid therapy.
Collapse
Affiliation(s)
- Kensuke Kubota
- Endoscopic Unit, Yokohama City University Hospital, Yokohama, Japan
| | - Takaya Oguchi
- Department of Gastroenterology, Graduate School of Medicine, Shinshu University, Matsumoto, Japan
| | - Nao Fujimori
- Department of Gastroenterology, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | - Kenta Yamada
- Department of Gastroenterology, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Itaru Naitoh
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yoshinobu Okabe
- Department of Gastroenterology, Kurume University, Kurume, Japan
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University, Shinagawa, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tsukasa Ikeura
- Department of Gastroenterology and Hepatology, Kansai Medical University, Hirakata, Japan
| | - Terumi Kamisawa
- Department of Internal Medicine, Tokyo Komagome Metropolitan Hospital, Tokyo, Japan
| | - Dai Inoue
- Department of Radiology, Graduate School of Medicine, Kanazawa University, Kanazawa, Japan
| | - Teru Kumagi
- Department of Gastroenterology, Graduate School of Medicine, Ehime University, Matsuyama, Japan
| | - Takeshi Ogura
- Department of Gastroenterology, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Yuzo Kodama
- Department of Gastroenterology, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Akio Katanuma
- Department of Gastroenterology, Teine Keijinkai Hospital, Sapporo, Japan
| | - Kenji Hirano
- Department of Gastroenterology, Takanawa Hospital, Tokyo, Japan
| | - Kazuo Inui
- Department of Gastroenterology, Bantane Hospital, Fujita Health University, Nagoya, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Junichi Sakagami
- Department of Gastroenterology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takayoshi Nishino
- Department of Gastroenterology, Tokyo Women's Medical University, Yachiyo Medical Center, Yachiyo, Japan
| | - Atsushi Kanno
- Department of Gastroenterology, Jichi Medical University, Shimono, Japan
| | - Yusuke Kurita
- Endoscopic Unit, Yokohama City University Hospital, Yokohama, Japan
| | - Kazuichi Okazaki
- Department of Gastroenterology and Hepatology, Kansai Medical University, Hirakata, Japan
| | - Seiji Nakamura
- Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| |
Collapse
|
3
|
Donet JA, Barkin JA, Keihanian T, Nemeth Z, Barkin JS. Pancreatic Pseudocysts and Parenchymal Necrosis in Patients With Autoimmune Pancreatitis: A Systematic Review. Pancreas 2018; 47:952-7. [PMID: 30028447 DOI: 10.1097/MPA.0000000000001121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
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.
Collapse
|
4
|
Fabian E, Peck-Radosavljevic M, Krones E, Mueller H, Lackner C, Spreizer C, Putz-Bankuti C, Fuerst W, Wutte N, Fickert P, Mischinger H, Krejs GJ. Clinical-Pathological Conference Series from the Medical University of Graz : Case No 161: A 42-year-old journalist with fatigue, elevated liver function tests, hyperglycemia and pruritus. Wien Klin Wochenschr 2018; 130:545-556. [PMID: 30132197 PMCID: PMC6132877 DOI: 10.1007/s00508-018-1379-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 07/30/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Elisabeth Fabian
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Markus Peck-Radosavljevic
- Department of Internal Medicine and Gastroenterology, Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Elisabeth Krones
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Helmut Mueller
- Division of Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Caroline Lackner
- Department of Pathology, Medical University of Graz, Graz, Austria
| | - Christopher Spreizer
- Division of General Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Csilla Putz-Bankuti
- Department of Internal Medicine, Hörgas-Enzenbach Hospital, Gratwein-Straßengel, Austria
| | - Werner Fuerst
- Department of Internal Medicine, Leoben Hosptial, Leoben, Austria
| | - Nora Wutte
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
| | - Peter Fickert
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Hansjörg Mischinger
- Division of General Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Guenter J Krejs
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria.
