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Vernia F, Cirella L, Calvisi G, Viscido A, Latella G. Immunoglobulin G4-Related Disease of the Intestine: A Clinicopathological Entity to Be Considered. MEDICINA (KAUNAS, LITHUANIA) 2023; 60:57. [PMID: 38256319 PMCID: PMC10818347 DOI: 10.3390/medicina60010057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/18/2023] [Accepted: 12/26/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Immunoglobulin G4-related disease (IgG4-RD) is a recently recognized immune-mediated, systemic condition of unknown etiology, associated with fibroinflammatory lesions. Diagnosis is set in the presence of IgG4-positive plasma cell infiltration of the involved tissue and elevated serum IgG4 levels. However, approximately 30% of patients have normal serum IgG4 levels. IgG4-RD may affect several organs, including the pancreas, bile ducts, mesentery, retroperitoneum, and salivary glands, but the involvement of the gastrointestinal tract is uncommon. Materials and Methods: The case series of 4 patients with IgG4-RD involving the intestinal tract was observed in the period of 2017-2022. Colorectal and ileal biopsy specimens were stained with hematoxylin and eosin and immunohistochemical techniques using monoclonal antihuman IgG4 primary antibody. Diagnosis of IgG4-RD was based on the presence of >50 cells/ HPF and IgG4/IgG ratio >40 confirmed by two pathologists. Results: IgG4-RD was set in patients previously diagnosed as affected by Crohn's disease. Conclusions: Systematic IgG4 immunohistochemical staining should be considered in the diagnostic workup of patients with gastrointestinal strictures, mimicking Crohn's disease. The exact prevalence of the condition is likely more frequent than reported and should be defined by a large series of consecutive patients.
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Affiliation(s)
- Filippo Vernia
- Department of Life, Health, and Environmental Sciences, Division of Gastroenterology, Hepatology, and Nutrition, University of L’Aquila, Piazza S. Tommasi, 1, Coppito, 67100 L’Aquila, Italy; (F.V.); (A.V.)
| | - Laura Cirella
- Pathology Unit, San Salvatore Hospital, Via Lorenzo Natali, 1, Coppito, 67100 L’Aquila, Italy; (L.C.); (G.C.)
| | - Giuseppe Calvisi
- Pathology Unit, San Salvatore Hospital, Via Lorenzo Natali, 1, Coppito, 67100 L’Aquila, Italy; (L.C.); (G.C.)
| | - Angelo Viscido
- Department of Life, Health, and Environmental Sciences, Division of Gastroenterology, Hepatology, and Nutrition, University of L’Aquila, Piazza S. Tommasi, 1, Coppito, 67100 L’Aquila, Italy; (F.V.); (A.V.)
| | - Giovanni Latella
- Department of Life, Health, and Environmental Sciences, Division of Gastroenterology, Hepatology, and Nutrition, University of L’Aquila, Piazza S. Tommasi, 1, Coppito, 67100 L’Aquila, Italy; (F.V.); (A.V.)
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2
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Kang S, Lee YS, Kim NH, Son JH, Kim JW, Joo M. Immunoglobulin G4-related Disease of the Small Bowel: A Case of Long-term Remission Achieved by Surgical Resection without Maintenance Therapy. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2023; 82:25-29. [PMID: 37489079 DOI: 10.4166/kjg.2023.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/04/2023] [Accepted: 06/13/2023] [Indexed: 07/26/2023]
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated fibroinflammatory disease. IgG4-RD can affect any organ system, including the pancreas, bile ducts, salivary glands, mesentery, and retroperitoneum. On the other hand, small intestine involvement is extremely rare. This paper describes a case of IgG4-RD involving the small bowel, particularly at the distal ileum. An 81-year-old female was admitted to the authors' hospital complaining of abdominal pain, dyspepsia, and hematochezia. The laboratory tests, including tumor markers and IgG4, were within normal limits. A colonoscopy did not show any abnormal findings. Abdominal computed tomography revealed segmental aneurysmal dilatation and wall thickening at the distal ileum, suggesting malignant conditions, such as small bowel lymphoma. The patient underwent an exploratory laparoscopy and ileocecectomy to differentiate a malignancy. A histopathology examination revealed dense lymphoplasmacytic infiltration, storiform fibrosis, and IgG4-positive plasma cells (>50 per high power field). The patient was finally diagnosed with IgG4-RD. The patient was followed up in the outpatient clinic for five years without recurrence. This paper suggests that a radical resection without maintenance therapy can be a treatment option, particularly when the IgG4-RD manifests as a localized gastrointestinal tract lesion.
