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Ino K, Arinuma Y, Akiya M, Kajita S, Okina S, Sakamoto J, Tanaka T, Matsueda Y, Wada T, Tanaka S, Oku K, Yamaoka K. IgG4-related disease complicated with diffuse and chronic gastrointestinal inflammation leading to small intestinal perforation. Mod Rheumatol Case Rep 2024; 8:323-328. [PMID: 38547341 DOI: 10.1093/mrcr/rxae012] [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] [Received: 11/21/2023] [Revised: 02/18/2024] [Accepted: 02/26/2024] [Indexed: 07/09/2024]
Abstract
Immunoglobulin (Ig) G4-related disease (IgG4-RD) is a systemic inflammatory disease characterised by elevated serum IgG4, IgG4+ cell infiltration, storiform fibrosis, and obliterative phlebitis. While IgG4-RD can affect various organs, gastrointestinal tract involvement is less common. Here, we report a 70-year-old female with IgG4-RD complicated with diffuse and chronic gastrointestinal inflammation, which led to small intestinal perforation. She had been suffering from anorexia, abdominal pain, vomiting, and diarrhoea and hospitalised due to recurrent ileus. Consequently, she was referred due to small intestinal perforation required for surgical intervention. Pathology revealed acute and chronic inflammation with massive IgG4+ plasmacyte infiltration into mucosa of the small intestine and ischaemic change secondarily caused by chronic inflammation. Random biopsies from the mucosa of stomach, duodenum, ileum, and colon also revealed diffuse and massive IgG4+ plasmacyte infiltration in stomach, duodenum, small intestine, and colon. She was diagnosed with IgG4-RD based on the pathological findings and elevated serum IgG4 levels. Glucocorticoid rapidly ameliorated the symptoms. IgG4-RD may cause gastrointestinal manifestations, and histopathological assessment should be considered, even in the absence of specific characteristics of IgG4-RD.
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Affiliation(s)
- Kazuma Ino
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yoshiyuki Arinuma
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Masashi Akiya
- Division of Pathology, The Cancer Institute, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Sabine Kajita
- Department of Pathology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Sosei Okina
- Department of Hematology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Junichi Sakamoto
- Department of Gastrointestinal Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Tomoki Tanaka
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yu Matsueda
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Tatsuhiko Wada
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Sumiaki Tanaka
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kenji Oku
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kunihiro Yamaoka
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
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2
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Pezhouh MK, Lam-Himlin D, Zaheer A, Voltaggio L. Systemic diseases affecting the GI tract: A review of clinical and histopathologic manifestations. Ann Diagn Pathol 2024; 73:152351. [PMID: 39004038 DOI: 10.1016/j.anndiagpath.2024.152351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Accepted: 05/31/2024] [Indexed: 07/16/2024]
Abstract
A variety of systemic diseases may affect the gastrointestinal (GI) tract. Since the GI tract responds to injury in limited ways, identifying these processes may be challenging, especially on small endoscopic biopsies. This article reviews the clinicopathologic features of commonly encountered systemic diseases affecting the tubular GI tract: sarcoidosis, graft vs. host disease, mast cell disorders, systemic sclerosis, and IgG-4 related disease. In addition, we offer guidance in differentiating them from their mimics.
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Affiliation(s)
- Maryam K Pezhouh
- University of California San Diego, Department of Pathology, CA, United States of America
| | - Dora Lam-Himlin
- Mayo Clinic, Department of Laboratory Medicine and Pathology, AZ, United States of America
| | - Atif Zaheer
- Johns Hopkins University, Department of Radiology, MD, United States of America
| | - Lysandra Voltaggio
- Johns Hopkins University, Department of Pathology, MD, United States of America.