| |
Collapse
|
5
|
Yamamoto K, Itoi T, Sofuni A, Tsuchiya T, Tsuji S, Tanaka R, Tonozuka R, Honjo M, Mukai S, Kamada K, Fujita M, Asai Y, Matsunami Y, Nagakawa Y. The Role of Endoscopic Ultrasound-guided Drainage for Autoimmune Pancreatitis-associated Pancreatic Cysts: A Report of Five Cases and a Literature Review. Intern Med 2018; 57:1523-1531. [PMID: 29434161 PMCID: PMC6028677 DOI: 10.2169/internalmedicine.9779-17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 09/26/2017] [Indexed: 12/29/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Kenjiro Yamamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | - Atsushi Sofuni
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | - Takayoshi Tsuchiya
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | - Shujiro Tsuji
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | - Reina Tanaka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | - Ryosuke Tonozuka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | - Mitsuyoshi Honjo
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | - Shuntaro Mukai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | - Kentaro Kamada
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | - Mitsuru Fujita
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | - Yasutsugu Asai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | - Yukitoshi Matsunami
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | | |
Collapse
|
6
|
Heo WG, Kim TH, Kim YJ, Chon HK, Woo YS, Sohn YW. Autoimmune Pancreatitis Complicated With Pancreatic Ascites, Pancreatic Ductal Leakage, and Multiple Pseudocyst. Pancreas 2017; 46:e10-1. [PMID: 27977636 DOI: 10.1097/MPA.0000000000000687] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
|
7
|
Abstract
Autoimmune pancreatitis (AIP) can be chronic or recurrent, but frequently completely reversible after steroid treatment. A cystic lesion in AIP is a rare finding, and it can mimic a pancreatic cystic neoplasm. Difficulties in an exact diagnosis interfere with treatment, and surgery cannot be avoided in some cases. We report the history of a 63-year-old male presenting with jaundice and pruritus. AIP was confirmed by imaging and elevated IgG4 blood levels, and the patient completely recovered after corticosteroid therapy. One year later, he presented with a recurrent episode of AIP with elevated IgG4 levels, accompanied by the appearance of multiple intrapancreatic cystic lesions. All but 1 of these cysts disappeared after steroid treatment, but the remaining cyst in the pancreatic head was even somewhat larger 1 year later. Pancreatoduodenectomy was finally performed. Histology showed the wall of the cystic lesion to be fibrotic; the surrounding pancreatic tissue presented fibrosis, atrophy and lymphoplasmacytic infiltration by IgG4-positive cells, without malignant elements. Our case illustrates the rare possibility that cystic lesions can be part of AIP. These pseudocysts appear in the pancreatic segments involved in the autoimmune disease and can be a consequence of the local inflammation or related to ductal strictures. Steroid treatment should be initiated, after which these cysts can completely disappear with recovery from AIP. Surgical intervention may be necessary in some exceptional cases.
Collapse
Affiliation(s)
- Macarena Gompertz
- Gastroenterology Section, Department of Internal Medicine, Santiago, Chile
| | - Claudia Morales
- Department of Pathology, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Hernán Aldana
- Department of Radiology, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Jaime Castillo
- Department of Surgery, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Zoltán Berger
- Gastroenterology Section, Department of Internal Medicine, Santiago, Chile
| |
Collapse
|
8
|
Kubota K, Fujita Y, Sato T, Sekino Y, Hosono K, Kobayashi N, Fujisawa N, Kagawa K, Fujisawa T, Matsuhashi N, Tanida E, Sakaguchi T, Endo I, Nakajima A. Autoimmune pancreatitis associated with pancreatic cyst: how can we manage it? J Hepatobiliary Pancreat Sci 2014; 21:902-10. [PMID: 25214236 DOI: 10.1002/jhbp.160] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Autoimmune pancreatitis (AIP) with cyst formation (ACF) is often refractory to corticosteroid treatment (CST). AIM To determine the characteristic features for the development of ACF. METHODS We studied characteristics in AIP patients (n = 116) whether any factors might be related to ACF. Additionally, an individual database of 24 patients was compiled to investigate factors included CST effectiveness. RESULT The results of univariate analysis for type 1 AIP patients revealed significant association of ACF with the elevation of pancreatic enzymes, peripancreas vascular involvement (PVI) and varix formation at disease onset (P < 0.05), while multivariate analysis revealed only the absence of varix formation (odds ratio = 0.033, P = 0.0015) as a significant independent predictor of the development of ACF. The comparison of the characteristic features in ACF grouped by the diameter of the cysts revealed that only the effectiveness of the CST was significantly recognized in ACF measuring less than 55 mm in diameter than that with patients in the group with smaller cysts (P < 0.05). CONCLUSION The varix formation is an independent predictor of the development of ACF. A pooled analysis indicated that the disease process might be irreversible in AIP patients with large cystic lesions exceeding 55 mm in diameter and those patients tended to show a refractory course even if CST were conducted.