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Affiliation(s)
- Seokin Kang
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Yoon Suk Lee
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Nam-Hoon Kim
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Jun Hyuk Son
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Jong Wook Kim
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Mee Joo
- Department of Pathology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
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3
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Zhan WL, Liu L, Jiang W, He FX, Qu HT, Cao ZX, Xu XS. Immunoglobulin G4-related disease in the sigmoid colon in patient with severe colonic fibrosis and obstruction: A case report. World J Gastrointest Surg 2022; 14:1169-1178. [PMID: 36386398 PMCID: PMC9640331 DOI: 10.4240/wjgs.v14.i10.1169] [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: 07/10/2022] [Revised: 09/03/2022] [Accepted: 10/18/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated condition characterized by abundant IgG4 positive plasma cells and fibrosis in the affected tissues. It affects most parts of the body; however, there are not many reports on IgG4-RD involving the colon.
CASE SUMMARY A 50-year-old man complaining of intermittent fever for more than two years was referred to our hospital. Based on various investigations before surgery, we diagnosed him with chronic perforation of the sigmoid colon caused by inflammatory change or tumor. IgG blood tests before the operation suggested IgG4-RD, and postoperative pathology confirmed this prediction.
CONCLUSION We present a patient with IgG4-RD with colon involvement, which is an uncommon site. This report will expand the understanding of IgG4-RD in unknown tissues.
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Affiliation(s)
- Wen-Li Zhan
- Department of Gastrointestinal Surgery, Tongji Hospital, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Liang Liu
- Department of Gastrointestinal Surgery, Tongji Hospital, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Wei Jiang
- Department of Gastrointestinal Surgery, Tongji Hospital, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Fang-Xun He
- Department of Gastrointestinal Surgery, Tongji Hospital, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Hai-Tao Qu
- Anorectal Disease Center, The First Affiliated Hospital of Henan University of Traditional Chinese Medicine, Zhengzhou 450000, Henan Province, China
| | - Zhi-Xin Cao
- Department of Gastrointestinal Surgery, Tongji Hospital, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Xiang-Shang Xu
- Department of Gastrointestinal Surgery, Tongji Hospital, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
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4
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Yoshidome Y, Mizoguchi A, Narimatsu K, Takahashi S, Hirata D, Ono S, Onoyama Y, Suzuki S, Horiuchi T, Chiya N, Ikeyama K, Tahara H, Tomioka A, Ito S, Tanemoto R, Nishii S, Inaba K, Sugihara N, Hanawa Y, Horiuchi K, Wada A, Akita Y, Higashiyama M, Komoto S, Tomita K, Yoshimatsu S, Matsukuma S, Hokari R. Immunoglobulin G4‐related disease accompanying a small intestinal ulcer: A case. DEN OPEN 2022; 2:e76. [PMID: 35310696 PMCID: PMC8828200 DOI: 10.1002/deo2.76] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/30/2021] [Accepted: 10/24/2021] [Indexed: 11/06/2022]
Abstract
Immunoglobulin (Ig)G4‐related disease (IgG4‐RD) is a systemic condition associated with fibroinflammatory lesions and is characterized by elevated serum IgG4 levels and IgG4‐positive cell infiltration into the affected tissues. It has been reported that IgG4‐RD affects a variety of organs but uncommonly affects the gastrointestinal tract. In particular, there are few cases of lesions in the small intestine, except for sclerosing mesenteritis, which were mostly diagnosed from surgical specimens. Herein, we describe the case of a 70‐year‐old man who initially presented with abdominal pain, headache, later cognitive decline, and gait disturbance caused by IgG4‐RD. Colonoscopy revealed irregular ulcers in the terminal ileum, and computed tomography of the head showed hypertrophic pachymeningitis. Numerous IgG4‐positive cells were detected in the ileal and dural biopsies. We diagnosed the patient with IgG4‐RD and started steroid pulse therapy. After initiation of treatment, the symptoms quickly improved. The patient was discharged from the hospital after starting oral prednisolone treatment (30 mg). The dosage was gradually reduced to 10 mg. A follow‐up colonoscopy revealed scarring of the ileal ulcers. This case may provide valuable information regarding the endoscopic findings of small intestinal lesions in IgG4‐RD.
