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Mills KC, Majumder S. What Is the Latest in Autoimmune Pancreatitis. Gastroenterol Clin North Am 2025; 54:245-258. [PMID: 39880531 DOI: 10.1016/j.gtc.2024.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2025]
Abstract
Autoimmune pancreatitis (AIP) is a steroid-responsive fibroinflammatory disorder with 2 clinically distinct subtypes known as type 1 autoimmune and type 2 autoimmune pancreatitis. Type 1 AIP is considered the pancreatic manifestation of immunoglobulin G4-related disease, a systemic disease often presenting with other organ involvement. Advances in understanding the unique clinical presentation, imaging findings, histopathology, and clinical course of this relatively uncommon disease have led to international consensus regarding diagnosis and treatment. While corticosteroids remain the mainstay of treatment, several emerging novel therapies have been explored primarily in the context or relapsing and refractory cases.
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Affiliation(s)
- Krystal C Mills
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Shounak Majumder
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
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2
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Mittal N, Oza VM, Muniraj T, Kothari TH. Diagnosis and Management of Acute Pancreatitis. Diagnostics (Basel) 2025; 15:258. [PMID: 39941188 PMCID: PMC11816589 DOI: 10.3390/diagnostics15030258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2024] [Revised: 01/14/2025] [Accepted: 01/16/2025] [Indexed: 02/16/2025] Open
Abstract
Acute pancreatitis is an inflammatory condition of the exocrine pancreas that is a common indication for hospital admission and has had an increasing incidence in the last few decades. The diagnosis of acute pancreatitis requires the satisfaction of two out of three criteria: (1) abdominal pain radiating to the back, (2) serum lipase or amylase levels three or more times the upper limit of the normal level, and (3) findings indicating pancreatitis obtained via a computed tomography (CT) scan or magnetic resonance imaging (MRI). The different etiologies include gallstones, autoimmune disorders, alcohol abuse, smoking, hypertriglyceridemia, obesity, drugs, and post-endoscope retrograde cholangiopancreatography (ERCP). The initial investigation includes serum amylase and lipase analysis, a lipid panel including triglycerides, analysis of immunoglobulins, a full blood count, electrolyte analysis, a hemoglobin A1c test, a complete metabolic panel, and transabdominal ultrasound. The initial therapy includes oxygen supplementation, the provision of intravenous fluids, pain control, and a nutrition regime. Early oral feeding is encouraged if tolerated; if not, liquid supplement provision or enteral tube feeding within 48 h of admission has shown better outcomes. Some complications of acute pancreatitis are necrosis, infection, insulin resistance leading to diabetes mellitus, and pancreatic exocrine insufficiency requiring enzyme supplementation. Patients need to attend regular follow-ups and abstain from alcohol and smoking (if warranted) to prevent the recurrence of acute pancreatitis. The mortality rate of acute pancreatitis has decreased in the past few decades because of better management skills, but the recent rise in acute pancreatitis episodes is concerning. Sustained endeavors through clinical trials are required to establish a broad variety of drugs that can be used for acute pancreatitis episodes.
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Affiliation(s)
- Nitish Mittal
- Department of Internal Medicine, The University of Texas Health Sciences Center, Houston, TX 77030, USA (V.M.O.)
| | - Veeral M. Oza
- Department of Internal Medicine, The University of Texas Health Sciences Center, Houston, TX 77030, USA (V.M.O.)
- Section of Digestive Disease, Edward via College of Osteopathic Medicine and Bon Secours Mercy Health Medical Center, Greenville, SC 29673, USA
| | - Thiruvengadam Muniraj
- Section of Digestive Disease, Yale University School of Medicine, New Haven, CT 06520, USA;
| | - Truptesh H. Kothari
- Section of Digestive Disease, University of Rochester Medical Center, Rochester, NY 14642, USA
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3
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Farhat H, Dib C, Tlaiss Y, Tabcheh A, Hani P. A Rare Case of Autoimmune Pancreatitis in a 9-Year-Old Male Patient: A Comprehensive Diagnosis and Successful Treatment. Case Rep Gastrointest Med 2024; 2024:5564385. [PMID: 39670183 PMCID: PMC11637616 DOI: 10.1155/crgm/5564385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 06/25/2024] [Accepted: 11/27/2024] [Indexed: 12/14/2024] Open
Abstract
Autoimmune pancreatitis (AIP) is a rare and complex condition that can be difficult to identify due to its resemblance to malignancies. This case report presents a unique instance of AIP in a 9-year-old male patient who presented with painless jaundice and elevated liver function test results. His symptoms were persistent even after previous common bile duct stent placement, requiring additional investigation. The possibility of AIP was raised by further serological tests and imaging examinations. The diagnosis was then confirmed by multiple characteristic findings revealed through history, imaging, clinical examination, histology, and lab results. Treatment was initiated with corticosteroids, which resulted in a complete resolution of symptoms and remarkable recovery. This case emphasizes the significance of including AIP in the differential diagnosis of pancreatic disorders, even in pediatric patients.
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Affiliation(s)
- Hadi Farhat
- Department of General Surgery, Faculty of Medicine and Medical Sciences, University of Balamand, Dekwaneh, Beirut, Lebanon
| | - Christie Dib
- Department of General Surgery, Faculty of Medicine and Medical Sciences, University of Balamand, Dekwaneh, Beirut, Lebanon
| | - Yehya Tlaiss
- Department of General Surgery, Faculty of Medicine and Medical Sciences, University of Balamand, Dekwaneh, Beirut, Lebanon
| | - Ayman Tabcheh
- Department of Gastroenterology, Faculty of Medicine and Medical Sciences, University of Balamand, Dekwaneh, Beirut, Lebanon
| | - Pierre Hani
- Department of Gastroenterology, Faculty of Medicine and Medical Sciences, University of Balamand, Dekwaneh, Beirut, Lebanon
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Kane K, Velayos FS, Lee JK, Cherny S, Karia K. A Response-able Diagnosis: Type 2 Autoimmune Pancreatitis in the Setting of Ulcerative Colitis. Dig Dis Sci 2024; 69:1934-1938. [PMID: 38637453 DOI: 10.1007/s10620-024-08408-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Accepted: 03/26/2024] [Indexed: 04/20/2024]
Affiliation(s)
- Kevin Kane
- Department of Gastroenterology and Hepatology, Kaiser Permanente San Francisco Medical Center, 2350 Geary Boulevard, 2nd Floor, San Francisco, CA, 94115, USA.
| | - Fernando S Velayos
- Department of Gastroenterology and Hepatology, Kaiser Permanente San Francisco Medical Center, 2350 Geary Boulevard, 2nd Floor, San Francisco, CA, 94115, USA
| | - Jeffrey K Lee
- Department of Gastroenterology and Hepatology, Kaiser Permanente San Francisco Medical Center, 2350 Geary Boulevard, 2nd Floor, San Francisco, CA, 94115, USA
| | - Sarah Cherny
- Department of Pathology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - Kunal Karia
- Department of Gastroenterology and Hepatology, Kaiser Permanente San Francisco Medical Center, 2350 Geary Boulevard, 2nd Floor, San Francisco, CA, 94115, USA
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5
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Gallo C, Dispinzieri G, Zucchini N, Invernizzi P, Massironi S. Autoimmune pancreatitis: Cornerstones and future perspectives. World J Gastroenterol 2024; 30:817-832. [PMID: 38516247 PMCID: PMC10950636 DOI: 10.3748/wjg.v30.i8.817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/18/2023] [Accepted: 01/25/2024] [Indexed: 02/26/2024] Open
Abstract
Autoimmune pancreatitis (AIP) is an autoimmune subtype of chronic pancreatitis resulting from the aberrant immune response against the pancreas, leading to inflammation and fibrosis. Although AIP is rare, its incidence is increasing and is often misdiagnosed as other pancreatic diseases. AIP is commonly classified into two types. Type 1 AIP (AIP-1) is typically associated with elevated serum immunoglobulin G4 (IgG4) levels and systemic manifestations, while type 2 AIP is typically a more localized form of the disease, and may coexist with other autoimmune disorders, especially inflammatory bowel diseases. Additionally, there is emerging recognition of a third type (type 3 AIP), which refers to immunotherapy-triggered AIP, although this classification is still gaining acceptance in medical literature. The clinical manifestations of AIP mainly include painless jaundice and weight loss. Elevated serum IgG4 levels are particularly characteristic of AIP-1. Diagnosis relies on a combination of clinical, laboratory, radiological, and histological findings, given the similarity of AIP symptoms to other pancreatic disorders. The mainstay of treatment for AIP is steroid therapy, which is effective in most cases. Severe cases might require additional imm-unosuppressive agents. This review aims to summarize the current knowledge of AIP, encompassing its epidemiology, etiology, clinical presentation, diagnosis, and treatment options. We also address the challenges and controversies in diagnosing and treating AIP, such as distinguishing it from pancreatic cancer and managing long-term treatment, highlighting the need for increased awareness and knowledge of this complex disease.
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Affiliation(s)
- Camilla Gallo
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, Fondazione IRCCS San Gerardo dei Tintori; University of Milano-Bicocca, Monza 20900, Italy
| | - Giulia Dispinzieri
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, Fondazione IRCCS San Gerardo dei Tintori; University of Milano-Bicocca, Monza 20900, Italy
| | - Nicola Zucchini
- Department of Pathology, Fondazione IRCCS San Gerardo dei Tintori, Monza 20900, Italy
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, Fondazione IRCCS San Gerardo dei Tintori; University of Milano-Bicocca, Monza 20900, Italy
| | - Sara Massironi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, Fondazione IRCCS San Gerardo dei Tintori; University of Milano-Bicocca, Monza 20900, Italy
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6
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Hines OJ, Pandol SJ. Management of chronic pancreatitis. BMJ 2024; 384:e070920. [PMID: 38408777 DOI: 10.1136/bmj-2023-070920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Chronic pancreatitis results from repeated episodes of pancreatic inflammation and associated fibrosis leading to the loss of functional exocrine and endocrine pancreatic function. The disease is manifested by abdominal pain, deterioration in quality of life, food maldigestion and malabsorption, diabetes, and an increased risk for pancreatic adenocarcinoma. This review summarizes the latest evidence on the diagnosis and management of chronic pancreatitis and its manifestations. In particular, this review discusses advances in understanding of the role of genetic disorders in the mechanisms of the disease and surgical options for patients refractory to medical therapy. Furthermore, clinical trials are under way to develop medical therapeutics.
