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Ishigami K, Shitani M, Kimura Y, Hasegawa T, Masaki Y, Ito A, Akutsu N, Yamamoto M, Motoya M, Sasaki S, Takahashi H, Takemasa I, Nakase H. Ectopic relapse of IgG4-related disease presenting as IgG4-related sclerosing cholecystitis: A case report and review of literature. Medicine (Baltimore) 2018; 97:e13868. [PMID: 30593191 PMCID: PMC6314772 DOI: 10.1097/md.0000000000013868] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
RATIONALE Immunoglobulin (Ig) G4-related disease (IgG4-RD) is a chronic inflammatory disorder characterized by high levels of serum IgG4, swollen organs with fibrosis and abundant infiltration of IgG4-positive plasmacytes. PATIENT CONCERNS An 82-year-old male visited our hospital for an evaluation of a pancreatic enlargement and a bilateral submandibular adenopathy. Further investigation revealed elevation of serum IgG4 and bilateral lacrimal submandibular adenopathy. We diagnosed him with IgG4-related disease (IgG4-RD) and started administration of corticosteroid (CS) therapy. Both pancreatic enlargement and adenopathy rapidly improved; however, there was a new occurrence of diffuse wall thickening of the gallbladder during CS treatment. DIAGNOSIS Radiological examination revealed diffuse wall thickening of the gallbladder, and its inner layer was smooth and homogenous. These findings suggested an inflammatory change, but the possibility of malignancy could not be excluded. INTERVENTIONS The patient underwent laparoscopic cholecystectomy for a pathological diagnosis. OUTCOMES Histological examination revealed a transmural infiltration of IgG4 positive plasma cells and dense fibrosis. The patient was pathologically diagnosed with IgG4 related cholecystitis presenting as an ectopic relapse. LESSONS There are 2 major types of IgG4-related cholecystitis, a diffuse wall thickening type and a mass formation type. It is sometimes difficult to differentiate IgG4-related cholecystitis with gallbladder cancer.Corticosteroid (CS) is effective for induction of remission; however, we sometimes encounter disease relapse after reduction of CS dose. We should be mindful that some patients may relapse with new organ involvements even if the primary site and serum IgG4 level are well controlled.
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Affiliation(s)
| | | | | | | | | | - Ayako Ito
- Department of Gastroenterology and Hepatology
| | | | - Motohisa Yamamoto
- Department of Rheumatology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | | | | | - Hiroki Takahashi
- Department of Rheumatology, Sapporo Medical University School of Medicine, Sapporo, Japan
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Utility of FDG PET/CT for Differential Diagnosis of Patients Clinically Suspected of IgG4-Related Disease. Clin Nucl Med 2016; 41:e237-43. [DOI: 10.1097/rlu.0000000000001153] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Lian L, Wang C, Tian JL. IgG4-related retroperitoneal fibrosis: a newly characterized disease. Int J Rheum Dis 2016; 19:1049-1055. [PMID: 27125330 DOI: 10.1111/1756-185x.12863] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Retroperitoneal fibrosis (RPF) is a rare disease characterized by chronic, nonspecific inflammatory and sclerotic or fibrotic tissue in the periaortic or periiliac retroperitoneum that encases adjacent structures. There will be a series of clinical manifestations once the proliferated fibrous tissues encase the abdominal aorta, iliac arteries and urinary duct. RPF is generally divided into two types: idiopathic retroperitoneal fibrosis (IRPF) without identified pathogenesis, making up about two-thirds of cases, and secondary retroperitoneal fibrosis. Recent studies on Immunoglobulin G4-related disease (IgG4-RD) reveal that abundant infiltration of IgG4 positive plasma cells is found in biopsies on the mass of RPF of some IRPF patients, which is identified as one spectrum of IgG4-RD and is named IgG4-related RPF. IgG4-related RPF is often misdiagnosed as retroperitoneal visceral malignancy and is treated with surgery. In addition, because of its good response to glucocorticoid, early detection and treatment is important. We review the definition, epidemiology, clinical features, diagnostic criteria, treatment and prognosis of IgG4-related RPF in this article to raise awareness of this newly characterized disease.