Collapse
Affiliation(s)
- Kensuke Kubota
- Division of Gastroenterology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama, 236-0004, Japan.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Nakaji S, Hirata N, Fujii H, Iwaki K, Shiratori T, Kobayashi M, Wakasugi S, Ishii E, Takeyama H, Hoshi K. A case of focal autoimmune pancreatitis (AIP) mimicking an intraductal papillary mucinous neoplasm (IPMN). Clin J Gastroenterol 2013; 6:329-33. [PMID: 26181739 DOI: 10.1007/s12328-013-0392-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 05/17/2013] [Indexed: 12/27/2022]
Abstract
The present case involved a 76-year-old man with a cystic mass in the head of his pancreas. The cystic lesion, which measured 17.7 × 9.8 mm, was first detected by ultrasonography (US) at the age of 72 years. Follow-up endoscopic ultrasonography (EUS) performed at 4 years after the lesion had first been detected revealed a mural nodule measuring 14.0 × 8.4 mm in the cyst. Endoscopic retrograde pancreatography (ERP) imaging revealed that the main pancreatic duct was in communication with the cyst and that there was no irregular narrowing of the main pancreatic duct. On the basis of these results, the patient was diagnosed with an intraductal papillary mucinous neoplasm (IPMN), and stomach-preserving pancreaticoduodenectomy was performed. A histopathological examination revealed that the interior of the cystic part of the lesion was lined by a pancreatic ductal epithelium. A pathological examination of the nodular lesion detected storiform fibrosis, severe lymphoplasmacytic infiltration, and hyperplasia in the pancreatic duct epithelium together with a small amount of mucus. On immunohistological staining, the infiltrating lymphoplasmacytes were found to be positive for IgG4. Accordingly, the patient was diagnosed with focal autoimmune pancreatitis (AIP). In conclusion, we reported a case of focal AIP mimicking IPMN. This case showed neither enlargement of the pancreas nor irregular narrowing of the main pancreatic duct.
Collapse
Affiliation(s)
- So Nakaji
- Department of Gastroenterology, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, Japan.