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Affiliation(s)
- O Joe Hines
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Stephen J Pandol
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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7
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Agboola AA, Mohamed KH, Syed M, Shiwlani S, Butt R, Reza RR, Haseeb M, Nasir H. Type 1 Autoimmune Pancreatitis Masquerading as Pancreatic Head Carcinoma. Cureus 2023; 15:e47471. [PMID: 38022068 PMCID: PMC10662655 DOI: 10.7759/cureus.47471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2023] [Indexed: 12/01/2023] Open
Abstract
Obstructive jaundice is a joint clinical presentation with many etiologies, including pancreatic cancer and autoimmune pancreatitis (AIP). Differentiating between these two conditions is pivotal due to the divergent management approaches and prognoses. In this case report, we present a case of a 49-year-old female patient who presented with weight loss, intermittent chronic abdominal pain, and jaundice. She was initially suspected of having pancreatic cancer because of clinical presentation and imaging findings. However, she was ultimately diagnosed with Type 1 AIP due to histopathology findings and elevated immunoglobulin G4. This case highlights the complexities in diagnosis, the role of advanced imaging techniques and tissue sampling, and the lessons learned regarding managing this challenging clinical scenario.
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Affiliation(s)
| | - Khalid H Mohamed
- Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, GBR
| | - Maria Syed
- Surgery, Aga Khan University Hospital, Karachi, PAK
| | | | - Rowaida Butt
- Family Medicine, Avalon University School of Medicine, Ohio, USA
| | | | - Muhammad Haseeb
- Internal Medicine, Allama Iqbal Medical College, Lahore, PAK
- Internal Medicine, Bahria International Hospital, Lahore, PAK
| | - Hira Nasir
- Internal Medicine, Mayo Hospital, Lahore, PAK
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Chatterjee A, de la Fuente J, Rech KL, Takahashi N, Majumder S. A Rare Cause of Abdominal Pain: Erdheim-Chester Disease. ACG Case Rep J 2023; 10:e01049. [PMID: 37305802 PMCID: PMC10249710 DOI: 10.14309/crj.0000000000001049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 04/06/2023] [Indexed: 06/13/2023] Open
Abstract
A 65-year-old man presented with hematuria, night sweats, nausea, intermittent nonbloody diarrhea, and abdominal pain. Computed tomography angiogram with enterography showed retroperitoneal fibrosis surrounding both kidneys and ureters without any evidence of vascular obstruction or hydronephrosis. Laparoscopic biopsy demonstrated fibroadipose tissue involved by a subtle histiocytic infiltrate in a background of marked fibrosis, scattered lymphocytes, and plasma cells. The histiocytes strongly expressed CD163, Factor XIIIa, and BRAF V600E. He was diagnosed with Erdheim-Chester disease, a rare histiocytic neoplasm uncommonly presenting with gastroenterological manifestations.
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Affiliation(s)
- Arjun Chatterjee
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH
| | - Jaime de la Fuente
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Karen L. Rech
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Shounak Majumder
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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Creech ZA, Shastri D, Hussain MW, Ikram W, MacElwee M. A Case of Autoimmune Pancreatitis Presenting As Alcohol-Induced Necrotizing Pancreatitis. Cureus 2023; 15:e39616. [PMID: 37388613 PMCID: PMC10300237 DOI: 10.7759/cureus.39616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2023] [Indexed: 07/01/2023] Open
Abstract
Autoimmune pancreatitis (AIP) is an inflammatory condition of the pancreas, commonly characterized by elevated levels of immunoglobulin G (IgG) 4. Diagnosis of this condition can be challenging in patients with risk factors for other pancreatitis etiologies and requires a comprehensive approach utilizing clinical, radiologic, and laboratory findings. Here, we present a case of an individual with a history of multiple prior hospitalizations for alcoholic pancreatitis, who presented with symptoms of abdominal pain, nausea, and vomiting. Computed tomography (CT) imaging revealed intra-abdominal abscesses and findings consistent with pancreatitis. Further laboratory results revealed elevated lipase and IgG4 levels, indicating AIP as the underlying cause. This case highlights the importance of considering AIP as a differential diagnosis in individuals presenting with pancreatic disease.
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Affiliation(s)
- Zachary A Creech
- Department of Internal Medicine, Creighton University School of Medicine, Phoenix, USA
| | - Divya Shastri
- Department of Internal Medicine, Creighton University School of Medicine, Phoenix, USA
| | | | - Waleed Ikram
- Department of Internal Medicine, Creighton University School of Medicine, Phoenix, USA
| | - Mark MacElwee
- Department of Internal Medicine, Valleywise Health Medical Center, Phoenix, USA
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Awadelkarim B, Vila J, Nayar MK, Leeds JS, Griffiths B, Oppong KW. Pancreaticobiliary versus head and neck presentation of immunoglobulin G4-related disease: different sides of the same coin? BMJ Open Gastroenterol 2023; 10:bmjgast-2022-000961. [PMID: 36707105 PMCID: PMC9884923 DOI: 10.1136/bmjgast-2022-000961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 12/07/2022] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND AND STUDY AIM Immunoglobulin G4-related disease (IgG4-RD) is a rare immune mediated fibroinflammatory condition. Pancreaticobiliary (PB) and head and neck (HN) are two of the most commonly involved anatomical sites. It has been postulated that PB IgG4-RD and HN IgG4-RD have distinct clinical phenotypes. Whether the optimum treatment regimen or response to therapy differs between them is unknown. We aimed to assess differences between PB and HN IgG4-RD in a cohort of IgG4 disease managed by an IgG4-RD multispecialty team. METHODS We performed a retrospective study of a prospectively maintained multidisciplinary IgG4-RD database to identify patients diagnosed with PB and HN IgG4-RD (based on initial presentation) between 2005 and 2019. The electronic patient records were reviewed. Use of immunosuppressive agents and clinical course was analysed. RESULTS 60 patients with PB IgG4-RD and 14 with HN IgG4-RD were included in the study. PB IgG4-RD was associated with older age at diagnosis 64 versus 51 years (p<0.001), higher serum IgG4 level as a multiple of upper limit of normal median (IQR) 2 (1-3.75) vs 1 (1-2), (p=0.04) and greater proportion with more than one organ involved 68% vs 33% (p=0.03). HN IgG4-RD was more likely to receive second-line therapy 71% versus 36% (p=0.03). Persistent elevation of serum IgG4 after therapy was more common in PB IgG4-RD 84% versus 43% (p=0.03). CONCLUSION These findings support the contention that PB IgG4-RD and HN IgG4-RD have different clinical profiles and represent distinct subtypes of IgG4-RD.
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Affiliation(s)
- Bidour Awadelkarim
- HPB Medicine, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Josephine Vila
- Rheumatology Department, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Manu K Nayar
- HPB Medicine, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - John S Leeds
- HPB Medicine, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Bridget Griffiths
- Rheumatology Department, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Kofi W Oppong
- HPB Medicine, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK .,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
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Sano T, Kikuta K, Takikawa T, Matsumoto R, Hamada S, Sasaki A, Kataoka F, Ikeda M, Miura S, Kume K, Masamune A. The M-ANNHEIM-AiP-Activity-Score is useful for predicting relapse in patients with type 1 autoimmune pancreatitis. Pancreatology 2023; 23:112-119. [PMID: 36509645 DOI: 10.1016/j.pan.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 11/17/2022] [Accepted: 12/03/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND/OBJECTIVES Proper assessment of disease activity and prediction of relapse are crucial for the management of autoimmune pancreatitis (AIP). The M-ANNHEIM-AiP-Activity-Score (MAAS) has been proposed to determine disease activity and predict relapse in German and Swedish patients with AIP. MAAS is calculated using six categories: pain report, pain control, exocrine insufficiency, endocrine insufficiency, imaging, and complications. This study aimed to clarify the usefulness of MAAS to predict relapse in Japanese patients with type 1 AIP. METHODS We retrospectively analyzed 117 patients with type 1 AIP undergoing initial and maintenance steroid treatments at our institute between April 2006 and March 2021. AIP was diagnosed according to the Japanese Diagnostic Criteria for AIP 2018. We examined the association of MAAS with relapse during and after maintenance treatment. RESULTS MAAS (median, 8 points) at the start of the initial treatment was reduced after treatment (median, 4 points; P < 0.001). A MAAS ≥11 points at the start of the initial treatment was associated with relapse. The initial treatment-induced reduction of MAAS<60% was more frequent in patients with relapse (75.0%) than in patients without relapse (37.6%; P = 0.007). MAAS at the start of maintenance treatment was higher for patients with relapse (median, 5 points) than that for patients without relapse (median, 4 points; P = 0.007). MAAS ≥4 points at the start of maintenance treatment was associated with subsequent relapse. CONCLUSIONS MAAS is useful for predicting relapse in patients with type 1 AIP undergoing maintenance therapy.
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Affiliation(s)
- Takanori Sano
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan
| | - Kazuhiro Kikuta
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan
| | - Tetsuya Takikawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan
| | - Ryotaro Matsumoto
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan
| | - Shin Hamada
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan
| | - Akira Sasaki
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan
| | - Fumiya Kataoka
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan
| | - Mio Ikeda
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan
| | - Shin Miura
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan
| | - Kiyoshi Kume
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan.
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12
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Ma DM, Dong XW, Han X, Ling Z, Lu GT, Sun YY, Yin XD. Pancreatitis and Pancreatic Cancer Risk. Technol Cancer Res Treat 2023; 22:15330338231164875. [PMID: 36972517 PMCID: PMC10052482 DOI: 10.1177/15330338231164875] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Purpose: The present retrospective study aimed to explore the relationship between pancreatitis and pancreatic cancer in the population cohort of the UK Biobank (UKB) (https://www.ukbiobank.ac.uk). Methods: From the 500 thousand population cohort of UKB, according to the age and gender of patients with pancreatic cancer 1:10, matching the control without pancreatic cancer, the binary Logistic regression model was used to analyze the relationship between pancreatitis and pancreatic cancer, and subgroup analyses were used to identify potential effect modifiers. Results: A total of 1538 patients with pancreatic cancer were compared with 15 380 controls. In the fully adjusted model, patients with pancreatitis had a significantly increased risk of pancreatic cancer compared with no pancreatitis. The risk of pancreatitis and pancreatic cancer increased with the age of pancreatitis, and the risk of pancreatic cancer was highest in the 61 to 70 age group. In addition, in the first 3 years of acute pancreatitis, the risk of pancreatic cancer increased significantly with the increase in the duration of the disease (odds ratio [OR] 29.13, 95% confidence interval [CI]: 16.34-51.93), after 3 years, the trend of increase decreased. After more than 10 years, there was no significant correlation between the risk of acute pancreatitis and pancreatic cancer. However, patients with chronic pancreatitis were significantly associated with an increased risk of pancreatic cancer only in the first 3 years (OR 28.14, 95% CI: 14.86-53.31). Conclusion: Pancreatitis may associate with an increased risk of pancreatic cancer. The older the age of pancreatitis, the higher the risk of pancreatic cancer. The risk of pancreatic cancer increases significantly in the first 3 years of the course of pancreatitis. This may provide an alternative strategy for the early identification of individuals at high risk of pancreatic cancer.
