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Wang M, Jiang Z, Liang H. Glucocorticoids in acute pancreatitis: a propensity score matching analysis. BMC Gastroenterol 2021; 21:331. [PMID: 34433425 PMCID: PMC8386156 DOI: 10.1186/s12876-021-01907-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 08/14/2021] [Indexed: 12/30/2022] Open
Abstract
Background There are few reports about the effect of glucocorticoids in the treatment of acute pancreatitis in humans. This study aims to evaluate the effect of glucocorticoids in the treatment of acute pancreatitis by propensity score matching analysis. Results Acute pancreatitis patients admitted between 2014 and 2019 were collected from the database and analyzed. Included patients were divided into the glucocorticoids-used group (GC group) and the non-glucocorticoids-used group (NGC group) according to whether glucocorticoids were used. A total of 818 eligible patients were included in the final analysis. Seventy-six patients were treated with glucocorticoids, and 742 patients were treated without glucocorticoids. Before propensity score matching, the triglyceride levels (38.2 ± 18.5 vs. 20.2 ± 16.8, P < 0.05) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores (7.1 ± 2.5 vs. 4.5 ± 2.1, P < 0.05) at admission were significantly higher in the GC group than in the NGC group. The incidence of multi-organ failure (33.3% vs. 11.9%, P < 0.05) was significantly higher in the GC group than in the NGC group. Patients in the GC group showed a positive balance of fluid intake and output over 72 h. After 1:1 propensity score matching, 59 patients from each group (GC and NGC) were included in the analysis. There were no significant differences in age, sex, body mass index, triglycerides, or APACHE II scores between the two groups (P > 0.05), and the patients’ clinical outcomes were reversed. The proportion of patients with organ failure (40.7% vs. 52.5%, p < 0.05) and multi-organ failure (35.0% vs. 67.7%, P < 0.05) was significantly lower in the GC group than in the NGC group. Furthermore, patients in the GC group had significantly shorter lengths of hospital stay (12.9 ± 5.5 vs. 16.3 ± 7.7, P < 0.05) and costs (25,348.4 ± 2512.6vs. 32,421.7 ± 2813.3, P < 0.05) than those in the NGC group. Conclusions This study presents preliminary confirmation of the beneficial effect of glucocorticoids in the treatment of acute pancreatitis. More high-quality prospective studies are needed in the future.
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Affiliation(s)
- Meng Wang
- Department of Traditional Chinese Medicine, General Hospital of Western Theater Command (Chengdu Military General Hospital), Chengdu, China
| | - Zongxing Jiang
- Department of General Surgery, General Hospital of Western Theater Command (Chengdu Military General Hospital), Chengdu, 613000, China
| | - Hongyin Liang
- Department of General Surgery, General Hospital of Western Theater Command (Chengdu Military General Hospital), Chengdu, 613000, China.
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Demir AM, Aydin F, Acar B, Kurt T, Poyraz A, Kiremitci S, Gülleroglu B, Azili MN, Bayrakci US. IgG4-related disease and ANCA positive vasculitis in childhood: a case-based review. Clin Rheumatol 2021; 40:3817-3825. [PMID: 33590421 DOI: 10.1007/s10067-021-05635-5] [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: 11/13/2020] [Revised: 01/31/2021] [Accepted: 02/03/2021] [Indexed: 12/24/2022]
Abstract
Autoimmune pancreatitis (AIP) type 1 is an IgG4-related disease (IgG4-RD), characterized by inflammatory pseudotumors and histologically by dense lymphoplasmacytic infiltrates rich in IgG4 positive plasma cells, storiform fibrosis, and obliterative phlebitis. Although quite rare, IgG4-RD was found to be associated with medium or small vessel vasculitides. A new overlap syndrome between IgG4-RD and ANCA-associated vasculitis (AAV) has recently been described in the adult population. Here we present a 16-year-old adolescent girl admitted with abdominal pain, episcleritis, palpable purpura, salivary gland enlargement, and bloody diarrhea. Laboratory investigations revealed findings of glomerulonephritis. Abdominal imaging surprisingly revealed a focal mass in the pancreatic tail, while the c-ANCA level was found to be quite high as well as serum IgG4 level. Biopsy of the pancreatic mass showed lymphoplasmacytic IgG4 positive cells infiltrating the pancreas with storiform fibrosis compatible with IgG4-related AIP. The renal biopsy that was done simultaneously showed necrotizing granulomatous vasculitis indicating AAV. Renal biopsy showed IgG4 positive plasma cells very rarely by immunohistochemical examination, which does not indicate any significance for IgG4-RD. Our diagnosis was IgG4-related AIP and AAV overlap syndrome, which has not been reported in the pediatric populations yet. IgG4-RD should be investigated in patients with ANCA-associated vasculitis who shows atypical organ involvement. We searched the Pubmed/Medline and Google Scholar databases to identify clinical findings, treatment, and outcome of the patients with IgG4-related AIP and AAV.