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Affiliation(s)
- Linjuan Lian
- Gerontology Department, Tianjin Medical University General Hospital, Tianjin, China
| | - Cong Wang
- Gerontology Department, Tianjin Medical University General Hospital, Tianjin, China
| | - Jian-Li Tian
- Gerontology Department, Tianjin Medical University General Hospital, Tianjin, China
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Sugimoto M, Takagi T, Suzuki R, Konno N, Watanabe K, Nakamura J, Kikuchi H, Waragai Y, Asama H, Takasumi M, Hikichi T, Watanabe H, Obara K, Ohira H. Efficacy of Steroid Pulse Therapy for Autoimmune Pancreatitis Type 1: A Retrospective Study. PLoS One 2015; 10:e0138604. [PMID: 26381760 PMCID: PMC4575182 DOI: 10.1371/journal.pone.0138604] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 08/31/2015] [Indexed: 01/12/2023] Open
Abstract
Autoimmune pancreatitis (AIP) is treatable with steroids, but relapse is frequent. The efficacy of steroid pulse therapy has been shown for various autoimmune diseases, but has not become established therapy. In this study, we reviewed the efficacy of steroid pulse therapy in 24 subjects who were diagnosed with AIP type 1 at our hospital. Patient characteristics, time-course of serum IgG4, and the cumulative relapse-free survival rate were compared between patients who received oral steroid therapy (oral group) and those who were treated with steroid pulse therapy (pulse group). Serum IgG4 was reduced significantly after therapy in both groups and the 5-year cumulative relapse-free survival rates in the two groups did not differ significantly (oral group 46.9%, pulse group 77.8%). However, in a subset of cases with diffuse pancreatic swelling, this rate was significantly lower in the oral group (33.3% vs. 100.0%, p = 0.046). These results suggest that steroid pulse therapy is effective for prevention of relapse in AIP patients with diffuse pancreatic swelling.
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Affiliation(s)
- Mitsuru Sugimoto
- Department of Gastroenterology and Rheumatology, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Tadayuki Takagi
- Department of Gastroenterology and Rheumatology, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Rei Suzuki
- Department of Gastroenterology and Rheumatology, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Naoki Konno
- Department of Gastroenterology and Rheumatology, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Ko Watanabe
- Department of Gastroenterology and Rheumatology, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Jun Nakamura
- Department of Gastroenterology and Rheumatology, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Hitomi Kikuchi
- Department of Gastroenterology and Rheumatology, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Yuichi Waragai
- Department of Gastroenterology and Rheumatology, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Hiroyuki Asama
- Department of Gastroenterology and Rheumatology, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Mika Takasumi
- Department of Gastroenterology and Rheumatology, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Hiroshi Watanabe
- Department of Gastroenterology and Rheumatology, Fukushima Medical University, School of Medicine, Fukushima, Japan
| | - Katsutoshi Obara
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology and Rheumatology, Fukushima Medical University, School of Medicine, Fukushima, Japan
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Islam AD, Selmi C, Datta-Mitra A, Sonu R, Chen M, Gershwin ME, Raychaudhuri SP. The changing faces of IgG4-related disease: Clinical manifestations and pathogenesis. Autoimmun Rev 2015; 14:914-22. [PMID: 26112170 DOI: 10.1016/j.autrev.2015.06.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 06/09/2015] [Indexed: 02/08/2023]
Abstract
Since the earliest reports in 2001, immunoglobulin G4 (IgG4)-related disease has been defined as an autoimmune systemic disease characterized by the lymphoplasmacytic infiltration of affected tissues leading to fibrosis and obliterative phlebitis along with elevated serum IgG4 levels. Prior to this unifying hypothesis, a plethora of clinical manifestations were considered as separate entities despite the similar laboratory profile. The pathology can be observed in virtually all organs and may thus be a challenging diagnosis, especially when the adequate clinical suspicion is not present or when obtaining a tissue biopsy is not feasible. Nonetheless, the most frequently involved organs are the pancreas and exocrine glands but these may be spared. Immunosuppressants lead to a prompt clinical response in virtually all cases and prevent histological sequelae and, as a consequence, an early differential diagnosis from other conditions, particularly infections and cancer, as well as an early treatment should be pursued. We describe herein two cases in which atypical disease manifestations were observed, i.e., one with recurrent neck lymph node enlargement and proptosis, and one with jaundice. Our understanding of the pathogenesis of IgG4-related disease is largely incomplete but data support a significant role for Th2 cytokines with the contribution of innate immunity factors such as Toll-like receptors, macrophages and basophils. Further, macrophages activated by IL4 overexpress B cell activating factors and contribute to chronic inflammation and the development of fibrosis. We cannot rule out the possibility that the largely variable disease phenotypes reflect different pathogenetic mechanisms and the tissue microenvironment may then contribute to the organ involvement.