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3
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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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4
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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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5
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Conti Bellocchi MC, Crinò SF, De Marchi G, De Pretis N, Ofosu A, Caldart F, Ciccocioppo R, Frulloni L. A Clinical and Pathophysiological Overview of Intestinal and Systemic Diseases Associated with Pancreatic Disorders: Causality or Casualty? Biomedicines 2023; 11:biomedicines11051393. [PMID: 37239064 DOI: 10.3390/biomedicines11051393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/01/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023] Open
Abstract
The relationship between chronic intestinal disease, including inflammatory bowel disease (IBD) and celiac disease (CelD), and pancreatic disorders has been little investigated. Although an increased risk of acute pancreatitis (AP), exocrine pancreatic insufficiency with or without chronic pancreatitis, and chronic asymptomatic pancreatic hyperenzymemia have been described in these patients, the pathogenetic link remains unclear. It may potentially involve drugs, altered microcirculation, gut permeability/motility with disruption of enteric-mediated hormone secretion, bacterial translocation, and activation of the gut-associated lymphoid tissue related to chronic inflammation. In addition, the risk of pancreatic cancer seems to be increased in both IBD and CelD patients with unknown pathogenesis. Finally, other systemic conditions (e.g., IgG4-related disease, sarcoidosis, vasculitides) might affect pancreatic gland and the intestinal tract with various clinical manifestations. This review includes the current understandings of this enigmatic association, reporting a clinical and pathophysiological overview about this topic.
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Affiliation(s)
| | - Stefano Francesco Crinò
- Diagnostic and Interventional Endoscopy of Pancreas, Pancreas Institute, University of Verona, 37134 Verona, Italy
| | - Giulia De Marchi
- Gastroenterology Unit, Department of Medicine, Pancreas Institute, University of Verona, 37134 Verona, Italy
| | - Nicolò De Pretis
- Gastroenterology Unit, Department of Medicine, Pancreas Institute, University of Verona, 37134 Verona, Italy
| | - Andrew Ofosu
- Division of Gastroenterology and Hepatology, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Federico Caldart
- Gastroenterology Unit, Department of Medicine, Pancreas Institute, University of Verona, 37134 Verona, Italy
| | - Rachele Ciccocioppo
- Gastroenterology Unit, Department of Medicine, Pancreas Institute, University of Verona, 37134 Verona, Italy
| | - Luca Frulloni
- Gastroenterology Unit, Department of Medicine, Pancreas Institute, University of Verona, 37134 Verona, Italy
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6
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Chen L, Almudaires A, Alzahrani M, Qumosani K, Chakrabarti S. IgG4-related disease as a rare cause of gastric outlet obstruction: a case report and literature review. BMC Gastroenterol 2021; 21:349. [PMID: 34544364 PMCID: PMC8454001 DOI: 10.1186/s12876-021-01927-x] [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: 06/02/2021] [Accepted: 09/14/2021] [Indexed: 11/22/2022] Open
Abstract
Background IgG4-related disease involvement of the digestive tract is very rare. In few reported cases of isolated gastric/duodenal IgG4-related disease, none of which resulted in luminal obstruction. Case presentation A 59 years old female presented with longstanding gastrointestinal symptoms. CT showed mural thickening of the proximal duodenum. Gastroscopy showed antral ulcer extending into the duodenum with outlet obstruction and biopsy showed acute on chronic duodenitis. Whipple’s procedure was performed and IgG4-related disease was diagnosed on final pathology. Symptoms were revolved on mycophenolate mofetil and prednisone with no recurrence. Conclusions Our case is the only reported case with gastric outlet obstruction secondary to gastroduodenal IgG4-related disease. The diagnosis should be considered in the differential diagnosis of unexplained duodenal stricture, gastric outlet obstruction or gastrointestinal ulceration. IgG4-related disease usually responds to steroids but long-term response rates to steroid-sparing agents, especially in the subset of patients with luminal IgG4-related disease remains to be determined.
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Affiliation(s)
- Lina Chen
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,Department of Pathology and Laboratory Medicine, London Health Sciences Centre and Western University, London, ON, Canada
| | - Abdulaziz Almudaires
- Division of Gastroenterology, Department of Medicine, London Health Sciences Centre and Western University, London, ON, Canada
| | - May Alzahrani
- Division of Gastroenterology, Department of Medicine, London Health Sciences Centre and Western University, London, ON, Canada
| | - Karim Qumosani
- Division of Gastroenterology, Department of Medicine, London Health Sciences Centre and Western University, London, ON, Canada
| | - Subrata Chakrabarti
- Department of Pathology and Laboratory Medicine, London Health Sciences Centre and Western University, London, ON, Canada.