| | - Nobuto Hirata
- Department of Gastroenterology, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, Japan
| | - Hiroyuki Fujii
- Department of Gastroenterology, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, Japan
| | - Kosuke Iwaki
- Department of Gastroenterology, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, Japan
| | - Toshiyasu Shiratori
- Department of Gastroenterology, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, Japan
| | - Masayoshi Kobayashi
- Department of Gastroenterology, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, Japan
| | - Satoshi Wakasugi
- Department of Gastroenterology, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, Japan
| | - Eiji Ishii
- Department of Gastroenterology, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, Japan
| | - Hiroyuki Takeyama
- Department of Anatomic Pathology, Kameda Medical Center, Kamogawa, Japan
| | - Kazuei Hoshi
- Department of Anatomic Pathology, Kameda Medical Center, Kamogawa, Japan
| |
Collapse
|
10
|
Ishikawa T, Itoh A, Kawashima H, Ohno E, Itoh Y, Nakamura Y, Hiramatsu T, Miyahara R, Ohmiya N, Haruta J, Goto H, Hirooka Y. Peripancreatic vascular involvements of autoimmune pancreatitis. J Gastroenterol Hepatol 2012; 27:1790-5. [PMID: 22849535 DOI: 10.1111/j.1440-1746.2012.07248.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Although peripancreatic vascular lesions are occasionally encountered in autoimmune pancreatitis (AIP), there are few reports focusing on these involvements. We aimed to investigate the peripancreatic vascular involvements associated with AIP. METHODS We retrospectively analyzed 54 AIP patients who met the International Consensus Diagnostic Criteria for AIP between July 2003 and October 2010. All of the 54 patients were subjected to multiphasic multidetector computed tomography, and the prevalence, location and prognosis of peripancreatic vascular involvements were investigated. RESULTS Of the 54 AIP patients, 24 (44.4%) exhibited involvements in the form of peripancreatic vascular lesions (stenoses of the splenic vein in 22 and of the superior mesenteric-portal vein in 13, development of perigastric collateral circulation in 18, gastric varices with a red color sign in one and thrombosis inside the portal vein in one). Diffuse-type AIP was associated with a significantly higher prevalence of vascular involvements compared with focal-type AIP (P = 0.033). A total of 14 out of 16 patients who underwent corticosteroid treatment showed improvement in vascular lesions. One case followed up without corticosteroid treatment and presenting an obstruction of the splenic vein exhibited involvements in the form of an infarction and hemorrhagic cysts of the spleen and ultimately underwent distal pancreatectomy and splenectomy. CONCLUSIONS Autoimmune pancreatitis patients show a high prevalence of peripancreatic vascular involvements. Thus, patients with vascular involvements are suitable candidates for steroid therapy with evaluation of its potential merits and demerits, even if they are asymptomatic.
Collapse
Affiliation(s)
- Takuya Ishikawa
- Department of Gastroenterology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Abstract
Autoimmune pancreatitis (AIP) remains one of the rarer forms of pancreatitis but has become increasingly well recognized and widely diagnosed as it is an important differential, particularly due to the dramatic response to appropriate therapy. It is now best considered as part of a multisystem disease and the notion of "IgG4-related systemic sclerosing disease" has become widely recognized as the number of extra-pancreatic associations of AIP grows. More recently AIP has been classified into two subtypes: lymphoplasmacytic sclerosing pancreatitis (LPSP) and idiopathic duct-centric pancreatitis (IDCP) with distinct geographical, age and sex distributions for the two subtypes, in addition to different pathological characteristics. The role of imaging is crucial in AIP and should be considered in conjunction with clinical, serological, and histopathological findings to make the diagnosis. Radiologists are uniquely placed to raise the possibility of AIP and aid the exclusion of significant differentials to allow the initiation of appropriate management and avoidance of unnecessary intervention. Radiological investigation may reveal a number of characteristic imaging findings in AIP but appearances can vary considerably and the focal form of AIP may appear as a pancreatic mass, imitating pancreatic carcinoma. This review will illustrate typical and atypical appearances of AIP on all imaging modes. Emphasis will be placed on the imaging features that are likely to prove useful in discriminating AIP from other causes prior to histopathological confirmation. In addition, examples of relevant differential diagnoses are discussed and illustrated.
Collapse
Affiliation(s)
- R D Proctor
- Department of Clinical Radiology, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | | | | | | | | |
Collapse
|
12
|
Abstract
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.
Collapse
Affiliation(s)
- Kyung Ae Chang
- Division of Gastroenterology, Department of Internal Medicine, Yeungnam University College of Medicine, 317-1 Daemyung 5-dong, Nam-gu, Daegu, 705-717, Korea
| | - Tae Nyeun Kim
- Division of Gastroenterology, Department of Internal Medicine, Yeungnam University College of Medicine, 317-1 Daemyung 5-dong, Nam-gu, Daegu, 705-717, Korea.