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Affiliation(s)
- Dong-Mei Ma
- Department of Oncology, 587863Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Xiao-Wu Dong
- Pancreatic Center, 587863Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
- Yangzhou Key Laboratory of Pancreatic Diseases, Yangzhou, China
| | - Xiao Han
- Department of Oncology, 587863Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Zhi Ling
- Department of Oncology, 587863Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Guo-Tao Lu
- Pancreatic Center, 587863Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
- Yangzhou Key Laboratory of Pancreatic Diseases, Yangzhou, China
| | - Yun-Yun Sun
- Pancreatic Center, 587863Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
- Yangzhou Key Laboratory of Pancreatic Diseases, Yangzhou, China
| | - Xu-Dong Yin
- Department of Oncology, 587863Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
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13
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Mack S, Flattet Y, Bichard P, Frossard JL. Recent advances in the management of autoimmune pancreatitis in the era of artificial intelligence. World J Gastroenterol 2022; 28:6867-6874. [PMID: 36632320 PMCID: PMC9827582 DOI: 10.3748/wjg.v28.i48.6867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 10/31/2022] [Accepted: 11/16/2022] [Indexed: 12/26/2022] Open
Abstract
Autoimmune pancreatitis (AIP) is a type of immune-mediated pancreatitis subdivided into two subtypes, type 1 and type 2 AIP. Furthermore, type 1 AIP is considered to be the pancreatic manifestation of the immunoglobulin G4 (IgG4)-related disease. Nowadays, AIP is increasingly researched and recognized, although its diagnosis represents a challenge for several reasons: False positive ultrasound-guided cytological samples for a neoplastic process, difficult to interpret levels of IgG4, the absence of biological markers to diagnose type 2 AIP, and the challenging clinical identification of atypical forms. Furthermore, 60% and 78% of type 1 and type 2 AIP, respectively, are retrospectively diagnosed on surgical specimens of resected pancreas for suspected cancer. As distinguishing AIP from pancreatic ductal adenocarcinoma can be challenging, obtaining a definitive diagnosis can therefore prove difficult, since endoscopic ultrasound fine-needle aspiration or biopsy of the pancreas are suboptimal. This paper focuses on recent innovations in the management of AIP with regard to the use of artificial intelligence, new serum markers, and new therapeutic approaches, while it also outlines the current management recommendations. A better knowledge of AIP can reduce the recourse to surgery and avoid its overuse, although such an approach requires close collaboration between gastroenterologists, surgeons and radiologists. Better knowledge on AIP and IgG4-related disease remains necessary to diagnose and manage patients.
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Affiliation(s)
- Sahar Mack
- Division of Gastroenterology, Department of Medical Specialties, University Hospital of Geneva, Geneva 1205, Switzerland
| | - Yves Flattet
- Division of Gastroenterology, Department of Medical Specialties, University Hospital of Geneva, Geneva 1205, Switzerland
| | - Philippe Bichard
- Division of Gastroenterology, Department of Medical Specialties, University Hospital of Geneva, Geneva 1205, Switzerland
| | - Jean Louis Frossard
- Division of Gastroenterology, Department of Medical Specialties, University Hospital of Geneva, Geneva 1205, Switzerland
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Shiraishi M, Igarashi T, Hiroaki F, Oe R, Ohki K, Ojiri H. Radiomics based on diffusion-weighted imaging for differentiation between focal-type autoimmune pancreatitis and pancreatic carcinoma. Br J Radiol 2022; 95:20210456. [PMID: 35946923 PMCID: PMC9733621 DOI: 10.1259/bjr.20210456] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 07/31/2022] [Accepted: 08/04/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To evaluate the parameters of support vector machine (SVM) using imaging data generated from the apparent diffusion coefficient (ADC) to differentiate between focal-type autoimmune pancreatitis (f-AIP) and pancreatic ductal adenocarcinoma (PDAC) when using SVM based on diffusion-weighted imaging. METHODS The 2D-ADCmean and texture parameters (16 texture features × [non-filter+17 filters]) were retrospectively segmented by 2 readers in 28 patients with f-AIP and 77 patients with pathologically proven PDAC. The diagnostic accuracy of the SVM model was evaluated by receiver operating characteristic curve analysis and calculation of the area under the curve (AUC). Interreader reliability was assessed by intraclass correlation coefficient (ICC). RESULTS The 2D-ADCmean and 3D-ADCmean were significantly lower in cases of f-AIP (1.10-1.15 × 10-3 mm2/s and 1.21-1.23× 10-3 mm2/s, respectively) vs PDAC (1.29-1.33 × 10-3 mm2/s and 1.41-1.43 × 10-3 mm2/s, respectively), with excellent and good interreader reliability, respectively (ICC = 0.909 and 0.891, respectively). Among the texture parameters, energy with exponential filtering yielded the highest AUC (Reader 1: 74.7%, Reader 2: 81.5%), with fair interreader reliability (ICC = 0.707). The non-linear SVM, a combination of 2D-ADCmean, object volume and exponential-energy showed an AUC value of 96.2% in the testing cohorts. CONCLUSION Our results suggest that non-linear SVM using a combination of 2D-ADCmean, object volume, and exponential-energy may assist in differentiating f-AIP from PDAC. ADVANCES IN KNOWLEDGE The radiomics based on an apparent diffusion coefficient value may assist in differentiating f-AIP from PDAC.
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Affiliation(s)
- Megumi Shiraishi
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Takao Igarashi
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Fujioka Hiroaki
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Rika Oe
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Kazuyoshi Ohki
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroya Ojiri
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
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15
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Szatmary P, Grammatikopoulos T, Cai W, Huang W, Mukherjee R, Halloran C, Beyer G, Sutton R. Acute Pancreatitis: Diagnosis and Treatment. Drugs 2022; 82:1251-1276. [PMID: 36074322 PMCID: PMC9454414 DOI: 10.1007/s40265-022-01766-4] [Citation(s) in RCA: 228] [Impact Index Per Article: 76.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2022] [Indexed: 11/11/2022]
Abstract
Acute pancreatitis is a common indication for hospital admission, increasing in incidence, including in children, pregnancy and the elderly. Moderately severe acute pancreatitis with fluid and/or necrotic collections causes substantial morbidity, and severe disease with persistent organ failure causes significant mortality. The diagnosis requires two of upper abdominal pain, amylase/lipase ≥ 3 ×upper limit of normal, and/or cross-sectional imaging findings. Gallstones and ethanol predominate while hypertriglyceridaemia and drugs are notable among many causes. Serum triglycerides, full blood count, renal and liver function tests, glucose, calcium, transabdominal ultrasound, and chest imaging are indicated, with abdominal cross-sectional imaging if there is diagnostic uncertainty. Subsequent imaging is undertaken to detect complications, for example, if C-reactive protein exceeds 150 mg/L, or rarer aetiologies. Pancreatic intracellular calcium overload, mitochondrial impairment, and inflammatory responses are critical in pathogenesis, targeted in current treatment trials, which are crucially important as there is no internationally licenced drug to treat acute pancreatitis and prevent complications. Initial priorities are intravenous fluid resuscitation, analgesia, and enteral nutrition, and when necessary, critical care and organ support, parenteral nutrition, antibiotics, pancreatic exocrine and endocrine replacement therapy; all may have adverse effects. Patients with local complications should be referred to specialist tertiary centres to guide further management, which may include drainage and/or necrosectomy. The impact of acute pancreatitis can be devastating, so prevention or reduction of the risk of recurrence and progression to chronic pancreatitis with an increased risk of pancreas cancer requires proactive management that should be long term for some patients.
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Affiliation(s)
- Peter Szatmary
- Liverpool Pancreatitis Research Group, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Tassos Grammatikopoulos
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Wenhao Cai
- Liverpool Pancreatitis Research Group, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,West China Centre of Excellence for Pancreatitis and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Huang
- West China Centre of Excellence for Pancreatitis and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Rajarshi Mukherjee
- Liverpool Pancreatitis Research Group, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.,Department of Molecular Physiology and Cell Signalling, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool , UK
| | - Chris Halloran
- Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Georg Beyer
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Robert Sutton
- Liverpool Pancreatitis Research Group, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK. .,Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK. .,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
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16
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Correlation of Autoimmune Pancreatitis and Malignancy: Systematic Review and Meta-Analysis. Dig Dis Sci 2022; 67:3252-3264. [PMID: 34297267 DOI: 10.1007/s10620-021-07179-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 07/14/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND There is conflicting evidence regarding autoimmune pancreatitis (AIP) association with pancreatic and non-pancreatic cancers. Literature lacks data on overall prevalence of malignancies in autoimmune pancreatitis. AIM Given the lack of definite evidence, we aimed to pool and summarize data from available literature regarding prevalence of different malignancies in AIP. METHODS We conducted a systematic search of MEDLINE, EMBASE, Cochrane Register of Controlled Trials, and Web of Science through February 16, 2021, to include observational studies assessing the incidence of cancer in AIP. We used the DerSimonian-Laird method with random effects for meta-analysis. Pooled prevalence, 95% confidence interval (CI), and I2 statistic are reported. RESULTS A total of 17 studies with 2746 patients were included assessing the prevalence of cancer in AIP. The overall prevalence of cancer in AIP was 9.6% [95% confidence interval (CI), 5.7-13.5%]. The cancers with the highest prevalence in AIP population were gastric and colorectal cancer, with prevalence of 1.3% (95% CI, 0.5-2.1%) and 1.2% (95% CI, 0.6-1.8%), respectively. CONCLUSION We demonstrate the prevalence of different cancers in AIP. Inflammatory surge in AIP and subsequent carcinogenesis is one explanation for this association. Moreover, AIP can be a paraneoplastic syndrome manifestation of malignancies.
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17
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Massironi S, Fanetti I, Viganò C, Pirola L, Fichera M, Cristoferi L, Capurso G, Invernizzi P, Danese S. Systematic review-pancreatic involvement in inflammatory bowel disease. Aliment Pharmacol Ther 2022; 55:1478-1491. [PMID: 35505465 PMCID: PMC9322673 DOI: 10.1111/apt.16949] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/28/2022] [Accepted: 04/18/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) is a chronic inflammatory immune-mediated disorder of the gut with frequent extra-intestinal complications. Pancreatic involvement in IBD is not uncommon and comprises a heterogeneous group of conditions, including acute pancreatitis (AP), chronic pancreatitis (CP), autoimmune pancreatitis (AIP) and pancreatic exocrine insufficiency (PEI); however, data on such an association remain sparse and heterogeneous. METHOD PubMed/MEDLINE and EMBASE databases were searched for studies investigating pancreatic involvement in patients with IBD. RESULTS Four thousand one hundred and twenty-one records were identified and 547 screened; finally, 124 studies were included in the review. AP is the most frequent pancreatic manifestation in IBD; the majority of AP cases in IBD are due to gallstones and drugs but cases of idiopathic AP are increasingly reported. AIP is a rare disease, but a strong association with IBD has been demonstrated, especially for type 2 and ulcerative colitis. The pathogenetic link between IBD and AIP remains unclear, but an immune-mediated pathway seems plausible. An association between CP and PEI with IBD has also been suggested, but data are to date scarce and conflicting. CONCLUSION This is the first systematic review of the association between IBD and pancreatic diseases. Gallstones and drugs should be considered the most probable causes of AP in IBD, with type 2 AIP also being possible.