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Affiliation(s)
- Arzu Meltem Demir
- Department of Pediatric Gastroenterology, Ankara City Hospital, Ankara, Turkey.
| | - Fatma Aydin
- Department of Pediatric Rheumatology, Ankara City Hospital, Ankara, Turkey
| | - Banu Acar
- Department of Pediatric Rheumatology, Ankara City Hospital, Ankara, Turkey
| | - Tuba Kurt
- Department of Pediatric Rheumatology, Ankara City Hospital, Ankara, Turkey
| | - Aylar Poyraz
- Department of Pathology, Gazi University Medical Faculty, Ankara, Turkey
| | - Saba Kiremitci
- Department of Pathology, Ankara University Medical Faculty, Ankara, Turkey
| | - Basak Gülleroglu
- Department of Pediatric Radiology, Ankara City Hospital, Ankara, Turkey
| | - Müjdem Nur Azili
- Department of Pediatric Surgery, Ankara City Hospital, Ankara, Turkey
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Drake M, Dodwad SJM, Davis J, Kao LS, Cao Y, Ko TC. Sex-Related Differences of Acute and Chronic Pancreatitis in Adults. J Clin Med 2021; 10:300. [PMID: 33467580 PMCID: PMC7830423 DOI: 10.3390/jcm10020300] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/12/2021] [Accepted: 01/12/2021] [Indexed: 02/06/2023] Open
Abstract
The incidence of acute and chronic pancreatitis is increasing in the United States. Rates of acute pancreatitis (AP) are similar in both sexes, but chronic pancreatitis (CP) is more common in males. When stratified by etiology, women have higher rates of gallstone AP, while men have higher rates of alcohol- and tobacco-related AP and CP, hypercalcemic AP, hypertriglyceridemic AP, malignancy-related AP, and type 1 autoimmune pancreatitis (AIP). No significant sex-related differences have been reported in medication-induced AP or type 2 AIP. Whether post-endoscopic retrograde cholangiopancreatography pancreatitis is sex-associated remains controversial. Animal models have demonstrated sex-related differences in the rates of induction and severity of AP, CP, and AIP. Animal and human studies have suggested that a combination of risk factor profiles, as well as genes, may be responsible for the observed differences. More investigation into the sex-related differences of AP and CP is desired in order to improve clinical management by developing effective prevention strategies, diagnostics, and therapeutics.
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Affiliation(s)
| | | | | | | | - Yanna Cao
- Department of Surgery, UT Health Houston, Houston, TX 77030, USA; (M.D.); (S.-J.M.D.); (J.D.); (L.S.K.)
| | - Tien C. Ko
- Department of Surgery, UT Health Houston, Houston, TX 77030, USA; (M.D.); (S.-J.M.D.); (J.D.); (L.S.K.)