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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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10
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Abstract
PURPOSE OF REVIEW Increasing use of small bowel endoscopy unravels ulcers in a relevant number of patients. Although often attributed to inflammatory bowel disease (IBD), these ulcers may be unspecific or caused by a variety of other diseases. This review summarizes the recent literature related to differential diagnosis of small bowel ulcers. RECENT FINDINGS NSAID enteropathy is the major differential diagnosis to IBD in patients with small bowel ulcers. Intestinal tuberculosis must be considered in patients at risk. Rare causes for small bowel ulcers are autoinflammatory, neoplastic, vascular diseases, or nontuberculous infections. Morphology of small bowel ulcers cannot provide a reliable differentiation, and even histology is not specific in all cases. History with special focus on NSAID medication and clinical symptoms not typical for IBD, laboratory tests in the search of systemic disease, and microbiologic testing of biopsies can be helpful. Genetic testing allows identification of few rare entities like defects in prostaglandin metabolism. SUMMARY Due to a massive overlap in the endoscopic appearance of small bowel ulcers between possible causes, diagnosis should be based on broad information also including history, histology, imaging, and laboratory tests.
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11
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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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Ciccone F, Ciccone A, Di Ruscio M, Vernia F, Cipolloni G, Coletti G, Calvisi G, Frieri G, Latella G. IgG4-Related Disease Mimicking Crohn's Disease: A Case Report and Review of Literature. Dig Dis Sci 2018; 63:1072-1086. [PMID: 29417330 DOI: 10.1007/s10620-018-4950-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 01/26/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Fabiana Ciccone
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazza S. Tommasi, 1, Coppito, 67100, L'Aquila, Italy
| | - Antonio Ciccone
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazza S. Tommasi, 1, Coppito, 67100, L'Aquila, Italy
| | - Mirko Di Ruscio
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazza S. Tommasi, 1, Coppito, 67100, L'Aquila, Italy
| | - Filippo Vernia
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazza S. Tommasi, 1, Coppito, 67100, L'Aquila, Italy
| | - Gianluca Cipolloni
- Pathology Unit, San Salvatore Hospital, Via Lorenzo Natali, 1, Coppito, 67100, L'Aquila, Italy
| | - Gino Coletti
- Pathology Unit, San Salvatore Hospital, Via Lorenzo Natali, 1, Coppito, 67100, L'Aquila, Italy
| | - Giuseppe Calvisi
- Pathology Unit, San Salvatore Hospital, Via Lorenzo Natali, 1, Coppito, 67100, L'Aquila, Italy
| | - Giuseppe Frieri
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazza S. Tommasi, 1, Coppito, 67100, L'Aquila, Italy
| | - Giovanni Latella
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazza S. Tommasi, 1, Coppito, 67100, L'Aquila, Italy.
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13
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Infrequent organ involvement of IgG4-related diseases: a literature review. Clin Rheumatol 2018; 37:1153-1159. [PMID: 29502226 DOI: 10.1007/s10067-018-4048-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 01/30/2018] [Accepted: 02/19/2018] [Indexed: 01/28/2023]
Abstract
IgG4-related disease (IgG4-RD) is a chronic and systemic disease that can involve multiple organs. The most commonly involved organs include the salivary glands, orbital adnexal structures, paranasal sinus, thyroid, lungs, breasts, aorta, pancreas, biliary ducts, kidneys, retroperitoneum, lymph nodes, prostate, pituitary, and endocranium. Due to increased disease research, several new site-specific nuances of IgG4-RD have been described. The authors have reviewed the recent literature and briefly summarize the infrequent organ involvement of IgG4-RD.