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Affiliation(s)
- Sara Massironi
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMonzaItaly
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE‐LIVER)San Gerardo HospitalMonzaItaly
| | - Ilaria Fanetti
- Gastroenterology and Endoscopy Unit, ASST Ovest MilaneseLegnano HospitalLegnanoItaly
| | - Chiara Viganò
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMonzaItaly
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE‐LIVER)San Gerardo HospitalMonzaItaly
| | - Lorena Pirola
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMonzaItaly
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE‐LIVER)San Gerardo HospitalMonzaItaly
| | - Maria Fichera
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMonzaItaly
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE‐LIVER)San Gerardo HospitalMonzaItaly
| | - Laura Cristoferi
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMonzaItaly
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE‐LIVER)San Gerardo HospitalMonzaItaly
| | - Gabriele Capurso
- Pancreas Translational & Clinical Research Center, Pancreato‐Biliary Endoscopy & Endosonography DivisionSan Raffaele Scientific Institute IRCCSMilanItaly
| | - Pietro Invernizzi
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMonzaItaly
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE‐LIVER)San Gerardo HospitalMonzaItaly
| | - Silvio Danese
- Gastroenterology and EndoscopyIRCCS Ospedale San Raffaele and Vita‐Salute San Raffaele UniversityMilanItaly
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Long-Term Follow-Up and Immunomonitoring of Relapsing Type 1 Autoimmune Pancreatitis Treated With Rituximab. Pancreas 2022; 51:452-462. [PMID: 35835119 DOI: 10.1097/mpa.0000000000002048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES To evaluate the efficacy and safety of rituximab in relapsing type 1 autoimmune pancreatitis especially the long-term clinical and immunologic impacts. METHODS All consecutive patients with type 1 autoimmune pancreatitis were retrospectively included. The rituximab protocol was induction therapy of 375 mg·m -2 intravenous weekly for 4 weeks, followed by 500 mg intravenous every 6 months for 2 years. The follow-up included clinical examinations, biological tests, positron emission tomography scan, and immunomonitoring of lymphocyte CD 19+. RESULTS Among the 43 patients included, 15 received rituximab induction therapy, followed by maintenance in 10 cases because of 1 or more relapses after steroids (whether or not followed by immunosuppressants) and multiple organ involvement. All patients had a clinical, biological and morphological response, a deep and persistent drop in serum immunoglobulin G4 levels, an extinction of both pancreatic and extra pancreatic hypermetabolic positron emission tomography scan signals, and a depletion of B lymphocyte CD19+. No relapse occurred during the follow-up (62.8 ± standard error of the mean of 11.1 months). CONCLUSIONS Rituximab is an effective treatment for type 1 autoimmune pancreatitis that provides a rapid strong clinical, biological, and morphological response, which persists after discontinuation without any safety issues.
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19
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Gandhi S, de la Fuente J, Murad MH, Majumder S. Chronic Pancreatitis Is a Risk Factor for Pancreatic Cancer, and Incidence Increases With Duration of Disease: A Systematic Review and Meta-analysis. Clin Transl Gastroenterol 2022; 13:e00463. [PMID: 35142721 PMCID: PMC8963838 DOI: 10.14309/ctg.0000000000000463] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/15/2021] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Observational studies have suggested an increased risk of pancreatic ductal adenocarcinoma (PDAC) in patients with acute and chronic pancreatitis. We conducted a systematic review and meta-analysis to evaluate the magnitude of this association and summarize the published epidemiological evidence. METHODS We searched electronic databases (MEDLINE, Embase, Web of Science, Cochrane, and Scopus) and reference lists until January 18, 2021. Studies reporting quantitative association between pancreatitis and PDAC were included and assessed for eligibility, data abstraction, and risk of bias. Standardized incidence ratios (SIRs) were pooled using the random-effects model. RESULTS Twenty-five cohort and case-control studies met inclusion criteria. Meta-analysis of 12 chronic pancreatitis (CP) studies demonstrated an increased risk of PDAC in patients with CP (SIR: 22.61, 95% confidence interval [CI]: 14.42-35.44). This elevated risk persisted in subgroup analysis of studies that excluded patients diagnosed with PDAC within 2 years of CP diagnosis (SIR: 21.77, 95% CI: 14.43-32.720). The risk was higher in hereditary pancreatitis (SIR: 63.36, 95% CI: 45.39-88.46). The cumulative incidence rates of PDAC in CP increased with follow-up duration. Limited evidence in acute pancreatitis indicates higher PDAC risk in the subset of patients eventually diagnosed with CP. PDAC seems to be uncommon in patients with autoimmune pancreatitis, with 8 reported cases in 358 patients with autoimmune pancreatitis across 4 studies. DISCUSSION There is an increased risk of PDAC in patients with CP, and incidence rates increase with CP disease duration. Our results indicate that PDAC surveillance may be considered in individuals with long-standing CP.
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Affiliation(s)
- Sonal Gandhi
- Department of Medicine, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jaime de la Fuente
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohammad Hassan Murad
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Shounak Majumder
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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20
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Agarwal KK, Jassal R, Browne A, Hossain M, Akhtar R. Autoimmune Pancreatitis Masquerading as Pancreatic Cancer: A Case Report and Literature Review. Cureus 2022; 14:e21900. [PMID: 35265424 PMCID: PMC8898479 DOI: 10.7759/cureus.21900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2022] [Indexed: 11/05/2022] Open
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21
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Masood M. Autoimmune pancreatitis: What we know so far. JGH Open 2021; 6:3-10. [PMID: 35071782 PMCID: PMC8762623 DOI: 10.1002/jgh3.12688] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 11/12/2021] [Accepted: 11/20/2021] [Indexed: 12/19/2022]
Abstract
Autoimmune pancreatitis (AIP) is a rare, often‐missed disease that involves inflammation of the pancreas and strictures of the pancreatic duct. Its prevalence and incidence in the United States remain scarce. The disease has a varied presentation and often mimics pancreatic malignancy, which can make the diagnosis challenging. Most patients have an excellent response to corticosteroid therapy. Immunomodulators may be used in some cases. Rituximab is an effective, emerging treatment in steroid‐refractory cases. This study aims to review the two distinct types of AIP and provide a detailed analysis of the diagnostic approach and treatment modalities.
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Affiliation(s)
- Muaaz Masood
- Department of Internal Medicine Medical College of Georgia at Augusta University Augusta Georgia USA
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22
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Abstract
Chronic pancreatitis is a clinical entity that results from the progressive inflammation and irreversible fibrosis of the pancreas resulting from the cumulative injury sustained by the pancreas over time. It is an illness with variable presentations that can severely impact quality of life, while its long-term complications such as exocrine pancreatic insufficiency (EPI), diabetes mellitus, and risk of pancreatic cancer can become life threatening. The diagnosis of chronic pancreatitis can be challenging as despite the recent advancements in imaging technology, the radiographic findings do not become prominent until late stages of disease. Thus, the physicians' clinical acumen in obtaining thorough history taking focusing on risk factors, clinical symptoms, in addition to high-quality imaging, often guide to the accurate diagnosis of chronic pancreatitis. Endoscopy also plays a pivotal role in the diagnosis and management of chronic pancreatitis. Endoscopic ultrasound (EUS) is believed to be the most sensitive modality for diagnosing chronic pancreatitis. Despite efforts, however, natural history studies have demonstrated that 61% of individuals with chronic pancreatitis will require at least one endoscopic intervention, while 31% will require a surgical procedure as part of their management strategy. Recent advancements in genomic studies have furthered our understanding of the genetic polymorphisms that are associated with the pathogenesis of chronic pancreatitis. Genetic testing offers the potential to reveal treatable pancreatitis-related disorders, and can inform decision making with regard to radical therapies for persistent or severe disease such as total pancreatectomy with islet autotransplantation (TPIAT). The management of patients suffering from chronic pancreatitis often requires a multi-disciplinary approach, addressing pertinent symptoms as well as the sequelae of chronic inflammation and fibrosis. Abdominal pain is the prevailing symptom and most common complication of chronic pancreatitis, and impairs quality of life. Although heavily dependent on a wide range of analgesia, endoscopic treatment such as endoscopic retrograde cholangiopancreatography (ERCP) and surgical intervention can offer long-lasting relief of symptoms. For EPI, treatment with pancreatic enzyme supplements offers marginal-to-moderate relief. The most feared complication of chronic pancreatitis-the development of pancreatic cancer-has no known prevention measure to date.
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Barker C. What Is the Cause of This Biliary Stricture? J Adv Pract Oncol 2021; 12:216-219. [PMID: 34109053 PMCID: PMC8017795 DOI: 10.6004/jadpro.2021.12.2.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
This article describes the presentation and workup of a 63-year-old male with a bile duct stricture, followed by a discussion on management.
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Affiliation(s)
- Caeli Barker
- The University of Texas MD Anderson Cancer Center, Houston, Texas
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24
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Suzuki H, Ishikawa T, Ohno E, Iida T, Uetsuki K, Yashika J, Yamada K, Yoshikawa M, Furukawa K, Nakamura M, Honda T, Ishigami M, Kawashima H, Fujishiro M. An initial trial of quantitative evaluation of autoimmune pancreatitis using shear wave elastography and shear wave dispersion in transabdominal ultrasound. Pancreatology 2021; 21:682-687. [PMID: 33648879 DOI: 10.1016/j.pan.2021.02.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 02/09/2021] [Accepted: 02/14/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES We aimed to examine therapeutic efficacy and prognosis prediction of autoimmune pancreatitis (AIP) using shear wave elastography (SWE) and shear wave dispersion (SWD) in transabdominal ultrasound (US). METHODS The subjects were 23 patients with diffuse type 1 AIP who underwent SWE and SWD, and 34 controls with a normal pancreas. Elasticity and dispersion were defined as the pancreatic elastic modulus (PEM) and dispersion slope, respectively. PEM and dispersion slope were compared between AIP and control cases, and the short-term therapeutic effect and long-term prognosis were examined. RESULTS PEM (30.9 vs. 6.6 kPa, P < 0.001) and dispersion slope (15.3 vs. 13.0 (m/sec)/kHz, P = 0.011) were significantly higher in AIP cases than in controls. Among the 17 AIP patients followed-up in two weeks after treatment, these parameters were 12.7 kPa and 10.5 (m/sec)/kHz with median decrease rate of 37.2% and 32.8%, respectively, which were significantly higher than the change in the size of pancreatic parenchyma (14.4%, P = 0.026). Fourteen of these subjects were followed up for >12 months, during which 2 had relapse; diabetes improved in 5 and worsened in 2; in 60% of cases, the pancreatic parenchyma was atrophied. The % change in PEM after two weeks was tended to be higher in non-atrophy cases. CONCLUSION SWE and SWD measurement in US may be useful for quantitative assessment of AIP and evaluation of short-term treatment efficacy.