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Blaho M, Dítě P, Kunovský L, Kianička B. Autoimmune pancreatitis - An ongoing challenge. Adv Med Sci 2020; 65:403-408. [PMID: 32805624 DOI: 10.1016/j.advms.2020.07.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 04/15/2020] [Accepted: 07/13/2020] [Indexed: 02/07/2023]
Abstract
Autoimmune pancreatitis is a rare form of chronic pancreatitis. The first descriptions of the disease date back to the 1990s. Etiology is multifactorial, with the use of genetic, environmental and complex immunological mechanisms. It is classified into two subtypes. Type 1 is part of a group of diseases called IgG4-related disease. Clinically is autoimmune pancreatitis manifested by icterus and abdominal discomfort. It can rarely present as acute pancreatitis. There is also a completely asymptomatic form of the disease. The diagnosis is based on abnormalities in histology, imaging methods, serology, the involvement of other organs in relation to IgG4-related disease, and a significant positive response to corticosteroid therapy. Differential diagnosis between the focal form of autoimmune pancreatitis and pancreatic cancer can be complicated, with endosonography playing an important role. In the treatment, we use corticosteroids and other immunosuppressants including biological therapy. Patients with the asymptomatic disease should also be treated to prevent late complications and exocrine and endocrine insufficiency. In addition to drug treatment, endoscopic and/or surgical treatment may be necessary. Even after recovery, the disease can relapse. The relationship between autoimmune pancreatitis and malignancies has not been clearly confirmed. The goal of this review is to provide a comprehensive look at autoimmune pancreatitis and translate latest scientific knowledge into clinical practice.
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Affiliation(s)
- Martin Blaho
- Department of Internal Medicine, Department of Gastroenterology, University Hospital Ostrava, Ostrava, Czech Republic; Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic; Department of Internal Medicine II - Gastroenterology and Geriatrics, Faculty of Medicine, Palacký University Olomouc and University Hospital, Olomouc, Czech Republic
| | - Petr Dítě
- Department of Internal Medicine, Department of Gastroenterology, University Hospital Ostrava, Ostrava, Czech Republic; Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Lumír Kunovský
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Brno, Czech Republic; Department of Surgery, University Hospital Brno, Brno, Czech Republic; Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Bohuslav Kianička
- Faculty of Medicine, Masaryk University, Brno, Czech Republic; 2nd Department of Internal Medicine, Department of Gastroenterology, St. Anne's University Hospital, Brno, Czech Republic.
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Alcohol and Smoking Mediated Modulations in Adaptive Immunity in Pancreatitis. Cells 2020; 9:cells9081880. [PMID: 32796685 PMCID: PMC7463831 DOI: 10.3390/cells9081880] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 12/12/2022] Open
Abstract
Pancreatitis is a condition of pancreatic inflammation driven by injury to the pancreatic parenchyma. The extent of acinar insult, intensity, and type of immune response determines the severity of the disease. Smoking, alcohol and autoimmune pancreatitis are some of the predominant risk factors that increase the risk of pancreatitis by differentially influencing the adaptive immune system. The overall decrease in peripheral lymphocyte (T-, B- and (natural killer T-) NKT-cell) count and increased infiltration into the damaged pancreatic tissue highlight the contribution of adaptive immunity in the disease pathology. Smoking and alcohol modulate the responsiveness and apoptosis of T- and B-cells during pancreatic insult. Acute pancreatitis worsens with smoking and alcohol, leading to the development of systemic inflammatory response syndrome and compensatory anti-inflammatory response syndrome, suggesting the critical role of adaptive immunity in fatal outcomes such as multiple organ dysfunction. The presence of CD4+ and CD8+ T-lymphocytes and perforin-expressing cells in the fibrotic tissue in chronic pancreatitis modulate the severity of the disease. Due to their important role in altering the severity of the disease, attempts to target adaptive immune mediators will be critical for the development of novel therapeutic interventions.
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Combination Therapy with Empagliflozin and Insulin Results in Successful Glycemic Control: A Case Report of Uncontrolled Diabetes Caused by Autoimmune Pancreatitis and Subsequent Steroid Treatment. Case Rep Endocrinol 2019; 2019:9415347. [PMID: 30895163 PMCID: PMC6393920 DOI: 10.1155/2019/9415347] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 02/01/2019] [Indexed: 12/24/2022] Open
Abstract
A 66-year-old Japanese male presented with thirst, polyuria, and hemoglobin A1c and postprandial glucose levels (13.1% and 529 mg/dL, respectively) that indicated severe hyperglycemia. Based on his high immunoglobulin G4 level and the results of magnetic resonance imaging and magnetic resonance cholangiopancreatography, we diagnosed him with autoimmune pancreatitis. Insulin was initiated to control his diabetes. One month later, the patient commenced on prednisolone therapy for the treatment of autoimmune pancreatitis, after which his total insulin dosage increased to a maximum of 52 units/day. When the prednisolone dosage was later tapered, the patient's total dosage of insulin was reduced to 42 units/day. However, he had gained 3.6 kg from the start of prednisolone therapy, and 42 units/day was insufficient for maintaining glycemic control. Thus, empagliflozin, a sodium-dependent glucose transporter 2 (SGLT2) inhibitor, was added. Thereafter, we were able to reduce the patient's total dosage of insulin; it was eventually discontinued with good glycemic control and weight loss. Such results suggest that the combination of insulin with an SGLT2 inhibitor may be a viable option for the treatment of diabetic patients on prednisolone therapy.