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Affiliation(s)
- Yuta Yoshidome
- Department of Gastroenterology National Defense Medical College Saitama Japan
| | - Akinori Mizoguchi
- Department of Gastroenterology National Defense Medical College Saitama Japan
| | - Kazuyuki Narimatsu
- Department of Gastroenterology National Defense Medical College Saitama Japan
| | - Shun Takahashi
- Department of Gastroenterology National Defense Medical College Saitama Japan
| | - Dai Hirata
- Department of Gastroenterology National Defense Medical College Saitama Japan
| | - Shinji Ono
- Department of Gastroenterology National Defense Medical College Saitama Japan
| | - Yusuke Onoyama
- Department of Gastroenterology National Defense Medical College Saitama Japan
| | - Seiya Suzuki
- Department of Gastroenterology National Defense Medical College Saitama Japan
| | - Tomoaki Horiuchi
- Department of Gastroenterology National Defense Medical College Saitama Japan
| | - Nanoka Chiya
- Department of Gastroenterology National Defense Medical College Saitama Japan
| | - Keisuke Ikeyama
- Department of Gastroenterology National Defense Medical College Saitama Japan
| | - Hiroyuki Tahara
- Department of Gastroenterology National Defense Medical College Saitama Japan
| | - Akira Tomioka
- Department of Gastroenterology National Defense Medical College Saitama Japan
| | - Suguru Ito
- Department of Gastroenterology National Defense Medical College Saitama Japan
| | - Rina Tanemoto
- Department of Gastroenterology National Defense Medical College Saitama Japan
| | - Shin Nishii
- Department of Gastroenterology National Defense Medical College Saitama Japan
| | - Kenichi Inaba
- Department of Gastroenterology National Defense Medical College Saitama Japan
| | - Nao Sugihara
- Department of Gastroenterology National Defense Medical College Saitama Japan
| | - Yoshinori Hanawa
- Department of Gastroenterology National Defense Medical College Saitama Japan
| | - Kazuki Horiuchi
- Department of Gastroenterology National Defense Medical College Saitama Japan
| | - Akinori Wada
- Department of Gastroenterology National Defense Medical College Saitama Japan
| | - Yoshihiro Akita
- Department of Gastroenterology National Defense Medical College Saitama Japan
| | - Masaaki Higashiyama
- Department of Gastroenterology National Defense Medical College Saitama Japan
| | - Shunsuke Komoto
- Department of Gastroenterology National Defense Medical College Saitama Japan
| | - Kengo Tomita
- Department of Gastroenterology National Defense Medical College Saitama Japan
| | - Shinya Yoshimatsu
- Department of Pathology and Laboratory Medicine National Defense Medical College Hospital Saitama Japan
| | - Susumu Matsukuma
- Department of Pathology and Laboratory Medicine National Defense Medical College Hospital Saitama Japan
| | - Ryota Hokari
- Department of Gastroenterology National Defense Medical College Saitama Japan
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5
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Rosevics L, Ramos Júnior O. ILEOSCOPY: WHEN ILEAL EVALUATION IS NOT MANDATORY DURING COLONOSCOPY. ARQUIVOS DE GASTROENTEROLOGIA 2021; 58:175-179. [PMID: 34231662 DOI: 10.1590/s0004-2803.202100000-30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 02/02/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Ileitis is defined as ileal inflammation, with several etiologies, including inflammatory bowel disease (IBD), and can be evaluated during the colonoscopy exam, but its mandatory evaluation is discussed, because of few diagnosis and procedure time. OBJECTIVE This study aims to evaluate the correlation of colonoscopic ileitis with the clinical presentation, in order to identify the cases where ileal examination is mandatory. METHODS A retrospective, cross-sectional study was conducted between 2013 and 2017. The examination report, indications for colonoscopy, and medical records were evaluated in order to identify whether the colonoscopic findings were clinically significant. Patients over 18 years of age who had undergone ileoscopy were included, whereas patients below 18 years of age, those with previous intestinal resections, and repeated examinations of the same patient in the study period were excluded. The estimated association measure was the odds ratio with 95% confidence intervals. P-values <0.05 indicated statistical significance. RESULTS A total of 3382 cases were included. Among these participants, 64.5% were females and the average age was 56.9±13.1 years (18-89 years). Ileal alterations were observed in 5.3% of the patients, with 2.69% being clinically significant between all patients, and 0.96% excluding those with IBD. There was a positive correlation between the ileitis findings and IBD control examinations and a negative correlation in screening and change in bowel habit indications. Among the indications with ileitis clinically significant, IBD control still had a positive correlation, 'diarrhea' and 'others' did not show a statistical significance, and all other indications presented a negative correlation for ileal assessment. CONCLUSION Ileal evaluation in only mandatory in IBD control. When the main colonoscopy objective is detecting colonic neoplasms, ileoscopy is unnecessary.