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Affiliation(s)
- Hirotaka Suzuki
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan, 65 Tsuruma-Cho, Showa-ku, Nagoya City, 466-8550, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan, 65 Tsuruma-Cho, Showa-ku, Nagoya City, 466-8550, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan, 65 Tsuruma-Cho, Showa-ku, Nagoya City, 466-8550, Japan
| | - Tadashi Iida
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan, 65 Tsuruma-Cho, Showa-ku, Nagoya City, 466-8550, Japan
| | - Kota Uetsuki
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan, 65 Tsuruma-Cho, Showa-ku, Nagoya City, 466-8550, Japan
| | - Jun Yashika
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan, 65 Tsuruma-Cho, Showa-ku, Nagoya City, 466-8550, Japan
| | - Kenta Yamada
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan, 65 Tsuruma-Cho, Showa-ku, Nagoya City, 466-8550, Japan
| | - Masakatsu Yoshikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan, 65 Tsuruma-Cho, Showa-ku, Nagoya City, 466-8550, Japan
| | - Kazuhiro Furukawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan, 65 Tsuruma-Cho, Showa-ku, Nagoya City, 466-8550, Japan
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan, 65 Tsuruma-Cho, Showa-ku, Nagoya City, 466-8550, Japan
| | - Takashi Honda
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan, 65 Tsuruma-Cho, Showa-ku, Nagoya City, 466-8550, Japan
| | - Masatoshi Ishigami
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan, 65 Tsuruma-Cho, Showa-ku, Nagoya City, 466-8550, Japan
| | - Hiroki Kawashima
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan 65 Tsuruma-Cho, Showa-ku, Nagoya City, 466-8550, Japan.
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan, 65 Tsuruma-Cho, Showa-ku, Nagoya City, 466-8550, Japan
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Yoon SB, Moon SH, Kim JH, Park JW, Kim SE, Kim MH. Determination of the duration of glucocorticoid therapy in type 1 autoimmune pancreatitis: A systematic review and meta-analysis. Pancreatology 2021; 21:S1424-3903(21)00474-9. [PMID: 34090808 DOI: 10.1016/j.pan.2021.05.303] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/18/2021] [Accepted: 05/21/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The indications for maintenance glucocorticoid therapy (MGT) and its duration after initial remission of type 1 autoimmune pancreatitis (AIP) remain controversial. In contrast to the Japanese treatment protocol, the Mayo protocol does not recommend MGT after initial remission. This study aimed to evaluate the relapse rate in patients with type 1 AIP according to the duration of glucocorticoid therapy. METHODS We conducted a systematic literature review up until November 30, 2020, and identified 40 studies reporting AIP relapse rates. The pooled relapse rates were compared between groups according to the protocol and duration of glucocorticoids (routine vs. no MGT; glucocorticoids ≤6 months vs. 6-12 months vs. 12-36 months vs. ≥ 36 months). The pooled rates of adverse events related to glucocorticoids were also evaluated. RESULTS Meta-analysis indicated calculated pooled relapse rates of 46.6% (95% confidence interval (CI), 38.9-54.3%) with glucocorticoids for ≤ 6 months, 44.3% (95% CI, 38.8-49.8%) for 6-12 months, 34.1% (95% CI, 28.6-39.7%) for 12-36 months, and 27.0% (95% CI, 23.4-30.6%) for ≥ 36 months. The rate of relapse was also significantly lower in patients with routine-use protocol of MGT (31.2%; 95% CI, 27.5-34.8%) than in patients with no MGT protocol (44.1%; 95% CI, 35.8-52.4%). Adverse events were comparable between groups. CONCLUSIONS The rate of relapse tended to decrease with extended durations of glucocorticoid therapy up to 36 months. Clinicians may decide the duration of glucocorticoids according to patient condition, including comorbidities and risk of relapse.
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Affiliation(s)
- Seung Bae Yoon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sung-Hoon Moon
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea; Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, South Korea.
| | - Jong Hyeok Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea; Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, South Korea
| | - Ji Won Park
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea; Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, South Korea
| | - Sung Eun Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea; Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, South Korea
| | - Myung-Hwan Kim
- Department of Internal Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, South Korea
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Maatman TK, Zyromski NJ. In Brief. Curr Probl Surg 2021. [PMID: 32297552 DOI: 10.1016/j.cpsurg.2020.100859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ichikawa S, Kromrey ML, Motosugi U, Onishi H. Optimal target b-value on computed diffusion-weighted magnetic resonance imaging for visualization of pancreatic ductal adenocarcinoma and focal autoimmune pancreatitis. Abdom Radiol (NY) 2021; 46:636-646. [PMID: 32740865 DOI: 10.1007/s00261-020-02695-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/21/2020] [Accepted: 07/25/2020] [Indexed: 12/26/2022]
Abstract
PURPOSE To compare computed diffusion-weighted imaging (cDWI) feasibility with that of directly acquired DWI for visualizing pancreatic ductal adenocarcinoma (PDAC) and focal autoimmune pancreatitis (AIP). METHODS From April 2012 to January 2017, 135 patients with PDAC (n = 111) or focal AIP (n = 24) were retrospectively enrolled. They underwent DWI with b-values of 0, 500, and 1000 s/mm2. From DWI0 and DWI1000, we generated cDWIs with targeted b-values of 1500, 2000, and 3000 s/mm2. The lesions' signal intensities, image quality, signal intensity ratio (SIR) of lesions and pancreatic parenchyma to spinal cord, and lesion-to-pancreatic parenchyma contrast ratio (CR) were compared among the five DWI protocols (DWI500, DWI1000, cDWI1500, cDWI2000, and cDWI3000). SIR was analyzed by receiver operating characteristic (ROC) analyses. RESULTS DWI500, DWI1000, and cDWI1500 had higher image quality than cDWI2000 and cDWI3000 (P < 0.001). The incidence of clear hyperintense PDAC was highest on cDWI2000, followed by cDWI1500, and cDWI3000 (P < 0.001-0.002), while the incidence of clear hyperintense AIP was higher on DWI1000, cDWI1500, and cDWI2000 than on DWI500 and cDWI3000 (P = 0.001-0.022). SIRs decreased whereas CRs increased as the b-value increased, for both PDAC and AIP. The area under the ROC curve (AUC) of SIRlesion was significantly lower on cDWI1500 than on cDWI2000 and cDWI3000 (P < 0.001). CONCLUSION cDWI1500 or cDWI2000 generated from b-values of 0 and 1000 s/mm2 were the most effective for visualizing PDAC and focal AIP; however, the SIRlesion AUC was significantly lower on cDWI1500 than on cDWI2000 and cDWI3000.
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Affiliation(s)
- Shintaro Ichikawa
- Department of Radiology, University of Yamanashi, 1110 Shimokato, Chuo-shi, 409-3898, Yamanashi, Japan.
| | - Marie-Luise Kromrey
- Department of Radiology, University of Yamanashi, 1110 Shimokato, Chuo-shi, 409-3898, Yamanashi, Japan
- Department of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - Utaroh Motosugi
- Department of Radiology, University of Yamanashi, 1110 Shimokato, Chuo-shi, 409-3898, Yamanashi, Japan
- Department of Diagnostic Radiology, Kofu Kyoritsu Hospital, Kofu, Yamanashi, Japan
| | - Hiroshi Onishi
- Department of Radiology, University of Yamanashi, 1110 Shimokato, Chuo-shi, 409-3898, Yamanashi, Japan
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Maatman TK, Zyromski NJ. Chronic Pancreatitis. Curr Probl Surg 2020; 58:100858. [PMID: 33663691 DOI: 10.1016/j.cpsurg.2020.100858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/03/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Thomas K Maatman
- Resident in General Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Nicholas J Zyromski
- Professor of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA..
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Xiang B, Lv X, Dai C. Unusual case of pancreas disease involving parotid gland and submandibular gland. Intern Med J 2020; 50:888-889. [PMID: 32656982 DOI: 10.1111/imj.14900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/11/2019] [Accepted: 10/24/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Bingjie Xiang
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang City, China
| | - Xiaohui Lv
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang City, China
| | - Cong Dai
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang City, China
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Gao Y, Chen Y, Zhang Z, Yu X, Zheng J. Recent Advances in Mouse Models of Sjögren's Syndrome. Front Immunol 2020; 11:1158. [PMID: 32695097 PMCID: PMC7338666 DOI: 10.3389/fimmu.2020.01158] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 05/11/2020] [Indexed: 12/15/2022] Open
Abstract
Sjögren's syndrome (SS) is a complex rheumatoid disease that mainly affects exocrine glands, resulting in xerostomia (dry mouth) and xerophthalmia (dry eye). SS is characterized by autoantibodies, infiltration into exocrine glands, and ectopic expression of MHC II molecules on glandular epithelial cells. In contrast to the well-characterized clinical and immunological features, the etiology and pathogenesis of SS remain largely unknown. Animal models are powerful research tools for elucidating the pathogenesis of human diseases. To date, many mouse models of SS, including induced models, in which disease is induced in mice, and genetic models, in which mice spontaneously develop SS-like disease, have been established. These mouse models have provided new insight into the pathogenesis of SS. In this review, we aim to provide a comprehensive overview of recent advances in the field of experimental SS.
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Affiliation(s)
- Yunzhen Gao
- Institute of Psychiatry and Neuroscience, Xinxiang Medical University, Xinxiang, China
| | - Yan Chen
- Institute of Psychiatry and Neuroscience, Xinxiang Medical University, Xinxiang, China
| | - Zhongjian Zhang
- Institute of Psychiatry and Neuroscience, Xinxiang Medical University, Xinxiang, China
| | - Xinhua Yu
- Priority Area Asthma & Allergy, Research Center Borstel, Airway Research Center North (ARCN), Members of the German Center for Lung Research (DZL), Borstel, Germany
| | - Junfeng Zheng
- Institute of Psychiatry and Neuroscience, Xinxiang Medical University, Xinxiang, China
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Dumonceau JM, Delhaye M, Charette N, Farina A. Challenging biliary strictures: pathophysiological features, differential diagnosis, diagnostic algorithms, and new clinically relevant biomarkers - part 1. Therap Adv Gastroenterol 2020; 13:1756284820927292. [PMID: 32595761 PMCID: PMC7298429 DOI: 10.1177/1756284820927292] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 04/16/2020] [Indexed: 02/04/2023] Open
Abstract
It is frequently challenging to make the correct diagnosis in patients with biliary strictures. This is particularly important as errors may have disastrous consequences. Benign-appearing strictures treated with stents may later be revealed to be malignant and unnecessary surgery for benign strictures carries a high morbidity rate. In the first part of the review, the essential information that clinicians need to know about diseases responsible for biliary strictures is presented, with a focus on the most recent data. Then, the characteristics and pitfalls of the methods used to make the diagnosis are summarized. These include serum biomarkers, imaging studies, and endoscopic modalities. As tissue diagnosis is the only 100% specific tool, it is described in detail, including techniques for tissue acquisition and their yields, how to prepare samples, and what to expect from the pathologist. Tricks to increase diagnostic yields are described. Clues are then presented for the differential diagnosis between primary and secondary sclerosing cholangitis, IgG4-related sclerosing cholangitis, cholangiocarcinoma, pancreatic cancer, autoimmune pancreatitis, and less frequent diseases. Finally, algorithms that will help to achieve the correct diagnosis are proposed.