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Abstract
Type 1 autoimmune pancreatitis (AIP) is an IgG-4-related systemic disease that can manifest as a pancreatic disorder or another disorder of presumed autoimmune origin. Type 2 disease is typically characterized by absent IgG-4-positive cells. As patients often present with acute pancreatitis, obstructive jaundice, or pancreatic mass, it is imperative to exclude malignancy, a more common diagnosis. AIP may respond to corticosteroids, and has a strong association with other immune-mediated diseases. Recent literature suggests the benefit of immune-modulating therapy, including rituximab, although no consensus exists. This review covers the essentials of diagnosis, but focuses primarily on management of AIP.
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Affiliation(s)
- Kamraan Madhani
- Department of Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA; Department of Medicine, Waterbury Internal Medicine Residency Program, Waterbury Hospital, Yale New Haven Hospital, Main 3, 64 Robbins Street, Waterbury, CT 06708, USA
| | - James J Farrell
- Section of Digestive Diseases, Yale University School of Medicine, Yale Center for Pancreatic Disease, Yale University, LMP 1080, 15 York Street, New Haven, CT 06510, USA.
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Sandrasegaran K, Menias CO. Imaging in Autoimmune Pancreatitis and Immunoglobulin G4-Related Disease of the Abdomen. Gastroenterol Clin North Am 2018; 47:603-619. [PMID: 30115440 DOI: 10.1016/j.gtc.2018.04.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Autoimmune pancreatitis (AIP) is steroid-responsive fibroinflammatory disorder of the pancreas. There are 2 distinct subtypes of AIP, types 1 and 2. Type 1 is associated with systemic immunoglobulin (Ig)G4 disease and may affect multiple organs in the body. Type 2 is confined to the pancreas and shows an association with ulcerative colitis. This article describes the imaging findings of AIP and IgG4 disease in the liver, bile ducts, kidneys, and the retroperitoneal regions. The imaging differentiation of AIP from pancreas cancer is discussed.
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Affiliation(s)
- Kumaresan Sandrasegaran
- Department of Radiology, Indiana University School of Medicine, 550 North University Boulevard, UH0279, Indianapolis, IN 46202, USA.
| | - Christine O Menias
- Department of Radiology, Mayo Clinic School of Medicine, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
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Juarez LA, Gupta RR, Ruhnke GW. Gastric varices and splenic vein obstruction during steroid treatment for autoimmune pancreatitis: A case report and literature review. Medicine (Baltimore) 2018; 97:e11940. [PMID: 30142813 PMCID: PMC6112881 DOI: 10.1097/md.0000000000011940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
RATIONALE Few cases of autoimmune pancreatitis (AIP) complicated by gastric varices, in the absence of splenic vein obstruction, have been described in the medical literature. The findings in this case parallel those of 3 previously described cases from Japan and support a pathologic explanation for the evolution of gastric varices in relation to early splenomegaly and the role of steroid therapy for AIP. PATIENT CONCERNS A 50-year-old male with a history of transfusion-requiring erosive gastritis and recently diagnosed AIP on steroid therapy for 2 weeks presented with a 2-day history of lightheadedness, abdominal pain, and melena. DIAGNOSIS Esophagogastroduodenoscopy (EGD) revealed prominent varices in the gastric fundus. An abdominal ultrasound with Doppler demonstrated patency of the splenic, hepatic, and portal veins. Review of previous imaging revealed that the splenic vein and the superior mesenteric vein (SMV) were occluded prior to the diagnosis of AIP and steroid therapy initiation. OUTCOME Following resolution of hemodynamic instability through fluid resuscitation and blood transfusion, the remainder of his hospital course was uneventful. Subsequent to discontinuation of steroid therapy, he developed near total reocclusion of both the splenic vein and SMV. LESSON Early steroid treatment should be considered in patients with uncomplicated AIP to prevent the occlusive vascular complications that are frequently associated with the pathophysiology of this disease process.