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Murray C, Ryan R, O'Connell F, Conlon N, Nicholson S. The pulmonary artery sarcoma that wasn't. Histopathology 2017; 71:329-331. [PMID: 28295498 DOI: 10.1111/his.13213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Ciara Murray
- Department of Histopathology, St James's Hospital, Dublin, Ireland
| | - Ronan Ryan
- Department of Cardiothoracic Surgery, St James's Hospital, Dublin, Ireland
| | - Finbar O'Connell
- Department of Respiratory Medicine, St James's Hospital, Dublin, Ireland
| | - Niall Conlon
- Department of Immunology, St James's Hospital, Dublin, Ireland
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Moghaddam PA, Virk R, Sakhdari A, Prasad ML, Cosar EF, Khan A. Five Top Stories in Thyroid Pathology. Arch Pathol Lab Med 2016; 140:158-70. [PMID: 26910221 DOI: 10.5858/arpa.2014-0468-ra] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Thyroid carcinoma is the most common malignant tumor of endocrine organs, yet it only accounts for approximately 1% of all cancers in the United States with more than 35,000 new cases diagnosed each year and more than 450,000 people living with this disease. While most tumors can be diagnosed without much difficulty, a few tumor types, especially tumors with follicular pattern, sometimes pose a diagnostic challenge. OBJECTIVE To discuss morphologic, immunohistochemical, and molecular features of thyroid tumors. We also explore the clinicopathologic features of papillary microcarcinoma and medullary microcarcinoma and how the latter is related and differentiated from C-cell hyperplasia. Finally with the ever-growing list of organ systems involved in immunoglobulin (Ig) G4-related diseases, we discuss the still not completely explored IgG-4-related thyroid disease. DATA SOURCES Data were obtained from review of the pertinent peer-reviewed literature and institutional experience. CONCLUSIONS Histomorphologic evaluation still remains the gold standard for diagnosis in most cases of thyroid diseases. The application of ancillary studies such as immunohistochemistry and molecular diagnosis, including next-generation sequencing, is becoming more common.
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Affiliation(s)
- Parnian Ahmadi Moghaddam
- From the Department of Pathology, University of Massachusetts Memorial Medical Center, Worcester (Drs Moghaddam, Sakhdari, Cosar, and Khan)
| | - Renu Virk
- and the Department of Pathology, Yale School of Medicine, New Haven, Connecticut (Drs Virk and Prasad)
| | - Ali Sakhdari
- From the Department of Pathology, University of Massachusetts Memorial Medical Center, Worcester (Drs Moghaddam, Sakhdari, Cosar, and Khan)
| | - Manju L Prasad
- and the Department of Pathology, Yale School of Medicine, New Haven, Connecticut (Drs Virk and Prasad)
| | - Ediz F Cosar
- From the Department of Pathology, University of Massachusetts Memorial Medical Center, Worcester (Drs Moghaddam, Sakhdari, Cosar, and Khan)
| | - Ashraf Khan
- From the Department of Pathology, University of Massachusetts Memorial Medical Center, Worcester (Drs Moghaddam, Sakhdari, Cosar, and Khan)
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Kamiya M, Shane PY, Soejima M, Tohda S, Miyasaka N, Kohsaka H. IgG4-Related Sialoadenitis with a Skin Lesion and Multiple Mononeuropathies Suggesting Coexistent Cryoglobulinemic Vasculitis. Intern Med 2016; 55:1355-61. [PMID: 27181547 DOI: 10.2169/internalmedicine.55.5332] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 68-year-old man was admitted because of weakness of the left leg, dysesthesiae of the extremities and bilateral lower extremity purpura. A neurological examination showed mononeuritis multiplex with laboratory evidence of hypocomplementemia, cryoglobulinemia and leukocytoclastic vasculitis in the biopsy of a skin specimen. The patient also exhibited bilateral submandibular gland swelling, elevated serum IgG4 levels and infiltration of a large number of IgG4-positive plasma cells in the submandibular glands. These findings were consistent with both cryoglobulinemic vasculitis and IgG4-related disease. The administration of oral prednisolone (1 mg/kg/day) resolved the neurological manifestations and the swelling of the submandibular glands and cryoglobulinemia.
