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Metelli F, Manfredi G, Pagano N, Buscarini E, Crinò SF, Armellini E. The Role of Endoscopic Ultrasound and Ancillary Techniques in the Diagnosis of Autoimmune Pancreatitis: A Comprehensive Review. Diagnostics (Basel) 2024; 14:1233. [PMID: 38928649 PMCID: PMC11202526 DOI: 10.3390/diagnostics14121233] [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: 04/09/2024] [Revised: 06/04/2024] [Accepted: 06/07/2024] [Indexed: 06/28/2024] Open
Abstract
Autoimmune pancreatitis (AIP) is a unique form of chronic pancreatitis with a multifactorial pathogenesis. Historically, it has been classified as type 1 and type 2, according to its clinical and histological features. The diagnosis of AIP is challenging and relies on a combination of clinical, histopathologic, serologic, and imaging characteristics. In the available guidelines, the imaging hallmarks of AIP are based on cross-sectional imaging and cholangiopancreatography retrograde endoscopic findings. Endoscopic ultrasound (EUS) is generally used for pancreatic tissue acquisition to rule out pancreatic cancer and diagnose AIP with limited accuracy. Several papers reported the reliability of EUS for providing informative morphologic features of AIP. Nowadays, the improvement in the resolution of EUS conventional images and the development of new ancillary technologies have further increased the diagnostic yield of EUS: contrast-enhanced EUS and EUS elastography are non-invasive and real-time techniques that strongly support the diagnosis and management of pancreatic diseases. In this review article, we will present the role of conventional EUS and ancillary diagnostic techniques in the diagnosis of AIP to support clinicians and endosonographers in managing this condition.
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Affiliation(s)
- Flavio Metelli
- Gastroenterology and Endoscopy Department, ASST Maggiore Hospital Crema, 26013 Crema, Italy; (F.M.); (G.M.); (E.B.)
| | - Guido Manfredi
- Gastroenterology and Endoscopy Department, ASST Maggiore Hospital Crema, 26013 Crema, Italy; (F.M.); (G.M.); (E.B.)
| | - Nico Pagano
- Gastroenterology Unit, Department of Oncological and Specialty Medicine, University Hospital Maggiore della Carità, 28100 Novara, Italy;
| | - Elisabetta Buscarini
- Gastroenterology and Endoscopy Department, ASST Maggiore Hospital Crema, 26013 Crema, Italy; (F.M.); (G.M.); (E.B.)
| | - Stefano Francesco Crinò
- Diagnostic and Interventional Endoscopy of Pancreas, Pancreas Institute, University of Verona, 37134 Verona, Italy;
| | - Elia Armellini
- Gastroenterology and Endoscopy Unit, ASST-Bergamoest, 24068 Seriate, Italy
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Toyonaga H, Hayashi T, Hama K, Iwano K, Ando R, Ishii T, Kin T, Motoya M, Takahashi K, Katanuma A. The application of low echo reduction in endoscopic ultrasound-guided tissue acquisition for pancreatic mass lesions. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:1192-1195. [PMID: 37658642 DOI: 10.1002/jhbp.1348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/09/2023] [Accepted: 04/20/2023] [Indexed: 09/03/2023]
Abstract
Toyonaga and colleagues demonstrate, with accompanying video, the use of low echo reduction, which is a novel endoscopic ultrasound function provided by a new endoscopic ultrasound processor that increases contrast without white-out. Low echo reduction might be useful in improving lesion boundaries and needle visibility during endoscopic ultrasound-guided tissue acquisition.