| | - Si Hyung Lee
- Division of Gastroenterology, Department of Internal Medicine, Yeungnam University College of Medicine, 317-1 Daemyung 5-dong, Nam-gu, Daegu, 705-717, Korea
| |
Collapse
|
13
|
|
14
|
Nishimura N, Tamada K, Wada S, Ohashi A, Hatanaka H, Nakazawa K, Numao N, Kitamura A, Satoh K, Yamamoto H, Sugano K. Autoimmune pancreatitis associated with a large pancreatic pseudocyst that disappeared after corticosteroid therapy: a case report and literature review. Clin J Gastroenterol 2009; 2:199-203. [DOI: 10.1007/s12328-008-0059-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2008] [Accepted: 12/10/2008] [Indexed: 12/24/2022]
|
15
|
Morselli-Labate AM, Pezzilli R. Usefulness of serum IgG4 in the diagnosis and follow up of autoimmune pancreatitis: A systematic literature review and meta-analysis. J Gastroenterol Hepatol 2009; 24:15-36. [PMID: 19067780 DOI: 10.1111/j.1440-1746.2008.05676.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
High circulating serum immunoglobulin G4 (IgG4) levels have been proposed as a marker of autoimmune pancreatitis (AIP). The aim of the present study was to review the data existing in the English literature on the usefulness of the IgG4 serum levels in the diagnosis and follow up of patients with AIP. A total of 159 patients with AIP and 1099 controls were described in seven selected papers reporting the usefulness of serum IgG4 in diagnosing AIP. In total, 304 controls had pancreatic cancer, 96 had autoimmune diseases, and the remaining 699 had other conditions. The summary receiver-operating characteristic curve analysis was carried out by means of Meta-DiSc open-access software. Serum IgG4 showed good accuracy in distinguishing between AIP and the overall controls, pancreatic cancer and other autoimmune diseases (area under the curve [+/- SE]: 0.920 +/- 0.073, 0.914 +/- 0.191, and 0.949 +/- 0.024, respectively). The studies analyzed showed significantly heterogeneous specificity values in each of the three analyses performed. The analysis of the four studies comparing AIP and pancreatic cancers also showed significantly heterogeneous values of sensitivities and odds ratios. Regarding the usefulness of IgG4 as a marker of efficacy of steroid treatment, a decrease in the serum concentrations of IgG4 was found in the four available studies. The serum IgG4 subclass is a good marker of AIP, and its determination should be included in the diagnostic workup of this disease. However, the heterogeneity of the studies published until now means that more studies are necessary in order to better evaluate the true accuracy of IgG4 in discriminating AIP versus other autoimmune diseases.
Collapse
|
16
|
Kamisawa T, Anjiki H, Egawa N. Rapid disappearance of a pancreatic cyst after steroid therapy in a patient with autoimmune pancreatitis. Clin Gastroenterol Hepatol 2008; 6:e33-4. [PMID: 18691945 DOI: 10.1016/j.cgh.2008.04.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2008] [Revised: 04/27/2008] [Accepted: 04/29/2008] [Indexed: 02/07/2023]
Affiliation(s)
- Terumi Kamisawa
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | | | | |
Collapse
|
17
|
Esposito I, Born D, Bergmann F, Longerich T, Welsch T, Giese NA, Büchler MW, Kleeff J, Friess H, Schirmacher P. Autoimmune pancreatocholangitis, non-autoimmune pancreatitis and primary sclerosing cholangitis: a comparative morphological and immunological analysis. PLoS One 2008; 3:e2539. [PMID: 18596913 DOI: 10.1371/journal.pone.0002539] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2008] [Accepted: 05/27/2008] [Indexed: 12/17/2022] Open
Abstract
Background Autoimmune pancreatocholangitis (AIPC) is an emerging, not completely characterized disease. Aim of this study was the comprehensive evaluation of a series of AIPC patients, who were diagnosed and treated in a European institution between January 2003 and July 2006. Methodology/Principal Findings Thirty-three patients with histologically confirmed AIPC were analyzed and compared to 20 patients with non-autoimmune chronic pancreatitis (CP) and 14 patients with primary sclerosing cholangitis (PSC). Clinical features and conventional histopathology were taken into account. Immunohistochemistry and real-time quantitative PCR were used for the characterization of the inflammatory infiltrate and the stromal reaction. AIPC was localized in the pancreatic head in 94% of the patients. Intra- and/or extrapancreatic biliary tract involvement was present in 64% of the cases. The number of infiltrating T-lymphocytes, macrophages and total plasma cells was significantly higher in AIPC than in CP (3-, 4- and 8-fold increase, respectively). The absolute number of IgG4-positive plasma cells was higher in AIPC than in CP and PSC (7-fold and 35-fold increase, respectively), but significance was only reached in comparison with PSC. CXCR5- and CXCL13-positive cells were almost exclusively detected in AIPC. Conclusions/Significance AIPC is mainly a disease of the pancreatic head with possible extension into the periphery of the gland and/or into the biliary tract/gallbladder. The morphology of AIPC, as well as the immune- and stromal reaction is characteristic and comparable between cases with and without biliary tract involvement. Immunological markers (IgG4, CXCR5, CXCL13) can be of diagnostic relevance in specific settings.