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Affiliation(s)
- Mari Kamiya
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Japan
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Deshpande V. IgG4-Related Disease of the Gastrointestinal Tract: A 21st Century Chameleon. Arch Pathol Lab Med 2015; 139:742-9. [PMID: 26030243 DOI: 10.5858/arpa.2014-0181-ra] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Immunoglobulin G4 (IgG4)-related disease is a systemic fibroinflammatory disease capable of affecting virtually any organ. Although the pancreas and hepatobiliary system are commonly affected, involvement of the tubular gut is unusual. The pancreatic manifestations of this disease (autoimmune pancreatitis) often mimic pancreatic carcinoma, whereas the hepatobiliary manifestations are mistaken for cholangiocarcinoma or primary sclerosing cholangitis. The characteristic histologic features include a dense lymphoplasmacytic infiltrate, storiform-type fibrosis, and obliterative phlebitis. An increase in IgG4(+) plasma cells and an IgG4 to IgG ratio of more than 40% are considered obligatory components of the diagnostic algorithm. OBJECTIVE To review the challenges associated with the diagnosis of IgG4-related disease of the gastrointestinal tract. DATA SOURCES A review of pertinent literature, along with the author's personal experience, based on institutional and consultation materials. CONCLUSION The complete spectrum of histologic changes is seldom captured in a biopsy specimen, and thus, the histopathology findings are best interpreted within the overall clinical context. Increased IgG4(+) plasma cells are identified in a variety of benign and malignant diseases of the gastrointestinal tract.
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Affiliation(s)
- Vikram Deshpande
- From the Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston
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Calvo J, Carbonell N, Scatton O, Marzac C, Ganne-Carrie N, Wendum D. Hepatic nodular lymphoid lesion with increased IgG4-positive plasma cells associated with primary biliary cirrhosis: a report of two cases. Virchows Arch 2015; 467:613-7. [PMID: 26358058 DOI: 10.1007/s00428-015-1841-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 07/20/2015] [Accepted: 08/20/2015] [Indexed: 12/24/2022]
Abstract
The nodular lymphoid lesion of the liver known as reactive lymphoid hyperplasia or pseudolymphoma is rare and its pathogenesis is unknown. We report two cases of nodular lymphoid lesions of the liver with numerous IgG4-positive plasma cells in patients with primary biliary cirrhosis. Histologically, in both cases, the lesion showed a dense lymphoplasmacytic infiltrate with lymphoid follicles and granulomas. Fibrous tissue was scarce and without a storiform pattern. Obliterative phlebitis was not identified. The IgG4+ plasma cell counts were 82 and 76 per high power field, with an IgG4/IgG ratio of 75 and 64 %, respectively, which qualifies the lesions according to the diagnostic criteria for IgG4-related disease as « probable histological feature of IgG4-related disease ». There were no rearrangements of immunoglobulin heavy-chain genes and plasma cells had a polytypic pattern of kappa and lambda light-chain expression. The non-tumor liver showed primary biliary cirrhosis with destructive cholangitis without IgG4 plasma cells. In both cases, IgG4-related disease was not found in other organs neither at the time of diagnosis nor 3 years later. Serum IgG4 levels normalized after local ablation of the lesions. It seems unlikely that these lesions are a manifestation of IgG4-related disease. However, because the pathogenesis of both nodular lymphoid lesions and IgG4-related disease remains unclear, further studies are needed to elucidate a potential link between nodular lymphoid lesions of the liver and an increased number of IgG4 plasma cells. More definite conclusions will be possible when the pathogenesis of IgG4-related disease has been clarified.
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Affiliation(s)
- Jessica Calvo
- Department of Pathology, AP-HP Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, F-75012, Paris, France. .,Sorbonne Universités, UPMC, Univ Paris 06, Paris, France.