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Affiliation(s)
- Haruka Toyonaga
- Center for Gastroenterology, Teine Keijinkai Hospital, Hokkaido, Japan
| | - Tsuyoshi Hayashi
- Center for Gastroenterology, Teine Keijinkai Hospital, Hokkaido, Japan
| | - Kazuki Hama
- Center for Gastroenterology, Teine Keijinkai Hospital, Hokkaido, Japan
| | - Kosuke Iwano
- Center for Gastroenterology, Teine Keijinkai Hospital, Hokkaido, Japan
| | - Ryo Ando
- Center for Gastroenterology, Teine Keijinkai Hospital, Hokkaido, Japan
| | - Tatsuya Ishii
- Center for Gastroenterology, Teine Keijinkai Hospital, Hokkaido, Japan
| | - Toshifumi Kin
- Center for Gastroenterology, Teine Keijinkai Hospital, Hokkaido, Japan
| | - Masayo Motoya
- Center for Gastroenterology, Teine Keijinkai Hospital, Hokkaido, Japan
| | | | - Akio Katanuma
- Center for Gastroenterology, Teine Keijinkai Hospital, Hokkaido, Japan
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Approach to management of pancreatic strictures: the gastroenterologist's perspective. Clin J Gastroenterol 2021; 14:1587-1597. [PMID: 34405382 DOI: 10.1007/s12328-021-01503-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 08/13/2021] [Indexed: 12/15/2022]
Abstract
Pancreatic strictures represent a complex clinical problem which often requires multidisciplinary management with a team of gastroenterologists, surgeons and radiologists. Dominant strictures are largely due to inflammatory processes of the pancreas like chronic pancreatitis. However, differentiating benign from malignant processes of the pancreas, leading to strictures is imperative and remains a challenge. With advances in endoscopic management, options for therapy include endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound-guided pancreatic drainage (EUS-PD) in situations where ERCP is not feasible or fails. However, endoscopic therapy is suited for a select group of patients and surgery remains key to management in many patients. In this narrative review, we look at the gastroenterologist's perspective and approach to pancreatic ductal strictures, including endoscopic and surgical management.
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Naitoh I, Nakazawa T. Classification and Diagnostic Criteria for IgG4-Related Sclerosing Cholangitis. Gut Liver 2021; 16:28-36. [PMID: 34380781 PMCID: PMC8761932 DOI: 10.5009/gnl210116] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/06/2021] [Accepted: 06/14/2021] [Indexed: 11/20/2022] Open
Abstract
IgG4-related sclerosing cholangitis (IgG4-SC) can be classified into four types based on cholangiographic findings and regions of biliary stricture. This cholangiographic classification is useful to differentiate IgG4-SC from mimickers including cholangiocarcinoma, primary sclerosing cholangitis, and pancreatic cancer. Autoimmune pancreatitis (AIP) is a valuable clue for the diagnosis of IgG4-SC because the two are frequently found in association with each other. Two sets of diagnostic criteria for IgG4-SC have been proposed. In Japan, the clinical diagnostic criteria 2020 were recently developed. These clinical diagnostic criteria include narrowing of the intrahepatic and/or extrahepatic bile duct, thickening of the bile duct wall, serological findings, pathological findings, other organ involvement, and effectiveness of steroid therapy. When these criteria are applied, IgG4-SC is initially classified as associated or not associated with AIP, and cholangiographic classification is used for differential diagnosis. In most instances, IgG4-SC can be diagnosed on the basis of clinical diagnostic criteria. However, it is challenging to diagnose isolated IgG4-SC or IgG4-SC not associated with AIP. Here, we review the classification and diagnostic criteria for IgG4-SC, specifically focusing on the clinical diagnostic criteria 2020 and a large IgG4-SC case series from a nationwide survey in Japan.
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Affiliation(s)
- Itaru Naitoh
- Department of Gastroenterology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takahiro Nakazawa
- Department of Gastroenterology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Endoscopic retrograde cholangiopancreatography and intraductal ultrasonography in the diagnosis of autoimmune pancreatitis and IgG4-related sclerosing cholangitis. J Med Ultrason (2001) 2021; 48:573-580. [PMID: 34331625 DOI: 10.1007/s10396-021-01114-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 06/10/2021] [Indexed: 12/17/2022]
Abstract
Endoscopic retrograde cholangiopancreatography is used to evaluate the narrowing of the main pancreatic duct in autoimmune pancreatitis (AIP) and biliary stricture in IgG4-related sclerosing cholangitis (IgG4-SC). Intraductal ultrasonography enables detailed visualization of the thickening of the bile duct wall in IgG4-SC. Pancreatic cancer, cholangiocarcinoma, and primary sclerosing cholangitis are important mimicking conditions of AIP and IgG4-SC. Diffuse or segmental stricture without marked upstream dilatation is a typical pancreatographic finding in AIP. By contrast, a single, short stricture with marked upstream dilatation is a typical finding in pancreatic cancer. The cholangiogram of IgG4-SC is classified into four types based on biliary stricture location, and this cholangiogram classification is useful for the differential diagnosis of IgG4-SC. Endoscopic retrograde cholangiography can be used to distinguish between IgG4-SC and primary sclerosing cholangitis. A segmental/long and intrapancreatic stricture is a characteristic finding of IgG4-SC, whereas band-like strictures, a beaded or pruned-tree appearance, and diverticulum-like outpouching are characteristic of primary sclerosing cholangitis. The characteristic intraductal ultrasonographic findings of circular-symmetrical wall thickening, smooth outer and inner margins, and homogeneous internal echo at the biliary stricture site are useful for diagnosis of IgG4-SC. Thickening of the bile duct wall at non-stricture sites is also a typical intraductal ultrasonographic finding of IgG4-SC and can be used for differential diagnosis from cholangiocarcinoma. Transpapillary bile duct and duodenal papilla biopsy during endoscopic retrograde cholangiopancreatography are also useful in the diagnosis of IgG4-SC.