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Affiliation(s)
- Leticia Rosevics
- Universidade Federal do Paraná, Hospital de Clínicas, Curitiba, PR, Brasil
| | - Odery Ramos Júnior
- Universidade Federal do Paraná, Hospital de Clínicas, Curitiba, PR, Brasil
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6
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Rosevics L, Kotze LR, Ramos Júnior O. ILEITIS - DO ENDOSCOPIST AND PATHOLOGIST SPEAK THE SAME LANGUAGE? ARQUIVOS DE GASTROENTEROLOGIA 2021; 58:145-149. [PMID: 34231660 DOI: 10.1590/s0004-2803.202100000-25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 01/30/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Ileitis is defined as an inflammation of the ileum, which is evaluated during colonoscopy. Biopsies should be performed on altered ileus, aiding to the diagnosis. OBJECTIVE Evaluate the correlation of anatomopathological findings on ileitis between pathologists and endoscopists. METHODS A retrospective, cross-sectional study, between 2013 and 2017. Examination report, indications for colonoscopy, and medical records were evaluated to identify whether the colonoscopic findings were clinically significant. Anatomopathological samples were reviewed by a pathologist expert in gastrointestinal tract. Patients over 18 years of age who had undergone ileoscopy were included, whereas patients below 18 years of age and those with previous intestinal resections were excluded. The correlation was assessed using the kappa coefficient index. RESULTS A total of 5833 colonoscopies were conducted in the study period and 3880 cases were included. Ileal alterations were observed in 206 cases, with 2.94% being clinically significant. A hundred and sixty three biopsies were evaluated using the kappa index, resulting in agreement among pathologists of 0.067 and among pathologist and endoscopist of 0.141. CONCLUSION It was observed that despite the low concordance between pathologists and endoscopists, there was no change in patient outcomes. This study confirms the importance of knowledge of the main anatomopathological changes related to ileitis by pathologists and endoscopists, making the best diagnosis and follow-up.
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Affiliation(s)
- Leticia Rosevics
- Universidade Federal do Paraná, Hospital de Clínicas, Curitiba, PR, Brasil
| | - Luiz Roberto Kotze
- Universidade Federal do Paraná, Hospital de Clínicas, Curitiba, PR, Brasil
| | - Odery Ramos Júnior
- Universidade Federal do Paraná, Hospital de Clínicas, Curitiba, PR, Brasil
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7
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Uchino K, Notohara K, Uehara T, Kuraishi Y, Itakura J, Matsukawa A. Utility of gastric biopsy in diagnosing IgG4-related gastrointestinal disease. Pathol Int 2020; 71:124-134. [PMID: 33378576 DOI: 10.1111/pin.13059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 01/13/2023]
Abstract
The utility of gastric biopsy for diagnosing immunoglobulin (Ig)G4-related gastrointestinal disease (IgG4-GID) remains unclear. Bottom-heavy plasmacytosis (BHP) is a distinct feature of IgG4-GID. To clarify the feasibility of using gastric biopsies to diagnose BHP in IgG4-GID, we analyzed the histological features and immunostaining of gastric biopsy specimens from 31 known IgG4-related disease (IgG4-RD) patients and we assessed the presence of BHP in 1696 consecutive routine gastric biopsies. Cases with both >10 IgG4-positive plasma cells per high-power field and an IgG4/IgG-positive ratio >40% were defined as IgG4-high. Ten of the 31 IgG4-RD patients were concluded to have IgG4-GID, in which IgG4-positive plasma cells were notably detected at the deeper part of the mucosa. Six cases displayed BHP whereas the remaining four cases showed transmural infiltration with concomitant Helicobacter pylori-associated gastritis. In addition to BHP, we identified two unique histologic features for IgG4-GID: plasmacytic aggregation in the muscularis mucosae and permeative plasmacytic infiltration between fundic glands in the non-atrophic mucosa. Six of the routine cases (0.35%) displayed BHP, including a case with IgG4-RD. IgG4-GID can be suspected by the presence of gastric biopsy specimens with characteristic histological features. Such cases are recommended to undergo further examinations to determine whether IgG4-RD is present.