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Affiliation(s)
- Arshia Duza Islam
- Department of Internal Medicine, Division of Rheumatology, Allergy and Clinical Immunology, University of California Davis, School of Medicine, Davis, CA, USA; VA Medical Center Sacramento, Mather, CA, USA
| | - Carlo Selmi
- Division of Rheumatology and Clinical Immunology, Humanitas Research Hospital, Rozzano, Italy; BIOMETRA Department, University of Milan, Italy
| | | | - Rebecca Sonu
- Department of Pathology and Laboratory Medicine, University of California Davis, School of Medicine, Davis, CA, USA
| | - Mingyi Chen
- Department of Pathology and Laboratory Medicine, University of California Davis, School of Medicine, Davis, CA, USA
| | - M Eric Gershwin
- Department of Internal Medicine, Division of Rheumatology, Allergy and Clinical Immunology, University of California Davis, School of Medicine, Davis, CA, USA
| | - Siba P Raychaudhuri
- Department of Internal Medicine, Division of Rheumatology, Allergy and Clinical Immunology, University of California Davis, School of Medicine, Davis, CA, USA; VA Medical Center Sacramento, Mather, CA, USA.
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Affiliation(s)
- Miyu Tajima
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
- Department of Cardiology, Sakakibara Heart Institute
| | | | - Yukio Hiroi
- Department of Cardiology, National Center for Global Health and Medicine
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Matsubayashi H, Uesaka K, Kanemoto H, Aramaki T, Nakaya Y, Kakushima N, Ono H. Reduction of splenic volume by steroid therapy in cases with autoimmune pancreatitis. J Gastroenterol 2013; 48:942-50. [PMID: 23076542 DOI: 10.1007/s00535-012-0692-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2012] [Accepted: 09/17/2012] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Splenomegaly is sometimes recognized in autoimmune diseases and chronic pancreatitis; however, it has not yet been studied in autoimmune pancreatitis (AIP). The current study analyzed splenic volume and its associated factors in cases with AIP. METHODS Splenic volume was measured using computed tomography (CT) volumetric analysis in 46 cases with AIP and compared with 92 age- and gender-matched controls, and 46 disease controls (liver cirrhosis). Forty-six cases of chronic pancreatitis were also analyzed. Cases with AIP were investigated for factors associated with splenic volume and splenic volume change in response to steroid therapy. RESULTS Splenic volume was significantly larger in AIP (149 ± 86 ml) than in controls (97 ± 38 ml) and in CP (108 ± 79 ml) (P < 0.0001 and 0.0002), and was smaller than in disease controls (222 ± 134 ml) (P = 0.003). In AIP cases, splenic volume was associated with age and gender (P = 0.04 and 0.02), and splenomegaly was recognized in 20 % (9/46) of cases. Abnormal uptake of (18)F-fluorodeoxyglucose was not detected in the spleen by positron emission tomography. Splenic vein (SpV) was frequently involved in AIP (67 %), but was all recanalized after steroid therapy. Splenic volume in cases with AIP was minimized to 77 % of the original (122 ± 40 ml) (P < 0.0001) and this trend was remarkable in cases with splenomegaly (66 %). In AIP, high serum IL-2 receptor level, diffuse pancreatic enlargement, and SpV stenosis were significantly associated with splenic shrinkage due to steroid treatment (P = 0.002, 0.02, and 0.03). CONCLUSIONS Splenomegaly was sometimes recognized in cases with AIP; however, these cases can be treated with steroids, especially in cases with diffuse pancreatic swelling and SpV stenosis.