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Noguchi K, Nakai Y, Mizuno S, Hirano K, Kanai S, Suzuki Y, Inokuma A, Sato T, Hakuta R, Ishigaki K, Saito K, Saito T, Hamada T, Takahara N, Kogure H, Isayama H, Koike K. Role of Endoscopic Ultrasonography-Guided Fine Needle Aspiration/Biopsy in the Diagnosis of Autoimmune Pancreatitis. Diagnostics (Basel) 2020; 10:diagnostics10110954. [PMID: 33203118 PMCID: PMC7698022 DOI: 10.3390/diagnostics10110954] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/12/2020] [Accepted: 11/12/2020] [Indexed: 12/12/2022] Open
Abstract
Type 1 autoimmune pancreatitis (AIP) is histologically characterized by lymphoplasmacytic sclerosing pancreatitis (LPSP). Recently, the diagnostic yield of endoscopic ultrasonography-guided fine needle aspiration/biopsy (EUS-FNA/B) for AIP has been reported. However, its role in the diagnostic flow of AIP is not fully elucidated. We retrospectively reviewed 53 consecutive patients who were suspected with AIP and underwent EUS-FNA/B. We evaluated the contribution of EUS-FNA/B to the diagnosis of AIP before considering response to steroid therapy among patients with diffuse enlargement of the pancreas and those with focal enlargement, respectively. Twenty-two patients showed diffuse pancreatic enlargement and 31 showed focal enlargement. The final diagnosis was definitive AIP in 32 patients, probable AIP in 2, possible AIP in 1, and mass-forming focal pancreatitis in 18. There was no change in diagnosis after EUS-FNA/B among patients with diffuse pancreatic enlargement, while diagnosis changed in 38.7% (12/31) among those with focal enlargement—there was a probable to definitive diagnosis in 4 patients, unspecified to definitive in 3, and unspecified to probable in 5. EUS-FNB provided a significantly higher sensitivity for typical pathological findings of LPSP than EUS-FNA, and 10 patients were diagnosed as pathologically definitive AIP by EUS-FNB, though none were by EUS-FNA (p = 0.002). EUS-FNA/B was useful in the diagnosis of focal type AIP, and steroid therapy could be introduced after the diagnosis was confirmed. Meanwhile, EUS-FNA/B provided no contribution to diagnosis of diffuse type AIP. EUS-FNB showed a higher diagnostic yield than FNA.
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Affiliation(s)
- Kensaku Noguchi
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
- Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, Tokyo 113-8655, Japan
- Correspondence: ; Tel.: +81-3-3815-5411; Fax: +81-3-5800-8812
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Kenji Hirano
- Department of Gastroenterology, Tokyo Takanawa Hospital, Tokyo 108-8606, Japan;
| | - Sachiko Kanai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Yukari Suzuki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Akiyuki Inokuma
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Tatsuya Sato
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Ryunosuke Hakuta
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Kazunaga Ishigaki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Kei Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo 113-8531, Japan;
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (K.N.); (S.M.); (S.K.); (Y.S.); (A.I.); (T.S.); (R.H.); (K.I.); (K.S.); (T.S.); (T.H.); (N.T.); (H.K.); (K.K.)