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Affiliation(s)
- Kaori Uchino
- Department of Pathology and Experimental Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan.,Department of Anatomic Pathology, Kurashiki Central Hospital, Okayama, Japan
| | - Kenji Notohara
- Department of Anatomic Pathology, Kurashiki Central Hospital, Okayama, Japan
| | - Takeshi Uehara
- Department of Laboratory Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Yasuhiro Kuraishi
- Department of Gastroenterology, Shinshu University School of Medicine, Nagano, Japan
| | - Junya Itakura
- Department of Anatomic Pathology, Kurashiki Central Hospital, Okayama, Japan
| | - Akihiro Matsukawa
- Department of Pathology and Experimental Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
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8
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Muto O, Tamakawa S, Takahashi K, Yokohama S, Takasoe A, Hirano F, Nishimura H, Saito H. IgG4-related Disease Manifesting as Gastroduodenal Ulcer Diagnosed by an Endoscopic Biopsy. Intern Med 2020; 59:2491-2497. [PMID: 32581158 PMCID: PMC7662039 DOI: 10.2169/internalmedicine.4483-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
A 26-year-old man was admitted to our hospital due to upper abdominal pain. He had previously been diagnosed with gastroduodenal ulcer at 23 and 25 years old and had been treated with proton-pump inhibitors. Endoscopic hemostasis and a biopsy were performed on the hemorrhagic gastroduodenal ulcers. Laboratory and pathologic examinations demonstrated elevated serum IgG4 levels and the infiltration of IgG4-positive plasma cells into the gastroduodenal tissues. Based on the clinicopathologic findings and after excluding other causes, he was diagnosed with IgG4-related gastroduodenal ulcer. We herein report a rare case of IgG4-related disease manifesting as a gastroduodenal ulcer diagnosed by an endoscopic biopsy.
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Affiliation(s)
- Osamu Muto
- Department of Gastroenterology, National Hospital Organization Asahikawa Medical Center, Japan
| | - Susumu Tamakawa
- Department of Pathology, National Hospital Organization Asahikawa Medical Center, Japan
| | - Kenji Takahashi
- Division of Metabolism and Biosystemic Science, Department of Medicine, Asahikawa Medical University, Japan
| | - Shiro Yokohama
- Department of Gastroenterology, National Hospital Organization Asahikawa Medical Center, Japan
| | - Ai Takasoe
- Department of Gastroenterology, National Hospital Organization Asahikawa Medical Center, Japan
| | - Fuminori Hirano
- Department of Gastroenterology, National Hospital Organization Asahikawa Medical Center, Japan
| | - Hideo Nishimura
- Department of Gastroenterology, National Hospital Organization Asahikawa Medical Center, Japan
| | - Hiroki Saito
- Department of Gastroenterology, National Hospital Organization Asahikawa Medical Center, Japan
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9
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Löhr JM, Beuers U, Vujasinovic M, Alvaro D, Frøkjær JB, Buttgereit F, Capurso G, Culver EL, de-Madaria E, Della-Torre E, Detlefsen S, Dominguez-Muñoz E, Czubkowski P, Ewald N, Frulloni L, Gubergrits N, Duman DG, Hackert T, Iglesias-Garcia J, Kartalis N, Laghi A, Lammert F, Lindgren F, Okhlobystin A, Oracz G, Parniczky A, Mucelli RMP, Rebours V, Rosendahl J, Schleinitz N, Schneider A, van Bommel EF, Verbeke CS, Vullierme MP, Witt H. European Guideline on IgG4-related digestive disease - UEG and SGF evidence-based recommendations. United European Gastroenterol J 2020; 8:637-666. [PMID: 32552502 DOI: 10.1177/2050640620934911] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The overall objective of these guidelines is to provide evidence-based recommendations for the diagnosis and management of immunoglobulin G4 (IgG4)-related digestive disease in adults and children. IgG4-related digestive disease can be diagnosed only with a comprehensive work-up that includes histology, organ morphology at imaging, serology, search for other organ involvement, and response to glucocorticoid treatment. Indications for treatment are symptomatic patients with obstructive jaundice, abdominal pain, posterior pancreatic pain, and involvement of extra-pancreatic digestive organs, including IgG4-related cholangitis. Treatment with glucocorticoids should be weight-based and initiated at a dose of 0.6-0.8 mg/kg body weight/day orally (typical starting dose 30-40 mg/day prednisone equivalent) for 1 month to induce remission and then be tapered within two additional months. Response to initial treatment should be assessed at week 2-4 with clinical, biochemical and morphological markers. Maintenance treatment with glucocorticoids should be considered in multi-organ disease or history of relapse. If there is no change in disease activity and burden within 3 months, the diagnosis should be reconsidered. If the disease relapsed during the 3 months of treatment, immunosuppressive drugs should be added.