Collapse
|
18
|
|
19
|
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.
Collapse
Affiliation(s)
- Petr Dite
- Department of Hepatogastroenterology, University Hospital, Jihlavska 20, 625 00 Brno, Czech Republic.
| | | | | | | |
Collapse
|
20
|
Kawakami H, Kuwatani M, Shinada K, Yamato H, Hirano S, Kondo S, Yonemori A, Itoh T, Matsuno Y, Asaka M. Autoimmune pancreatitis associated with hemorrhagic pseudocysts: a case report and literature review. Intern Med 2008; 47:603-8. [PMID: 18379144 DOI: 10.2169/internalmedicine.47.0731] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Autoimmune pancreatitis (AIP) is a new category of pancreatic diseases. AIP associated with pseudocysts is rare; only 8 cases have been reported in the literature. A 63-year-old man was admitted to our department because of upper left abdominal pain and back pain. Various imaging studies demonstrated swelling of the tail of the pancreas with hemorrhagic pseudocysts. The patient underwent a surgical operation. A pancreatogram of the specimen revealed total occlusion of the main pancreatic duct in the tail of the pancreas. Histopathological examination revealed that it was AIP with hemorrhagic pseudocysts.
Collapse
Affiliation(s)
- Hiroshi Kawakami
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Murawa D, Nowaczyk P, Adamczyk B. Giant Post-Inflammatory Pancreatic Cyst Associated with Giant Abdominal Hernia - a Case Report. Polish Journal of Surgery 2008; 80. [DOI: 10.2478/v10035-008-0052-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
22
|
Kawamura E, Habu D, Higashiyama S, Tsushima H, Shimonishi Y, Nakayama Y, Enomoto M, Kawabe J, Tamori A, Kawada N, Shiomi S. A case of sclerosing cholangitis with autoimmune pancreatitis evaluated by FDG-PET. Ann Nucl Med 2007; 21:223-8. [PMID: 17581721 DOI: 10.1007/s12149-007-0008-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2006] [Accepted: 02/06/2007] [Indexed: 12/24/2022]
Abstract
The extrapancreatic bile duct lesions in autoimmune pancreatitis are termed sclerosing cholangitis (SC with AIP), which is known to complicate AIP somewhat more frequently than other extrapancreatic lesions. In cases of SC with AIP, differentiation from primary SC, pancreatic cancer, and bile duct cancer is often difficult. In our patient, pancreatic cancer had to be ruled out at admission, given the findings of obstructive jaundice, pancreatic duct stenosis, and swelling of the pancreas. Fluorine-18-fluorodeoxyglucose positron emission tomography was useful in checking for the presence of extrapancreatic lesions, including SC, and was also useful in the evaluation of the response to steroid therapy for following the course of AIP.
Collapse
Affiliation(s)
- Etsushi Kawamura
- Department of Nuclear Medicine, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|