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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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8
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Miyoshi H, Kano M, Kobayashi S, Ito T, Masuda M, Mitsuyama T, Nakayama S, Ikeura T, Shimatani M, Uchida K, Takaoka M, Okazaki K. Diffuse Pancreatic Cancer Mimicking Autoimmune Pancreatitis. Intern Med 2019; 58:2523-2527. [PMID: 31178502 PMCID: PMC6761344 DOI: 10.2169/internalmedicine.2689-19] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The characteristic finding of sausage-shaped pancreas or capsule-like rim facilitates the diagnosis of autoimmune pancreatitis. We herein report a case of a 67-year-old man showing a sausage-shaped, enlarged pancreas with a capsule-like rim on computed tomography. Furthermore, endoscopic retrograde cholangiopancreatography demonstrated diffuse narrowing of the main pancreatic duct, in addition to stenosis of the lower bile duct. Finally, we were able to diagnose pancreatic cancer in this patient by an endoscopic ultrasound-guided fine-needle aspiration biopsy following peroral cholangioscopy and bile cytology. This report emphasizes the significance of pathological confirmation before starting treatment, even in cases with diffuse pancreatic enlargement.
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Affiliation(s)
- Hideaki Miyoshi
- Division of Gastroenterology and Hepatology, Kansai Medical University, Japan
| | - Masataka Kano
- Division of Gastroenterology and Hepatology, Kansai Medical University, Japan
| | - Sanshiro Kobayashi
- Division of Gastroenterology and Hepatology, Kansai Medical University, Japan
| | - Takashi Ito
- Division of Gastroenterology and Hepatology, Kansai Medical University, Japan
| | - Masataka Masuda
- Division of Gastroenterology and Hepatology, Kansai Medical University, Japan
| | - Toshiyuki Mitsuyama
- Division of Gastroenterology and Hepatology, Kansai Medical University, Japan
| | - Shinji Nakayama
- Division of Gastroenterology and Hepatology, Kansai Medical University, Japan
| | - Tsukasa Ikeura
- Division of Gastroenterology and Hepatology, Kansai Medical University, Japan
| | - Masaaki Shimatani
- Division of Gastroenterology and Hepatology, Kansai Medical University, Japan
| | - Kazushige Uchida
- Division of Gastroenterology and Hepatology, Kansai Medical University, Japan
| | - Makoto Takaoka
- Division of Gastroenterology and Hepatology, Kansai Medical University, Japan
| | - Kazuichi Okazaki
- Division of Gastroenterology and Hepatology, Kansai Medical University, Japan
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9
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Takagi Y, Kubota K, Takayanagi T, Kurita Y, Ishii K, Hasegawa S, Iwasaki A, Sato T, Fujita Y, Kato S, Kagawa K, Watanabe S, Sekino Y, Hosono K, Matsuhashi N, Yamanaka S, Iwao T, Yoshida K, Nakajima A. Clinical features of isolated proximal-type immunoglobulin G4-related sclerosing cholangitis. Dig Endosc 2019; 31:422-430. [PMID: 30570170 DOI: 10.1111/den.13320] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 12/14/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Immunoglobulin G4-related sclerosing cholangitis (IgG4-SC) presents as isolated proximal-type sclerosing cholangitis (i-SC). The present study sought to clarify the imaging differences between i-SC and Klatskin tumor. Differences between i-SC and IgG4-SC associated with autoimmune pancreatitis (AIP-SC) were also studied. METHODS Differentiating factors between i-SC and Klatskin tumor were studied. Serum IgG4 level, CA19-9 level, computed tomography (CT) findings, cholangiography findings (symmetrical smooth long stricture extending into the upper bile duct [SSLS]), endosonographic features (continuous symmetrical mucosal lesion to the hilar part [CSML]), endoscopic biopsy results, treatment, relapse, and survival were also compared between patients with i-SC and those with AIP-SC. RESULTS For a differential diagnosis between i-SC (N = 9) and Klatskin tumor (N = 47), the cut-off value of serum IgG4 level was 150 mg/dL (sensitivity, 0.857, specificity, 0.966). Logistic regression analysis indicated that serum IgG4 level, presence of SSLS, presence of CSML, and presence of swollen ampulla are independent factor for identifying i-SC. Relapse rate was significantly higher in the IgG4-SC with AIP group than in the i-SC group (log rank, P = 0.046). CONCLUSION Isolated proximal-type sclerosing cholangitis presents as a nodular lesion with SSLS and/or CSML mimicking a Klatskin tumor. Those endoscopic features might provide a diagnostic clue for i-SC. i-SC is likely to have a more favorable prognosis than IgG4-SC with AIP.