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Affiliation(s)
- J-Matthias Löhr
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden and Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Ulrich Beuers
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Miroslav Vujasinovic
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden and Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Domenico Alvaro
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité University Medicine Berlin, Berlin, Germany
| | - Gabriele Capurso
- PancreatoBiliary Endoscopy and EUS Division Pancreas Translational and Clinical Research Center IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Emma L Culver
- Translational Gastroenterology Unit, John Radcliffe Hospital and Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Enrique de-Madaria
- Gastroenterology Department, Alicante University General Hospital, ISABIAL, Alicante, Spain
| | - Emanuel Della-Torre
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Disease (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sönke Detlefsen
- Department of Pathology, Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
| | - Enrique Dominguez-Muñoz
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Piotr Czubkowski
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Nils Ewald
- Institute of Endocrinology, Diabetology and Metabolism, Johannes Wesling University hospital, Minden, Germany and Justus Liebig University Giessen, Giessen, Germany
| | - Luca Frulloni
- Department of Medicine, Pancreas Institute, University of Verona, Verona, Italy
| | - Natalya Gubergrits
- Department of Internal Medicine, Donetsk National Medical University, Lyman, Ukraine
| | - Deniz Guney Duman
- Department of Gastroenterology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Julio Iglesias-Garcia
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Nikolaos Kartalis
- Department of Abdominal Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Andrea Laghi
- Department of Surgical and Medical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
| | - Fredrik Lindgren
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Karolinska University Hospital, Stockholm, Sweden
| | | | - Grzegorz Oracz
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Andrea Parniczky
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; Heim Pál National Insitute of Pediatrics, Budapest, Hungary
| | | | - Vinciane Rebours
- Pancreatology Department, Beaujon Hospital, Clichy, Université de Paris, France
| | - Jonas Rosendahl
- Department of Internal Medicine I, Martin Luther University, Halle, Germany
| | - Nicolas Schleinitz
- Département de Médicine Interne Timone, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Alexander Schneider
- Department of Gastroenterology and Hepatology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany
| | - Eric Fh van Bommel
- Department of Internal Medicine, Dutch National Center of Expertise Retroperitoneal Fibrosis, Albert Schweitzer hospital, Dordrecht, the Netherlands
| | | | | | - Heiko Witt
- Else Kröner-Fresenius-Zentrum für Ernährungsmedizin, Paediatric Nutritional Medicine, Technische Universität München, Freising, Germany
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- See list at the end of this article
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Watanabe A, Goto T, Kamo H, Komine R, Kuroki N, Sugase T, Takaya T, Koga R, Hojo H, Taniguchi S, Ibusuki K, Koga K. Resection of lesions in the ileum of patients with IgG4-related disease may ameliorate disease progression without steroid administration. Surg Case Rep 2018; 4:148. [PMID: 30594958 PMCID: PMC6311175 DOI: 10.1186/s40792-018-0546-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 11/20/2018] [Indexed: 12/24/2022] Open
Abstract
Background IgG4-related disease (IgG4-RD) is a pathological condition that is characterized by an infiltrate composed of IgG4-positive plasma cells and recently recognized as an immune-mediated condition. It causes tissue throughout the body to become stiff and thickened due to autoimmune reactions that cause fibrosis and scarring. Disease-related changes commonly occur in the salivary glands, bile duct, pancreas, and lungs, but are seldom seen in the small bowel. A diagnosis of IgG4-RD is suspected if a high level of IgG4 is found on a blood test. The ideal diagnostic method is pathological examination, but because the clinical manifestations of IgG4-RD are very diverse and nonspecific, the disease may often go undiagnosed until an unrelated biopsy or resection specimen is obtained. The most common treatment for IgG4-RD is steroid use. However, tapering or stopping steroid administration is seen to result in recurrence in approximately 50% of cases. A complete cure is therefore considered extremely difficult. Case presentation A 69-year-old man with gastrointestinal obstruction underwent small bowel resection for two lesions. On histopathological examination, the specimen showed features of IgG4-RD. We performed several tests to detect other characteristics of IgG4-RD, but were unable to find any. The patient is being followed up regularly for a year and is being observed for any symptoms of recurrence. Conclusions We present a case of IgG4-RD wherein the ileum wall was significantly sclerosed, leading to gastrointestinal tract obstruction; therefore, we resected two sections of the ileum. We believe that resection of IgG4-RD lesions can help avoid long-term steroid use in patients, because the surgery completely eliminates the pathological origins of the condition.