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Affiliation(s)
- Jean-Marc Dumonceau
- Department of Gastroenterology, Charleroi
University Hospitals, Chaussée de Bruxelles 140, Charleroi, 6042,
Belgium
| | - Myriam Delhaye
- Department of Gastroenterology,
Hepatopancreatology and GI Oncology, Erasme University Hospital, Brussels,
Belgium
| | - Nicolas Charette
- Department of Gastroenterology, Charleroi
University Hospitals, Charleroi, Belgium
| | - Annarita Farina
- Department of Medicine, Geneva University,
Geneva, Switzerland
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Abstract
OBJECTIVE Since the time of inception of autoimmune pancreatitis (AIP), our knowledge of autoimmune pancreatitis has expanded significantly. The aim of this review is to provide an update on clinical manifestations, diagnosis, imaging features, and treatment of AIP. BACKGROUND AND CLINICAL SIGNIFICANCE Type 1 AIP is the pancreatic manifestation of IgG4-related systemic disease, which can be diagnosed using a combination of clinical, histopathological, pancreatic imaging findings in conjunction with manifestation in other organs, as well of responsiveness to steroid treatment. It is vital to differentiate AIP from pancreatic cancer since both can mimic each other clinically and radiologically. Type 2 AIP is a rare but distinct subtype of AIP which occurs mostly in the younger patient. CONCLUSION AIP is steroid-responsive chronic pancreatitis with distinct manifestations on imaging.
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Affiliation(s)
- Ashish Khandelwal
- Department of Radiology, Mayo Clinic, 200 First St, Rochester, MN, 55902, USA
| | - Dai Inoue
- Department of Radiology, Kanazawa Univeristy, 1192 Kakumamachi, Kanazawa, Ishikawa, 920-1192, Japan
| | - Naoki Takahashi
- Department of Radiology, Mayo Clinic, 200 First St, Rochester, MN, 55902, USA.
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Garcia Garcia de Paredes A, Rodriguez de Santiago E, Rodriguez-Escaja C, Iborra M, Algaba A, Cameo JI, de la Peña L, Gomollon F, Van Domselaar M, Busta R, Castaño Garcia A, Del Val A, Bermejo F, Gutierrez A, Guardiola J, Mesonero F, Riestra S, Nos P, Albillos A, Lopez-Sanroman A. Idiopathic acute pancreatitis in patients with inflammatory bowel disease: A multicenter cohort study. Pancreatology 2020; 20:331-337. [PMID: 32165149 DOI: 10.1016/j.pan.2020.02.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/02/2020] [Accepted: 02/14/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Idiopathic acute pancreatitis (IAP) in patients with inflammatory bowel disease (IBD) is not well characterized. Our purpose was to better understand this condition and its natural history. METHODS Retrospective cohort study conducted at nine Spanish IBD referral centers. Patients with IBD and a first episode of acute pancreatitis (AP) between 1998 and 2018 were included. Patients with a previous episode of AP or a diagnosis of chronic pancreatitis were excluded. IAP and non-IAP were compared by multivariate logistic regression and survival analysis. RESULTS We identified 185 patients with IBD (68.7% Crohn's disease) and a first episode of AP. Thirty-eight of those 185 (20.6%) fulfilled criteria for IAP. There were no severe cases of IAP. On multivariate analysis, AP before IBD diagnosis (21.1% vs. 3.4%, p = 0.04) and ulcerative colitis (52.6% vs. 23.1%, p = 0.002) were significantly more common in IAP. Further work-up was performed in 16/38 (42%) IAP patients, and a cause was identified in 6/16 (37.5%). Median time from AP to the end of follow-up was 6.3 years (3.1-10). Five-year risk of AP recurrence was significantly higher in IAP group (28% vs. 5.1%, log-rank p = 0.001), with a median time to first recurrence of 4.4 months (2.9-12.2). CONCLUSIONS IAP represents the second cause of AP in patients with IBD. It is more frequent in ulcerative colitis, and presents a high risk of recurrence. Additional imaging work-up after a first episode of IAP in IBD patients is highly advisable, as it identifies a cause in more than one-third of cases.
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Affiliation(s)
- Ana Garcia Garcia de Paredes
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Biosanitaria (IRYCIS), Madrid, Spain.
| | - Enrique Rodriguez de Santiago
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Biosanitaria (IRYCIS), Madrid, Spain
| | - Carlos Rodriguez-Escaja
- Gastroenterology and Hepatology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Marisa Iborra
- Gastroenterology and Hepatology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Spain
| | - Alicia Algaba
- Gastroenterology Department, Hospital Universitario de Fuenlabrada, Instituto de Investigación Sanitaria Hospital La Paz (IdiPaz), Madrid, Spain
| | - Jose Ignacio Cameo
- Gastroenterology and Hepatology Department, Hospital General Universitario de Alicante, Alicante, Spain
| | - Luisa de la Peña
- Gastroenterology and Hepatology Department, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Spain
| | - Fernando Gomollon
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Spain; Gastroenterology and Hepatology Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Manuel Van Domselaar
- Gastroenterology and Hepatology Department, Hospital Universitario de Torrejón, Torrejón de Ardoz, Spain
| | - Reyes Busta
- Gastroenterology and Hepatology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Andres Castaño Garcia
- Gastroenterology and Hepatology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Adolfo Del Val
- Gastroenterology and Hepatology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Fernando Bermejo
- Gastroenterology Department, Hospital Universitario de Fuenlabrada, Instituto de Investigación Sanitaria Hospital La Paz (IdiPaz), Madrid, Spain
| | - Ana Gutierrez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Spain; Gastroenterology and Hepatology Department, Hospital General Universitario de Alicante, Alicante, Spain
| | - Jordi Guardiola
- Gastroenterology and Hepatology Department, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Spain
| | - Francisco Mesonero
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Biosanitaria (IRYCIS), Madrid, Spain
| | - Sabino Riestra
- Gastroenterology and Hepatology Department, Hospital Universitario Central de Asturias, Oviedo, Spain; Instituto de Investigación Sanitaria Del Principado de Asturias (ISPA), Oviedo, Spain
| | - Pilar Nos
- Gastroenterology and Hepatology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Spain
| | - Agustin Albillos
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Biosanitaria (IRYCIS), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Spain
| | - Antonio Lopez-Sanroman
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Biosanitaria (IRYCIS), Madrid, Spain
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Porcu M, Solinas C, Migali C, Battaglia A, Schena M, Mannelli L, Addeo A, Willard-Gallo K, Saba L. Immune Checkpoint Inhibitor-Induced Pancreatic Injury: Imaging Findings and Literature Review. Target Oncol 2020; 15:25-35. [PMID: 31925647 DOI: 10.1007/s11523-019-00694-w] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The immunotherapy revolution in cancer treatment involves a variety of specialists, not only oncologists, but also internal medicine physicians, endocrinologists, dermatologists, gastroenterologists, rheumatologists, and radiologists, introducing new scenarios and novel challenges in the diagnosis and management of a number of novel immune-related adverse events. Among these, immune checkpoint inhibitor-induced pancreatic injury has been described (occurring in up to 4% of patients) and has been reported to be responsible for visits to the emergency departments in up to 1.9% of patients treated with immune checkpoint inhibitors. This side effect can be symptomatic or non-symptomatic, and can be associated with the development of long-term damage to the pancreas, requiring the involvement of different specialists, including radiologists and gastroenterologists in the multidisciplinary team that manages these patients. The aim of this narrative review is to provide a summary of the available literature related to immune checkpoint inhibitor-induced pancreatic injury including the epidemiology, the clinical findings, and the management algorithm for diagnosis with a detailed analysis of the differential diagnosis at imaging, and treatment. A more in-depth focus is dedicated to symptomatic acute pancreatitis with its peculiar findings at imaging (ultrasound, computed tomography, and magnetic resonance imaging).
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Affiliation(s)
- Michele Porcu
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, S.S: 554, km 4500, CAP: 09042, Monserrato, Cagliari, Italy.
| | | | | | | | - Marina Schena
- Azienda AUSL, Regional Hospital of Aosta, Aosta, Italy
| | | | - Alfredo Addeo
- Oncology Department, University Hospital of Geneva, Geneva, Switzerland
| | | | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, S.S: 554, km 4500, CAP: 09042, Monserrato, Cagliari, Italy
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Lee SJ, Shin SS, Heo SH, Jeong YY. Pictorial Review of Rare Pancreatic Tumors and Tumor-Like Lesions. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2020; 81:1134-1150. [PMID: 36238034 PMCID: PMC9431853 DOI: 10.3348/jksr.2020.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/28/2020] [Accepted: 04/09/2020] [Indexed: 11/21/2022]
Abstract
췌장에는 다양한 종류의 종양 및 종양 유사 병변들이 생길 수 있다. 이 가운데, 췌장선암은 췌장의 가장 흔한 종양으로서 일반적으로 췌장암이라고 하면 이 종양을 가리킨다. 최근에는 영상 검사의 기술적 진보와 이용이 증가하면서 췌장의 희귀 종양 및 종양 유사 병변들의 발견 빈도가 증가하고 있다. 췌장의 드문 종양 및 종양과 유사한 병변들은 치료 방침과 예후가 췌장선암과 다르기 때문에 이들 질환의 감별은 임상적으로 중요한 의의가 있다. 영상 검사는 포상세포암이나 신경초종 등의 희귀 종양 및 자가면역 췌장염 또는 염증성 거짓종양과 같은 종양 유사 병변들과 췌장선암의 감별 진단에 중요한 역할을 하지만 영상 소견만으로 이들 질환을 정확히 구분하는 것은 한계가 있다. 이 논문에서는 췌장에서 생길 수 있는 희귀 종양 및 종양 유사 병변들의 다양한 영상 소견들과 췌장선암과의 감별에 있어 도움이 되는 특징들을 제시하고자 한다.