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Affiliation(s)
- Hiroyuki Matsubayashi
- Division of Endoscopy, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi, Suntogun, Shizuoka, 411-8777, Japan.
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Kim JH, Chang JH, Nam SM, Lee MJ, Maeng IH, Park JY, Im YS, Kim TH, Kim CW, Han SW. Newly developed autoimmune cholangitis without relapse of autoimmune pancreatitis after discontinuing prednisolone. World J Gastroenterol 2012; 18:5990-3. [PMID: 23139619 PMCID: PMC3491610 DOI: 10.3748/wjg.v18.i41.5990] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 09/03/2012] [Accepted: 09/12/2012] [Indexed: 02/06/2023] Open
Abstract
A 57-year-old man presented with a 2-wk history of painless jaundice and weight loss. He had a large ill-defined enhancing mass-like lesion in the uncinate process of the pancreas with stricture of the distal common bile duct. Aspiration cytology of the pancreatic mass demonstrated inflammatory cells without evidence of malignancy. Total serum immunoglobulin G level was slightly elevated, but IgG4 level was normal. After the 2-wk 40 mg prednisolone trial, the patient’s symptoms and bilirubin level improved significantly. A follow-up computed tomography (CT) scan showed a dramatic resolution of the pancreatic lesion. A low dose steroid was continued. After six months he self-discontinued prednisolone for 3 wk, and was presented with jaundice again. A CT scan showed newly developed intrahepatic biliary dilatation and marked concentric wall thickening of the common hepatic duct and the proximal common bile duct without pancreatic aggravation. The patient’s IgG4 level was elevated to 2.51 g/L. Prednisolone was started again, after which his serum bilirubin level became normal and the thickening of the bile duct was resolved. This case suggests that autoimmune pancreatitis can progress to other organs that are not involved at the initial diagnosis, even with sustained pancreatic remission.
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Miyamoto Y, Kamisawa T, Tabata T, Hara S, Kuruma S, Chiba K, Inaba Y, Kuwata G, Fujiwara T, Egashira H, Koizumi K, Sekiya R, Fujiwara J, Arakawa T, Momma K, Asano T. Short and long-term outcomes of diabetes mellitus in patients with autoimmune pancreatitis after steroid therapy. Gut Liver 2012; 6:501-4. [PMID: 23170157 PMCID: PMC3493733 DOI: 10.5009/gnl.2012.6.4.501] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Accepted: 02/04/2012] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND/AIMS Autoimmune pancreatitis (AIP) is frequently associated with diabetes mellitus (DM). This study evaluated the effect of steroid therapy on the course of DM in AIP. METHODS Glucose tolerance was examined in 69 patients with AIP. DM onset was classified as either a simultaneous onset with AIP or an exacerbation of pre-existing DM. Based on the changes in the HbA1c levels and insulin dose, the responses of DM to steroids were classified as improved, no change, or worsened. RESULTS Thirty (46%) patients were diagnosed as having DM (simultaneous onset, n=17; pre-existing, n=13). Three months after starting the steroid treatment, the DM improved in 13 (54%) of 24 DM patients. The DM improved in 55%, had no change in 36%, and worsened in 9% of the 11 simultaneous onset DM patients, and it improved in 54%, had no change in 31%, and worsened in 15% of the 13 pre-existing DM patients. At approximately 3 years after starting the steroid treatment, the DM improved in 10 (63%) of 16 patients. The pancreatic exocrine function improved in parallel with the changes in the DM in seven patients. CONCLUSIONS Because approximately 60% of DM associated with AIP is responsive to steroids in the short- and long-terms, marked DM associated with AIP appears to be an indication for steroid therapy.