| | - Nicolas Carbonell
- Department of Hepatology, AP-HP Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, F-75012, Paris, France
| | - Olivier Scatton
- Department of Liver Surgery and Transplantation, AP-HP Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, F-75012, Paris, France.,Sorbonne Universités, UPMC, Univ Paris 06, Paris, France
| | - Christophe Marzac
- Department of Laboratory Hematology, AP-HP Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, F-75012, Paris, France
| | - Nathalie Ganne-Carrie
- Department of Hepatology, AP-HP Hôpital Jean Verdier, avenue du 14 juillet, F-93140, Bondy, France
| | - Dominique Wendum
- Department of Pathology, AP-HP Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, F-75012, Paris, France.,Sorbonne Universités, UPMC, Univ Paris 06, Paris, France
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MURAKAWA K, SAITO T, TSUTAHO A, YAMAMURA Y, KOINUMA J, ONO K, KIKUCHI K. Probable IgG4-related Sclerosing Disease Presenting as a Submucosal Tumor of the Stomach. ACTA ACUST UNITED AC 2014. [DOI: 10.3919/jjsa.75.394] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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20
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Abstract
IgG4-related disease, a newly established multisystemic disease can affect virtually every organ. Histologically, it is characterized by the presence of a dense lymphoplasmacytic infiltrate, storiform-type fibrosis, and obliterative phlebitis. The disease shows elevated serum and tissue IgG4. The pancreas and hepatobiliary tract are involved far more commonly than the tubular gut. This review summarizes the clinical and pathologic features of the gastrointestinal manifestations of IgG4-related disease and discusses the wide spectrum of diseases that this entity may mimic.
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Affiliation(s)
- Madelyn Lew
- Department of Pathology, Massachusetts General Hospital, 55 Fruit street, Boston, MA 02114, USA
| | - Vikram Deshpande
- Department of Pathology, Massachusetts General Hospital, 55 Fruit street, Boston, MA 02114, USA.
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Ko Y, Woo JY, Kim JW, Hong HS, Yang I, Lee Y, Hwang D, Min SJ. An immunoglobulin G4-related sclerosing disease of the small bowel: CT and small bowel series findings. Korean J Radiol 2013; 14:776-80. [PMID: 24043971 PMCID: PMC3772257 DOI: 10.3348/kjr.2013.14.5.776] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 06/11/2013] [Indexed: 12/24/2022] Open
Abstract
Immunoglobulin G4 (IgG4)-related sclerosing disease is rare and is known to involve various organs. We present a case of histologically proven IgG4-related sclerosing disease of the small bowel with imaging findings on computed tomography (CT) and small bowel series. CT showed irregular wall thickening, loss of mural stratification and aneurysmal dilatation of the distal ileum. Small bowel series showed aneurysmal dilatations, interloop adhesion with traction and abrupt angulation.
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Affiliation(s)
- Younghwan Ko
- Department of Radiology, Hallym University Dongtan Sacred Heart Hospital, Hwaseong 445-907, Korea
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Abstract
OPINION STATEMENT Having diagnosed a patient as having IgG4-related disease, I would have a low threshold for recommending immune-suppressive treatment, and would make that recommendation for any patient with vascular involvement. My initial approach would be prednisone at 40-60 mg/day with a plan to reduce the dose every two weeks, e.g., 40, 30, 20, 15, 10, 7.5, 5, and 2.5 mg for 2 weeks each. In the event of relapse, I would double the current prednisone dose, slow the taper, and add azathioprine, anticipating using that drug for one year if the patient were to remain in remission. In the event or subsequent relapse, I would stop azathioprine and use rituximab. In a patient with large artery involvement, I would consult a vascular surgeon soon after diagnosis, anticipating a need for surgical repair.
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Affiliation(s)
- Paul A Monach
- Vasculitis Center and Section of Rheumatology, Boston University School of Medicine, 72 East Concord Street, E-533, Boston, MA, 02118, USA,
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Abstract
Immunoglobulin G4-related sclerosing cholangitis (IgG4-SC) is a recently defined disease entity characterized by elevated serum IgG4, chronic progressive obstructive jaundice, and diffuse or mass-forming inflammatory reaction rich in IgG4-positive plasma cells and lymphocytes associated with fibrosclerosis and obliterative phlebitis, which shares a number of clinical, biochemical, and radiological features with primary sclerosing cholangitis (PSC) or cholangiocarcinoma (CC). IgG4-SC is commonly associated with autoimmune pancreatitis (AIP). Steroid therapy comprises the mainstay of treatment for IgG4-SC patients. However, liver transplantation is the only useful treatment for PSC patients, and CC patients require surgical therapy. Therefore, the accurate discrimination between IgG4-SC and PSC or CC is a very important issue. In this article, we will review the features and role of immunoglobulin G4 (IgG4), the diagnosis and therapy of IgG4-SC, and the relations between IgG4-SC and AIP, PSC or CC.
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