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Affiliation(s)
- Yuri Takagi
- Department of Gastroenterology and Hepatology, Yokohama City University, Graduate School of Medicine, Kanagawa, Japan
| | - Kensuke Kubota
- Department of Gastroenterology and Hepatology, Yokohama City University, Graduate School of Medicine, Kanagawa, Japan
| | - Takuya Takayanagi
- Department of Gastroenterology and Hepatology, Yokohama City University, Graduate School of Medicine, Kanagawa, Japan
| | - Yusuke Kurita
- Department of Gastroenterology and Hepatology, Yokohama City University, Graduate School of Medicine, Kanagawa, Japan
| | - Ken Ishii
- Department of Gastroenterology and Hepatology, Yokohama City University, Graduate School of Medicine, Kanagawa, Japan
| | - Sho Hasegawa
- Department of Gastroenterology and Hepatology, Yokohama City University, Graduate School of Medicine, Kanagawa, Japan
| | - Akito Iwasaki
- Department of Gastroenterology and Hepatology, Yokohama City University, Graduate School of Medicine, Kanagawa, Japan
| | - Takamitsu Sato
- Department of Gastroenterology and Hepatology, Yokohama City University, Graduate School of Medicine, Kanagawa, Japan
| | - Yuji Fujita
- Department of Gastroenterology and Hepatology, Yokohama City University, Graduate School of Medicine, Kanagawa, Japan
| | - Shingo Kato
- Department of Gastroenterology and Hepatology, Yokohama City University, Graduate School of Medicine, Kanagawa, Japan
| | - Koichi Kagawa
- Department of Gastroenterology and Hepatology, Yokohama City University, Graduate School of Medicine, Kanagawa, Japan
| | - Seitaro Watanabe
- Department of Gastroenterology and Hepatology, Yokohama City University, Graduate School of Medicine, Kanagawa, Japan
| | - Yusuke Sekino
- Department of Gastroenterology and Hepatology, Yokohama City University, Graduate School of Medicine, Kanagawa, Japan
| | - Kunihiro Hosono
- Department of Gastroenterology and Hepatology, Yokohama City University, Graduate School of Medicine, Kanagawa, Japan
| | | | - Shoji Yamanaka
- Department of Pathology, Yokohama City University Hospital, Kanagawa, Japan
| | - Toshiyasu Iwao
- Department of Gastroenterology, Aizu Central Hospital, Fukushima, Japan
| | - Koji Yoshida
- Department of Gastroenterology, Kawasaki Medical University, Okayama, Japan
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University, Graduate School of Medicine, Kanagawa, Japan
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Goodchild G, Pereira SP, Webster G. Immunoglobulin G4-related sclerosing cholangitis. Korean J Intern Med 2018; 33:841-850. [PMID: 30045615 PMCID: PMC6129623 DOI: 10.3904/kjim.2018.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 02/06/2018] [Indexed: 12/22/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a systemic fibroinflammatory condition of which IgG4-related sclerosing cholangitis (IgG4-SC) is the biliary manifestation. In this review, we provide an overview of IgG4-RD, with a focus on the biliary manifestations. In particular, we describe the important differential diagnoses of IgG4-SC, namely, primary sclerosing cholangitis and cholangiocarcinoma, outline diagnostic criteria for IgG4-SC, provide insight into possible pathophysiological mechanisms underlying the disease and discuss short and long-term management options of this recently described disease.