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Affiliation(s)
| | - Roop R. Gupta
- Gastroenterology, Department of Internal Medicine, Mercy Hospital and Medical Center
| | - Gregory W. Ruhnke
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL
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Kinugawa Y, Uehara T, Matsuda K, Kobayashi Y, Nakajima T, Hamano H, Kawa S, Higuchi K, Hosaka N, Shiozawa S, Ishigame H, Nakamura T, Maruyama Y, Nakazawa K, Nakaguro M, Sano K, Ota H. Promoter hypomethylation of SKI in autoimmune pancreatitis. Pathol Res Pract 2018. [PMID: 29534839 DOI: 10.1016/j.prp.2018.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The relationship between methylation abnormality and autoimmune pancreatitis (AIP)-a representative IgG4-related disease-has not yet been elucidated. We identified SKI might have a significant methylation abnormality in AIP through methylation array analysis using the Illumina Infinium Human Methylation 450K BeadChip array, and investigated the relationship of SKI with AIP clinicopathological features. The methylation rate of SKI was assessed by quantitative SYBR green methylation-specific PCR, and the degree of SKI expression in tissue specimens was assessed by immunohistochemistry in 10 AIP cases, 14 cases of obstructive pancreatitis area in pancreatic ductal adenocarcinoma (PDA) without a history of AIP, and 9 normal pancreas (NP) cases. The SKI methylation ratio was significantly lower in AIP than in PDA and NP. Additionally, the immunohistochemical staining-index (SI) score for SKI was significantly higher in AIP than NP, although there was no significant difference between AIP and PDA. There was a strong negative correlation between SI score and SKI methylation ratio, and between the serum concentrations of IgG4 and the SKI methylation ratio. There was a moderate positive correlation between the serum concentrations of IgG4 and SI. SKI is thought to be an oncogene indicating that SKI hypomethylation and carcinogenesis might be linked to AIP. Furthermore, the correlation between serum concentrations of IgG4 and SKI methylation levels suggest SKI might be involved in the pathogenesis of AIP. However, the role of SKI has not been clearly elucidated. Further studies are needed to understand further the function of SKI.
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Affiliation(s)
- Yasuhiro Kinugawa
- Department of Laboratory Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takeshi Uehara
- Department of Laboratory Medicine, Shinshu University School of Medicine, Matsumoto, Japan.
| | - Kazuyuki Matsuda
- Department of Laboratory Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yukihiro Kobayashi
- Department of Laboratory Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tomoyuki Nakajima
- Department of Laboratory Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hideaki Hamano
- Department of Gastroenterology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Shigeyuki Kawa
- Internal Medicine, Matsumoto Dental University, Shiojiri, Japan
| | - Kayoko Higuchi
- Department of Pathology, Aizawa Hospital, Matsumoto, Japan
| | - Noriko Hosaka
- Department of Pathology, Nagano Municipal Hospital, Nagano, Japan
| | | | | | | | | | - Koh Nakazawa
- Department of Clinical Laboratory, National Hospital Organization, Matsumoto Medical Center, Matsumoto Hospital, Matsumoto, Japan
| | - Masato Nakaguro
- Department of Pathology and Laboratory Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Kenji Sano
- Department of Pathology, Iida Municipal Hospital, Iida, Japan
| | - Hiroyoshi Ota
- Department of Laboratory Medicine, Shinshu University School of Medicine, Matsumoto, Japan; Department of Biomedical Laboratory Medicine, Shinshu University School of Medicine, Matsumoto, Japan
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Scharwächter C, Haage P. State of the Art Diagnosis of Pancreatic Ductal Adenocarcinoma. CURRENT RADIOLOGY REPORTS 2017. [DOI: 10.1007/s40134-017-0233-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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