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Affiliation(s)
- Seung Jae Lee
- Department of Radiology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Sang Soo Shin
- Department of Radiology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Suk Hee Heo
- Department of Radiology, Chonnam National University Medical School, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Yong Yeon Jeong
- Department of Radiology, Chonnam National University Medical School, Chonnam National University Hwasun Hospital, Hwasun, Korea
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Frommer L, Kahaly GJ. Autoimmune Polyendocrinopathy. J Clin Endocrinol Metab 2019; 104:4769-4782. [PMID: 31127843 DOI: 10.1210/jc.2019-00602] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 04/22/2019] [Indexed: 02/06/2023]
Abstract
CONTEXT This mini-review offers an update on the rare autoimmune polyendocrinopathy (AP) syndrome with a synopsis of recent developments. DESIGN AND RESULTS Systematic search for studies related to pathogenesis, immunogenetics, screening, diagnosis, clinical spectrum, and epidemiology of AP. AP (orphan code ORPHA 282196) is defined as the autoimmune-induced failure of at least two glands. AP is divided into the rare juvenile type I and the adult types II to IV. The prevalence is 1:100,000 and 1:20,000 for types I and types II to IV, respectively. Whereas type I (ORPHA 3453) is a monogenetic syndrome with an autosomal recessive transmission related to mutations in the autoimmune regulator (AIRE) gene, types II to IV are genetically complex multifactorial syndromes that are strongly associated with certain alleles of HLA genes within the major histocompatibility complex located on chromosome 6, as well as the cytotoxic T lymphocyte antigen 4 and the protein tyrosine phosphatase nonreceptor type 22 genes. Addison disease is the major endocrine component of type II (ORPHA 3143), whereas the coexistence of type 1 diabetes and autoimmune thyroid disease is characteristic for type III (ORPHA 227982). Genetic screening for the AIRE gene is useful in patients with suspected type I, whereas serological screening (i.e., diabetes/adrenal antibodies) is required in patients with monoglandular autoimmunity and suspected AP. If positive, functional endocrine testing of the antibody-positive patients as well as serological screening of their first-degree relatives is recommended. CONCLUSION Timely diagnosis, genetic counseling, and optimal long-term management of AP is best offered in specialized centers.
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Affiliation(s)
- Lara Frommer
- Orphan Disease Center for Autoimmune Polyendocrinopathy, Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - George J Kahaly
- Orphan Disease Center for Autoimmune Polyendocrinopathy, Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
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The Etiology of Pancreatic Manifestations in Patients with Inflammatory Bowel Disease. J Clin Med 2019; 8:jcm8070916. [PMID: 31247968 PMCID: PMC6679036 DOI: 10.3390/jcm8070916] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 06/18/2019] [Accepted: 06/21/2019] [Indexed: 02/07/2023] Open
Abstract
Inflammatory bowel disease (IBD) is an idiopathic chronic and recurrent condition that comprises Crohn's disease and ulcerative colitis. A pancreatic lesion is one of the extraintestinal lesions in patients with IBD. Acute pancreatitis is the representative manifestation, and various causes of pancreatitis have been reported, including those involving adverse effects of drug therapies such as 5-aminosalicylic acid and thiopurines, gall stones, gastrointestinal lesions on the duodenum, iatrogenic harm accompanying endoscopic procedures such as balloon endoscopy, and autoimmunity. Of these potential causes, autoimmune pancreatitis (AIP) is a relatively newly recognized disease and is being increasingly diagnosed in IBD. AIP cases can be divided into type 1 cases involving lymphocytes and IgG4-positive plasma cells, and type 2 cases primarily involving neutrophils; the majority of AIP cases complicating IBD are type 2. The association between IBD and chronic pancreatitis, exocrine pancreatic insufficiency, pancreatic cancer, etc. has also been suggested; however, studies with high-quality level evidence are limited, and much remains unknown. In this review, we provide an overview of the etiology of pancreatic manifestation in patients with IBD.
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38
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Guda NM, Trikudanathan G, Freeman ML. Idiopathic recurrent acute pancreatitis. Lancet Gastroenterol Hepatol 2019; 3:720-728. [PMID: 30215363 DOI: 10.1016/s2468-1253(18)30211-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/15/2018] [Accepted: 06/15/2018] [Indexed: 12/19/2022]
Abstract
Idiopathic recurrent acute pancreatitis is clinically challenging and has substantial socioeconomic consequences. Investigations are expensive and often reveal little about the cause of the disease. Little is known about the interaction between genetic, environmental, anatomical, and other factors that contribute to the disease. Data on the efficacy, safety, and long-term outcomes of endoscopic therapies are scarce. The effect of idiopathic recurrent pancreatitis on quality of life is often underestimated. A more thorough examination of the causes of the disease and the roles of other associated risk factors is needed, as are well designed clinical studies with robust and objectively measurable outcomes. Ideally, evaluation of the causes of disease and therapy should be done only in specialised centres, should follow a protocol, and all outcomes should be formally assessed.
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Affiliation(s)
- Nalini M Guda
- School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA; Aurora Saint Luke's Medical Center, Milwaukee, WI, USA.
| | - Guru Trikudanathan
- Department of Gastroenterology, University of Minnesota, Minneapolis, MN, USA
| | - Martin L Freeman
- Division of Gastroenterology, Hepatology, and Nutrition, Advanced Endoscopy Fellowship, and Islet Autotransplantation, University of Minnesota, Minneapolis, MN, USA
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Yadav D, Park WG, Fogel EL, Li L, Chari ST, Feng Z, Fisher WE, Forsmark CE, Jeon CY, Habtezion A, Hart PA, Hughes SJ, Othman MO, Rinaudo JA, Pandol SJ, Tirkes T, Serrano J, Srivastava S, Van Den Eeden SK, Whitcomb DC, Topazian M, Conwell DL. PROspective Evaluation of Chronic Pancreatitis for EpidEmiologic and Translational StuDies: Rationale and Study Design for PROCEED From the Consortium for the Study of Chronic Pancreatitis, Diabetes, and Pancreatic Cancer. Pancreas 2019; 47:1229-1238. [PMID: 30325862 PMCID: PMC6619499 DOI: 10.1097/mpa.0000000000001170] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Prospective Evaluation of Chronic Pancreatitis for Epidemiologic and Translational Studies (PROCEED) is the first prospective, observational cohort study of chronic pancreatitis (CP) in the United States. The primary goals of PROCEED are to define disease progression, test the predictive capability of candidate biomarkers, and develop a platform to conduct translational and mechanistic studies in CP. Using objective and consensus-driven criteria, PROCEED will enroll adults at different stages of CP-controls, suspected CP, and definite CP. In addition to collecting detailed information using structured case report forms and protocol-mandated evaluations at baseline and during follow-up, PROCEED will establish a linked biorepository of blood, urine, saliva, stool, pancreatic fluid, and pancreatic tissue. Enrollment for PROCEED began in June 2017. As of July 1, 2018, nine clinical centers of the Consortium for the Study of Chronic Pancreatitis, Diabetes, and Pancreatic Cancer are enrolling, and 350 subjects have completed baseline evaluation. In conclusion, PROCEED will provide the most accurate and reliable estimates to date on progression of CP. The established cohort and biorepository will facilitate numerous analyses, leading to new strategies for diagnosis, methods to monitor disease progression, and treatment of CP.
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Affiliation(s)
- Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Walter G. Park
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Evan L. Fogel
- Digestive and Liver Disorders, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Liang Li
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Suresh T. Chari
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | - Ziding Feng
- Biostatistics Program, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - William E. Fisher
- Division of General Surgery, Baylor College of Medicine, Houston, TX
| | - Christopher E. Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition. University of Florida, Gainesville, FL
| | - Christie Y. Jeon
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Aida Habtezion
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Phil A. Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Mohamed O. Othman
- Gastroenterology & Hepatology Section, Baylor College of Medicine, Houston, TX
| | - Jo Ann Rinaudo
- Cancer Biomarker Research Group, Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Rockville, MD
| | - Stephen J. Pandol
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Temel Tirkes
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN
| | - Jose Serrano
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Sudhir Srivastava
- Cancer Biomarker Research Group, Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Rockville, MD
| | | | - David C. Whitcomb
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
- Departments of Cell Biology & Physiology, University of Pittsburgh, and UPMC, Pittsburgh, PA
- Departments of Human Genetics, University of Pittsburgh, and UPMC, Pittsburgh, PA
| | - Mark Topazian
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | - Darwin L. Conwell
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
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Abstract
Type 1 autoimmune pancreatitis (AIP) is an IgG-4-related systemic disease that can manifest as a pancreatic disorder or another disorder of presumed autoimmune origin. Type 2 disease is typically characterized by absent IgG-4-positive cells. As patients often present with acute pancreatitis, obstructive jaundice, or pancreatic mass, it is imperative to exclude malignancy, a more common diagnosis. AIP may respond to corticosteroids, and has a strong association with other immune-mediated diseases. Recent literature suggests the benefit of immune-modulating therapy, including rituximab, although no consensus exists. This review covers the essentials of diagnosis, but focuses primarily on management of AIP.
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Affiliation(s)
- Kamraan Madhani
- Department of Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA; Department of Medicine, Waterbury Internal Medicine Residency Program, Waterbury Hospital, Yale New Haven Hospital, Main 3, 64 Robbins Street, Waterbury, CT 06708, USA
| | - James J Farrell
- Section of Digestive Diseases, Yale University School of Medicine, Yale Center for Pancreatic Disease, Yale University, LMP 1080, 15 York Street, New Haven, CT 06510, USA.
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Liu M, Hao M. Unique properties of IgG4 antibody and its clinical application in autoimmune pancreatitis. Scand J Gastroenterol 2018; 53:1121-1131. [PMID: 30175675 DOI: 10.1080/00365521.2018.1476915] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Autoimmune pancreatitis (AIP) is defined as a unique form of chronic pancreatitis characterized by clinical presentation with obstructive jaundice, a dense lymphoplasmacytic infiltrate and fibrosis histologically, and a dramatic response to steroids therapeutically. The possible role of IgG4 in driving the pathology of AIP is a controversial subject that has not been addressed satisfactorily. Objective: The purpose of this review is to discuss the unique biology of IgG4 that are important for its role and the clinical applications for serologic detection. METHODS Review of current literature about IgG4 antibody in the clinical application in AIP. RESULTS High serum levels of IgG4 are an important biomarker and broadly used for diagnosis, differentiation from diseases especially pancreatic cancer, and as a parameter to indicate disease activity, extra-pancreatic lesions, and treatment monitoring. However, some controversial studies show it has a limited specificity and sensitivity in these conditions. Conclusion: Although increasing studies have promoted our understanding of the structure and function of IgG4, there is still dilemma between the beneficial and the adverse aspect of IgG4 in the pathogenesis of AIP.
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Affiliation(s)
- Min Liu
- a Department of Clinical Laboratory , Jinan Dermatosis Prevention and Control Hospital , Jinan , People's Republic of China
| | - Mingju Hao
- b Department of Clinical Laboratory , Qianfo Mountain Hospital of Shandong University , Jinan , People's Republic of China
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Sandrasegaran K, Menias CO. Imaging in Autoimmune Pancreatitis and Immunoglobulin G4-Related Disease of the Abdomen. Gastroenterol Clin North Am 2018; 47:603-619. [PMID: 30115440 DOI: 10.1016/j.gtc.2018.04.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Autoimmune pancreatitis (AIP) is steroid-responsive fibroinflammatory disorder of the pancreas. There are 2 distinct subtypes of AIP, types 1 and 2. Type 1 is associated with systemic immunoglobulin (Ig)G4 disease and may affect multiple organs in the body. Type 2 is confined to the pancreas and shows an association with ulcerative colitis. This article describes the imaging findings of AIP and IgG4 disease in the liver, bile ducts, kidneys, and the retroperitoneal regions. The imaging differentiation of AIP from pancreas cancer is discussed.