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Affiliation(s)
- Yuji Miyamoto
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
- Department of Internal Medicine, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Terumi Kamisawa
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Taku Tabata
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Seiichi Hara
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Sawako Kuruma
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Kazuro Chiba
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Yoshihiko Inaba
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Go Kuwata
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Takashi Fujiwara
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Hideto Egashira
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Koichi Koizumi
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Ryoko Sekiya
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Junko Fujiwara
- Department of Endoscopy, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Takeo Arakawa
- Department of Endoscopy, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Kumiko Momma
- Department of Endoscopy, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Toru Asano
- Department of Internal Medicine, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
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Zaidan M, Adam J, Cervera-Pierot P, Joly D. The case ∣ a 69-year-old man with a 10-year history of idiopathic retroperitoneal fibrosis. Kidney Int 2012; 80:1379-80. [PMID: 22126986 DOI: 10.1038/ki.2011.357] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Mohamad Zaidan
- Service de Néphrologie Adulte, AP-HP, Hôpital Necker, Paris, France.
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Zaidan M, Ebbo M, Brochériou I, Ronco P, Schleinitz N, Boffa JJ. [IgG4-related disease and renal and urological involvement]. Nephrol Ther 2012; 8:499-507. [PMID: 22480723 DOI: 10.1016/j.nephro.2012.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Revised: 02/20/2012] [Accepted: 02/26/2012] [Indexed: 12/24/2022]
Abstract
Hyper-IgG4 syndrome, or IgG4-related disease, is an emerging disorder, involving one or more organ(s), and characterized by "storiform" fibrosis and inflammatory lesions with a predominance of IgG4+ plasma cells and increased IgG4 serum levels. Since the first report of auto-immune pancreatitis, numerous organ lesions have been reported and have been found to occur in a same patient including: sialadenitis, dacryoadenitis, lymphadenopathy, liver and biliary tract involvement, and renal and retroperitoneal lesions. Renal involvement was first described in 2004 and usually presents as functional and/or morphological abnormalities. In most cases, renal pathological analysis reveals tubulointerstitial nephritis that is rarely associated with glomerular lesions. Retroperitoneal fibrosis is also a typical feature that may be associated with periaortitis or inflammatory abdominal aortic aneurysm. First line treatment is based on corticosteroid therapy. Short-term outcome is usually favorable. However, patients should be carefully monitored for relapses and long-term complications. Although the multiple organ lesions share common clinical, biological, radiological and pathological features, no consensus diagnostic criteria have yet been validated for IgG4-related disease. Ruling out differential diagnoses is thus mandatory. Our literature review provides nephrologists, urologists and pathologists with key elements that will help in the early diagnosis and proper management of this new and emerging disorder.
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Affiliation(s)
- Mohamad Zaidan
- Service de néphrologie et dialyses, hôpital Tenon, Assistance publique des Hôpitaux de Paris, 4, rue de la Chine, 75020 Paris, France.
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Kang HJ, Song TJ, Yu E, Kim J. Idiopathic Duct Centric Pancreatitis in Korea: A Clinicopathological Study of 14 Cases. KOREAN JOURNAL OF PATHOLOGY 2011. [DOI: 10.4132/koreanjpathol.2011.45.5.491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Hyo Jeong Kang
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Jun Song
- Division of Gastroenterology, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Inje Universitiy College of Medicine, Goyang, Korea
| | - Eunsil Yu
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jihun Kim
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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