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Affiliation(s)
- George Goodchild
- Department of Gastroenterology, University College Hospital, London, UK
| | | | - George Webster
- Department of Gastroenterology, University College Hospital, London, UK
- Correspondence to George Webster, M.D. Department of Gastroenterology, University College Hospital, 250 Euston Rd, London NW1 2PG, UK Tel: +44-2034567890 Fax: +44-2034479218 E-mail:
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11
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Dong Y, D'Onofrio M, Hocke M, Jenssen C, Potthoff A, Atkinson N, Ignee A, Dietrich CF. Autoimmune pancreatitis: Imaging features. Endosc Ultrasound 2018; 7:196-203. [PMID: 28836516 PMCID: PMC6032703 DOI: 10.4103/eus.eus_23_17] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background and Objectives Autoimmune pancreatitis (AIP) remains a difficult disease to diagnose before treatment, particularly if presenting as a focal mass lesion. The purpose of this multicenter retrospective study is to analyze imaging features of histologically confirmed AIP to determine the additional diagnostic value of contrast-enhanced ultrasound (CEUS), contrast-enhanced endoscopic ultrasound (CE-EUS), and elastography to B-mode features. Patients and Methods We report on a retrospective data collection of 60 histologically confirmed cases of AIP in comparison to 16 patients with pancreatic adenocarcinomas (PDAC). All CE (-E) US examinations were assessed by two independent readers in consensus. The role of CEUS and CE-EUS for pancreatic evaluation was defined according to the 2011 European Federation of Societies for Ultrasound in Medicine and Biology guidelines. Results After injection of ultrasound (US) contrast agents, most AIP lesions displayed focal or diffuse isoenhancement (86.6%) in the arterial phase, while most of the PDAC lesions (93.7%) were hypoenhancing (P < 0.01). During the late phase, most AIP lesions were hyper-(65%) or iso-enhancing (35%), while most PDAC lesions were hypoenhancing (93.7%). CE-EUS was performed in a subset of ten patients and showed hyperenhancement in all AIP cases. Most focal AIP lesions (n = 27, 79.4%) were stiffer than the surrounding pancreatic parenchyma. Conclusions In this study, percutaneous and endoscopic contrast enhanced harmonic US techniques consistently revealed diffuse and focal types of AIP to have features consistent with vascularized lesions. Differentiation from the typically hypovascularized pancreatic adenocarcinoma was possible with CE (-E) US evaluation.
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Affiliation(s)
- Yi Dong
- Department of Ultrasound, Zhongshan Hospital, Fudan University, 200032 Shanghai, China
| | - Mirko D'Onofrio
- Department of Radiology, GB Rossi University Hospital, University of Verona, Verona, Italy
| | - Michael Hocke
- Medical Department, Helios Klinikum Meiningen, Meiningen, Germany
| | - Christian Jenssen
- Department of Internal Medicine, Krankenhaus Märkisch Oderland, Strausberg, Germany
| | - Andrej Potthoff
- Department of Gastroenterology, Hepatology and Endocrinology, Medizinische Hochschule Hannover, Hannover, Germany
| | - Nathan Atkinson
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Andre Ignee
- Medical Department, Caritas Krankenhaus, Uhlandstr. 7, D-97980, Bad Mergentheim, Germany
| | - Christoph F Dietrich
- Medical Department, Caritas Krankenhaus, Uhlandstr. 7, D-97980, Bad Mergentheim, Germany
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Bor R, Madácsy L, Fábián A, Szepes A, Szepes Z. Endoscopic retrograde pancreatography: When should we do it? World J Gastrointest Endosc 2015; 7:1023-1031. [PMID: 26322155 PMCID: PMC4549659 DOI: 10.4253/wjge.v7.i11.1023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 06/30/2015] [Accepted: 08/14/2015] [Indexed: 02/05/2023] Open
Abstract
Endoscopic retrograde pancreatography (ERP) is an accurate imaging modality in the diagnosis of pancreatobiliary diseases. However, its use has been substantially reduced due to the invasiveness of procedure, the risk of complications and the widespread availability of non-invasive cross-section imaging techniques (computed tomography, magnetic resonance imaging, and endoscopic ultrasound). Since the introduction of endoscopic sphincterotomy, ERP has transformed from diagnostic method to an almost exclusively therapeutic procedure. Pancreatic duct injection substantially increased the risk of post-ERP pancreatitis (1.6%-15.7%); therefore, according to international guidelines ERP is recommended only in cases where biliary intervention is required. However, the role of ERP in the management of pancreatic diseases is currently not clearly defined, but in some cases the filling of pancreatic duct may provide essential information complementing the results of non-invasive imaging techniques. The aim of this publication is to systematically summarize the literature dealing with the diagnostic yield of ERP. We would like to define the precise indications of ERP and overview a diagnostic protocol of pancreatic diseases depending on international guidelines and the opinion of Hungarian experts, because it may improve the diagnostic accuracy, minimize of burden of patients and reduce the risk of procedure related complications.
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