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Affiliation(s)
- Akihiro Watanabe
- Department of Gastrointestinal and General Surgery, Mitsui Memorial Hospital, Tokyo, Japan.
| | - Takashi Goto
- Department of Gastrointestinal and General Surgery, Koga General Hospital, Miyazaki, Japan
| | - Hitomi Kamo
- Department of Gastrointestinal and General Surgery, Koga General Hospital, Miyazaki, Japan
| | - Ryuji Komine
- Department of Gastrointestinal and General Surgery, Mitsui Memorial Hospital, Tokyo, Japan
| | - Naomi Kuroki
- Department of Gastrointestinal and General Surgery, Koga General Hospital, Miyazaki, Japan
| | - Takanobu Sugase
- Department of Gastrointestinal and General Surgery, Koga General Hospital, Miyazaki, Japan
| | - Tsuyoshi Takaya
- Department of Gastrointestinal and General Surgery, Koga General Hospital, Miyazaki, Japan
| | - Rintaro Koga
- Department of Gastrointestinal and General Surgery, Koga General Hospital, Miyazaki, Japan
| | - Hiroshi Hojo
- Department of Gastrointestinal and General Surgery, Koga General Hospital, Miyazaki, Japan
| | - Shoji Taniguchi
- Department of Gastrointestinal and General Surgery, Koga General Hospital, Miyazaki, Japan
| | - Kazuhiko Ibusuki
- Department of Gastrointestinal and General Surgery, Koga General Hospital, Miyazaki, Japan
| | - Kazumi Koga
- Department of Gastrointestinal and General Surgery, Koga General Hospital, Miyazaki, Japan
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Ileocecal IgG4-Related Disease: A Case Report Mimicking Malignancy. ACG Case Rep J 2018; 5:e84. [PMID: 30568972 PMCID: PMC6277136 DOI: 10.14309/crj.2018.84] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 09/12/2018] [Indexed: 12/24/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a chronic mass-forming inflammatory disease characterized by fibroblastic proliferation and mixed inflammatory cell infiltration. IgG4-RD can involve one or multiple organs, and the most commonly affected organs include the pancreas, salivary glands, and the orbit. We present a case of a 66-year-old man, with a history of sarcoidosis, who presented with an obstructing ileocecal mass highly suspicious for malignancy. After surgical resection and pathological and serological evaluation, a diagnosis of IgG4-RD was rendered. In the absence of other manifestations, preoperative diagnosis is challenging, and IgG4-RD may continue to be a diagnostic pitfall.