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Affiliation(s)
- Kumaresan Sandrasegaran
- Department of Radiology, Indiana University School of Medicine, 550 North University Boulevard, UH0279, Indianapolis, IN 46202, USA.
| | - Christine O Menias
- Department of Radiology, Mayo Clinic School of Medicine, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
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Nagpal SJS, Sharma A, Chari ST. Autoimmune Pancreatitis. Am J Gastroenterol 2018; 113:1301. [PMID: 29910463 DOI: 10.1038/s41395-018-0146-0] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 05/04/2018] [Indexed: 12/11/2022]
Abstract
Over the course of the last 2 decades our knowledge of autoimmune pancreatitis has increased exponentially. In this review, we summarize the clinical presentation, diagnosis and treatment of AIP, to better allow general gastroenterologists and primary care providers to consider AIP as a as a rare but important cause of painless obstructive jaundice and recurrent acute pancreatitis. While steroids remain the mainstay of first line therapy, a number of patients with type 1 AIP require immunomodulators or rituximab to maintain remission; recommendations on the management of relapses continue to evolve.
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Affiliation(s)
| | - Ayush Sharma
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Rana SS, Gupta R, Nada R, Gupta P, Basher R, Mittal BR, Sharma RK, Rawat A. Clinical profile and treatment outcomes in autoimmune pancreatitis: a report from North India. Ann Gastroenterol 2018; 31:506-512. [PMID: 29991897 PMCID: PMC6033754 DOI: 10.20524/aog.2018.0267] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 03/24/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Autoimmune pancreatitis (AIP) is a rare disease, and data from countries like India concerning its clinical presentation and long-term outcomes are scarce. We retrospectively evaluated the clinical presentation, imaging features and treatment outcomes of patients with AIP. METHODS We carried out a retrospective analysis of our database to identify patients diagnosed with and treated for AIP at our unit in a tertiary care hospital in North India. RESULTS Eighteen patients with AIP (mean age: 54.9±11.1 years; 13 male) were evaluated. Of these, 9 (50%) patients had probable type 1 AIP, 2 (11%) patients probable type 2 AIP, and 4 (22%) definite type 1 AIP. Patients with type 2 AIP were significantly younger than patients with type 1 (40.0±2.8 vs. 58.4±9.6 years). In type 1 AIP, other organ involvement was observed in 3/18 (17%) patients, whereas both patients with type 2 AIP had coexisting ulcerative colitis. The diagnosis of AIP was made after resective surgery in 6/18 (33.0%) patients. An accurate diagnosis of AIP could be made in all patients who underwent resection or core biopsy, but cytological examination after endoscopic ultrasound-guided fine-needle aspiration could not provide a definitive diagnosis in any patient. Initial treatment with steroids was given to 12 (67%) patients, with a 100% response, but the disease relapsed in 5/13 (38%) patients over a mean follow-up period of 34.2±21.6 weeks. CONCLUSION AIP is not rare in India and the majority of clinical manifestations, imaging features, treatment response and long-term outcomes are similar to those reported in the literature.
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Affiliation(s)
- Surinder S Rana
- Department of Gastroenterology (Surinder S. Rana, Pankaj Gupta, Ravi kumar Sharma), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh India
| | - Rajesh Gupta
- Department of Surgery (Rajesh Gupta), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh India
| | - Ritambhra Nada
- Department of Histopathology (Ritambhra Nada), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh India
| | - Pankaj Gupta
- Department of Gastroenterology (Surinder S. Rana, Pankaj Gupta, Ravi kumar Sharma), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh India
| | - Rajinder Basher
- Department of Nuclear Medicine (Rajinder Basher, Bhagwat R. Mittal), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh India
| | - Bhagwat R Mittal
- Department of Nuclear Medicine (Rajinder Basher, Bhagwat R. Mittal), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh India
| | - Ravi Kumar Sharma
- Department of Gastroenterology (Surinder S. Rana, Pankaj Gupta, Ravi kumar Sharma), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh India
| | - Amit Rawat
- Department of Pediatrics (Amit Rawat), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh India
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Hafezi-Nejad N, Singh VK, Fung C, Takahashi N, Zaheer A. MR Imaging of Autoimmune Pancreatitis. Magn Reson Imaging Clin N Am 2018; 26:463-478. [PMID: 30376982 DOI: 10.1016/j.mric.2018.03.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Autoimmune pancreatitis (AIP) is characterized by autoimmune inflammatory destruction of the pancreatic tissue. Imaging plays an essential role in the diagnosis. AIP type 1 is the pancreatic manifestation of immunoglobulin G4 (IgG4)-related disease and is associated with IgG4-positive plasma cell infiltration and fibrosis of multiple organ systems. Type 2 is a related disease with pancreatic inflammation with or without concurrent inflammatory bowel disease. The authors demonstrate the imaging findings that are associated with the pancreatic and extra-pancreatic manifestations of AIP. They emphasize the common MR imaging and magnetic resonance cholangiopancreatography findings to help make the diagnosis of AIP.
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Affiliation(s)
- Nima Hafezi-Nejad
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Vikesh K Singh
- Department of Internal Medicine, Pancreatitis Center, Johns Hopkins Medical Institutions, 1800 Orleans Street, Sheikh Zayed Tower, Baltimore, MD 21287, USA; Division of Gastroenterology, Johns Hopkins University, School of Medicine, 1800 Orleans Street, Sheikh Zayed Tower, Baltimore, MD 21287, USA
| | - Christopher Fung
- Department of Radiology and Diagnostic Imaging, University of Alberta, 2J2.00 WC Mackenzie Health Sciences Centre, 8440 112 Street Northwest, Edmonton, Alberta T6G 2R7, Canada
| | - Naoki Takahashi
- Department of Radiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Atif Zaheer
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, 600 North Wolfe Street, Baltimore, MD 21287, USA; Department of Internal Medicine, Pancreatitis Center, Johns Hopkins Medical Institutions, 1800 Orleans Street, Sheikh Zayed Tower, Baltimore, MD 21287, USA.
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46
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Abstract
Immunoglobulin G4-related disease is a fibroinflammatory systemic disease that is characterized by focal or diffuse organ infiltration by immunoglobulin G4-bearing plasma cells. Immunoglobulin G4-related disease may affect any organ, and a high index of suspicion is necessary for early detection to avoid irreversible fibrosis, organ dysfunction, and death. Tumor-forming lesions are common radiological features of immunoglobulin G4-related disease that need to be differentiated from malignancies. The diagnostic approach requires the integration of clinical, biochemical, and radiographic manifestations with classic histopathologic features, which remain crucial to diagnosis. The histology of immunoglobulin G4-related disease is determined by a dense lymphoplasmacytic infiltrate, storiform fibrosis, and obliterative phlebitis in the presence of increased immunoglobulin G4-positve plasma cells. Although immunoglobulin G4-related disease forms a distinct, clinically independent disease category, many questions and problems remain unanswered, especially on its pathogenesis and the role of immunoglobulin G4. Advances in the understanding of immunoglobulin G4-related disease are likely to change the diagnostic approach in the future and create potential targets for therapeutic purposes. Here we describe the concept of immunoglobulin G4-related disease and the most recent knowledge in the clinico-pathological characteristics on this emerging disease. This study can guide clinicians in early diagnosis and prevent unnecessary surgical resections.
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Affiliation(s)
| | | | - Metin Özdemirli
- Department of Pathology, Medstar Georgetown University Hospital, Washington, USA
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47
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Gut Microbiota-Immune System Crosstalk and Pancreatic Disorders. Mediators Inflamm 2018; 2018:7946431. [PMID: 29563853 PMCID: PMC5833470 DOI: 10.1155/2018/7946431] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 12/05/2017] [Accepted: 12/18/2017] [Indexed: 12/15/2022] Open
Abstract
Gut microbiota is key to the development and modulation of the mucosal immune system. It plays a central role in several physiological functions, in the modulation of inflammatory signaling and in the protection against infections. In healthy states, there is a perfect balance between commensal and pathogens, and microbiota and the immune system interact to maintain gut homeostasis. The alteration of such balance, called dysbiosis, determines an intestinal bacterial overgrowth which leads to the disruption of the intestinal barrier with systemic translocation of pathogens. The pancreas does not possess its own microbiota, and it is believed that inflammatory and neoplastic processes affecting the gland may be linked to intestinal dysbiosis. Increasing research evidence testifies a correlation between intestinal dysbiosis and various pancreatic disorders, but it remains unclear whether dysbiosis is the cause or an effect. The analysis of specific alterations in the microbiome profile may permit to develop novel tools for the early detection of several pancreatic disorders, utilizing samples, such as blood, saliva, and stools. Future studies will have to elucidate the mechanisms by which gut microbiota is modulated and how it tunes the immune system, in order to be able to develop innovative treatment strategies for pancreatic disorders.
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Ehlers L, Rohde S, Ibrahim S, Jaster R. Adoptive transfer of CD3 + T cells and CD4 + CD44 high memory T cells induces autoimmune pancreatitis in MRL/MpJ mice. J Cell Mol Med 2018; 22:2404-2412. [PMID: 29383850 PMCID: PMC5867153 DOI: 10.1111/jcmm.13537] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 12/07/2017] [Indexed: 12/23/2022] Open
Abstract
The immunopathogenesis of autoimmune pancreatitis (AIP) is poorly understood. Here, we have used MRL/MpJ mice, a model of spontaneous AIP, to address the role of cellular autoimmune processes in the initiation and progression of the disease. Therefore, different T cell subpopulations were adoptively transferred from sick to still healthy (but susceptible) MRL/MpJ mice. Unpurified splenocytes and CD3+ T cells both efficiently induced AIP, while CD4+ and CD8+ T cells alone, as well as splenocytes from healthy mice, were insufficient to trigger the disease. Strikingly, CD4+CD44high memory T cells, although transferred at lower numbers than other T cells, also induced AIP in recipient mice. Employing a modified experimental design, we also evaluated the effects of regulatory T cells (Tregs) on the progression of AIP in already diseased mice. Under the given experimental conditions, there was no significant suppressive effect of adoptively transferred Tregs on pancreatic histopathology. The results of our studies suggest a key role of T cell‐mediated processes in murine AIP. The effects of CD4+CD44high memory T cells are in accordance with genetic studies of our group, which had previously implicated this cell type into the pathogenesis of AIP. In follow‐up studies, we will focus on the interplay of cellular and humoral autoimmunity in the context of AIP.
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Affiliation(s)
- Luise Ehlers
- Department of Medicine II, Division of Gastroenterology, Rostock University Medical Center, Rostock, Germany
| | - Sarah Rohde
- Department of Medicine II, Division of Gastroenterology, Rostock University Medical Center, Rostock, Germany
| | - Saleh Ibrahim
- Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany.,Clinical Science Department, College of Medicine, American University of Sharjah, Sharjah, United Arab Emirates
| | - Robert Jaster
- Department of Medicine II, Division of Gastroenterology, Rostock University Medical Center, Rostock, Germany
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