Gastric varices and splenic vein obstruction during steroid treatment for autoimmune pancreatitis: A case report and literature review

Glucocorticoid therapy in pancreatic portal hypertension associated with autoimmune pancreatitis: A case report

BACKGROUND

Autoimmune pancreatitis (AIP) is a chronic form of pancreatitis characterized by diffused enlargement of the pancreas and irregular stenosis of the main pancreatic duct. Some studies have reported that AIP can cause hemorrhage of gastric varices (GV) related to portal hypertension (PH). However, such cases are rare. In addition, the association of PH with AIP is unclear. At the same time, the efficacy and duration of glucocorticoid therapy is also controversial.

CASE SUMMARY

In this case, we reported a case of GV in pancreatic PH associated with AIP. Enhanced abdominal computed tomography (CT) suggested splenic vein (SV) and superior mesenteric vein (SMV) thromboses. The patient received a long-term glucocorticoid therapy, that the initial dose of 40 mg is reduced weekly by 5 mg, and then reduced to 5 mg for long-term maintenance. CT and gastroscopic examination after 8 mo of treatment indicated that SV and SMV were recanalized, pancreatic stiffness and swelling were ameliorated, and the GV almost completely disappeared.

CONCLUSION

Long-term glucocorticoid therapy can alleviate the development of GV in patients with AIP and has potential reversibility.

Gastric Varices Rupture due to Splenic Vein Obstruction Associated with Autoimmune Pancreatitis

A 60-year-old man with a high IgG4 level was found to have pancreatic tail enlargement on computed tomography (CT), and autoimmune pancreatitis (AIP) was confirmed by a histological diagnosis. He was treated with prednisolone for one year and seven months, at which point his treatment finished. Four months later, however, he had hematemesis from gastric varices. CT showed recurrence of pancreatic tail enlargement with obstruction of the splenic artery and vein and formation of collateral blood vessels to the gastric fornix. Endoscopic injection sclerotherapy was performed, and he underwent splenectomy. This case highlights the importance of paying attention to peripancreatic vascular abnormalities during follow-up of AIP patients.

Spontaneous remission of autoimmune pancreatitis: Four case reports

BACKGROUND

Autoimmune pancreatitis (AIP) is a particular type of chronic pancreatitis, and steroid treatment of AIP is effective. Spontaneous remission (SR) of AIP without steroids is relatively rare. The international consensus for the treatment of autoimmune pancreatitis suggests that patients with AIP with obstructive jaundice, abdominal pain, and back pain related to the pancreas or the bile duct should be treated with steroids; most asymptomatic patients with AIP may improve without steroids. However, in our clinical work, we found that the clinical characteristics of AIP patients with SR vary. Four of these cases are described here. In addition, to our knowledge, there is no previously published report of dynamic imaging before and after SR of AIP at present.

CASE SUMMARY

We present the cases of four patients with AIP (two females and two males) in which the AIP improved spontaneously without steroid treatment. Two patients were asymptomatic, one patient had abdominal pain with obstructive jaundice, and one patient had intermittent right upper abdominal pain. Three patients presented with localized pancreatic enlargement and one with diffuse pancreatic enlargement. In addition to the pancreatic lesions, bile duct involvement was seen in two patients, and no extra-pancreatic organ involvement was found in the other two patients. The serum IgG4 level of all patients was more than twice the normal level. After SR in the four patients, the affected pancreases exhibited three types of image features: Return to normal, progressive fibrosis, and atrophy and calcification.

CONCLUSION

The clinical features of SR in our four patients with AIP differ, but the imaging findings share some characteristics. After SR, in some cases the affected pancreas could return to normal, although some patients suffer from progressive fibrosis and atrophy as well as calcification.

Peripancreatic vascular involvement in patients with type 1 autoimmune pancreatitis

BACKGROUND

Type 1 autoimmune pancreatitis (AIP) is the pancreatic manifestation of IgG4-related disease. However, this benign disease can result in the peripancreatic vascular involvement (PVI) on occasion, which increases the difficulty of diagnosis and treatment of this clinical entity as well as for differentiating it from pancreatic malignancies.

METHODS

We retrospectively reviewed the information on demographics, clinical presentation, laboratory, imaging and endoscopic findings of 101 hospitalized patients with type 1 AIP treated in our department. All the patients were divided into non-PVI and PVI groups according to the first hospitalized medical data. Univariate and multivariate analyses were performed to analyse the potential predictive parameter(s) of PVI in AIP patients.

RESULTS

Among the 101 type 1 AIP patients, 52 (51.5%) exhibited PVI, with a male/female ratio 5.5:1. Their average age was 58.37±8.68 years old. Univariate analysis revealed that the location of pancreatitis lesions, including the pancreatic tail (P=0.010), the presence of splenomegaly (P=0.001) and the white blood cell (WBC) number in peripheral blood (P=0.020), were significantly associated with PVI. The location of pancreatitis lesions, including the pancreatic tail (P=0.023), and the presence of splenomegaly (P=0.010) were found to be independent predictors of the development of PVI by a multivariable regression analysis. A total of 18 out of 25 patients in PVI group who underwent corticosteroid treatment and no less than 6 months radiological follow-up showed improvement in vascular lesions, and no case exhibited exacerbation of PVI lesions during follow-up. Of 36 patients in non-PVI group who were followed up for no less than 6 months, only one case exhibited PVI.

CONCLUSIONS

This retrospective study demonstrated that type 1 AIP was associated with a high proportion of PVI. Pancreatic tail involvement and splenomegaly may predict the PVI in type 1 AIP. PVI lesions are reversible in a subset of patients.

IgG4-related autoimmune pancreatitis combined with splenic vein thrombosis leading to variceal bleeding of the fundus: A case report

BACKGROUND

Bleeding from isolated gastric varices, though uncommon, may be life-threatening. There are few reports of autoimmune pancreatitis (AIP) with splenic vein thrombosis and subsequent left-sided portal hypertension complicated by gastric varices, and the effect of steroid therapy on gastric varices is unknown. We herein present one case of AIP complicated by gastric varices.

CASE SUMMARY

A 43-year-old man was diagnosed with AIP complicated by gastric varices, splenic vein obstruction, and splenomegaly. Although the AIP was improved after steroid therapy, gastric varices and splenic vein obstruction did not resolve.

CONCLUSION

For bleeding from isolated gastric varices with left portal hypertension, the cause should be actively sought after hemostasis therapy. Gastric varices or splenic vein obstruction may be an indication for steroid therapy, and splenic vein thrombosis may play a key role in the disappearance of gastric varices. Factors affecting the efficacy in splenic vein thrombosis are expected to be explored by future studies with more cases and longer follow-up.