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Gastrointestinal manifestation of immunoglobulin G4-related disease: clarification through a multicenter survey. J Gastroenterol 2018; 53:845-853. [PMID: 29222587 DOI: 10.1007/s00535-017-1420-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 11/28/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Several reports on immunoglobulin (Ig)G4-related disease (IgG4-RD) with gastrointestinal involvement (IgG4-related gastrointestinal disease; IgG4-GID) have been published, although this entity has not been fully established clinicopathologically. Thus, we carried out a multicenter survey. METHODS Patients with possible IgG4-GID who underwent resection were collected. Histologic slides were reevaluated, and eight cases with diffuse lymphoplasmacytic infiltration but without numerous neutrophils, granulations or epithelioid granulomas were further analyzed. RESULTS Overall, the IgG4 counts (87-345/high-power field) and IgG4/IgG-positive ratio were high (44-115%). The demographic findings included advanced age among the patients (55-80 years) and male preponderance (six cases). Six lesions (five gastric, one esophageal), consisting of lymphoplasmacytic infiltration with neural involvement in the muscularis propria and/or bottom-heavy plasmacytosis in the gastric mucosa, were histologically regarded as highly suggestive of IgG4-RD. Storiform fibrosis and obliterative phlebitis were found in two cases, and the former gave rise to a 7-cm-sized inflammatory pseudotumor (IPT) in one case. Ulceration and carcinoma co-existed in three and two lesions, respectively. All the patients had other organ involvement (OOI), and serum IgG4 levels were markedly elevated (four of five patients). The remaining two cases with gastric IPTs featuring reactive nodular fibrous pseudotumor or nodular lymphoid hyperplasia were regarded as possible cases of IgG4-RD because of the histologic findings and lack of OOI. CONCLUSIONS IgG4-GID is found in the setting of IgG4-RD, often with ulceration or cancer. Characteristic histologic findings are observed in the muscularis propria and gastric mucosa. Cases with IPT may be heterogeneous, and there may be mimickers of IgG4-GID.
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Ileocecal IgG4-Related Disease: A Case Report Mimicking Malignancy. ACG Case Rep J 2018. [DOI: 10.14309/02075970-201805110-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Hiyoshi Y, Oki E, Zaitsu Y, Ando K, Ito S, Saeki H, Morita M, Yamamoto H, Baba H, Maehara Y. IgG4-related disease of the ileocecal region mimicking malignancy: A case report. Int J Surg Case Rep 2014; 5:669-72. [PMID: 25194601 PMCID: PMC4189076 DOI: 10.1016/j.ijscr.2014.08.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 08/04/2014] [Accepted: 08/04/2014] [Indexed: 12/24/2022] Open
Abstract
The colonic IgG4-RD is rare. We report the case of a74-year-old female with IgG4-RD of the ileocecal region. The patient was diagnosed asmalignant lymphoma and underwent right-hemi colectomy. Postoperative pathologicalexamination revealed IgG4-RD of the ileocecal region. Surgical resection for IgG4-RDis necessary for cases with concerns of malignancy.
INTRODUCTION Immunoglobulin G4-related disease (IgG4-RD) is a systemic disease characterized by chronic fibrosing inflammation with abundant IgG4-positive plasma cells, and responds well to steroids. Previous reports of IgG4-RD have focused on pancreatic and extrapancreatic including the gastrointestinal tract, however, the colonic IgG4-RD is rare. PRESENTATION OF CASE We herein report the case of a 74-year-old female with edematous wall thickening of the terminal ileum to the lower ascending colon confirmed by several preoperative imaging studies, who underwent right hemi-colectomy for suspected malignant lymphoma. The resected specimen showed an irregular wall thickness with subserosal sclerosis, and the lesion was 10 cm in length from the terminal ileum to the ascending colon. The patient was diagnosed with IgG4-RD by pathological examinations, which demonstrated an increased number of IgG4-positive plasma cells (150/HPF), and an elevated IgG4/IgG ratio (50%). DISCUSSION Gastrointestinal IgG4-RD appears to be difficult to diagnose prior to surgical resection because of its rarity, and the similarity of its features to malignancy. The measurement of the serum IgG4 levels, immunohistochemical examination of biopsy specimens and use of several imaging modalities might help us to diagnose the disease without surgical resection, and this disease can generally be treated with steroid therapy. However, surgical resection for IgG4-RD may still be also necessary for patients with concerns regarding malignancy or with intractable gastrointestinal obstruction caused by this disease. CONCLUSION Gastrointestinal IgG4-RD often mimics malignancy, and we should therefore consider this disease in the differential diagnosis of colonic lesions in order to optimize the treatment.
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Affiliation(s)
- Yukiharu Hiyoshi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan.
| | - Eiji Oki
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Yoko Zaitsu
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Koji Ando
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Shuhei Ito
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Hiroshi Saeki
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Masaru Morita
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Hidetaka Yamamoto
- Department of Anatomic Pathology, Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Yoshihiko Maehara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan
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