Recent advances in the diagnosis and management of autoimmune pancreatitis. AJR Am J Roentgenol. 2014;202:1007-1021. [PMID: 24758653 DOI: 10.2214/ajr.13.11247]

Non-O1, Non-O139 Vibrio cholerae Bacteremia in an Autoimmune Pancreatitis Patient

Over 200 different serogroups of Vibrio cholerae based on O-polysaccharide specificity have been described worldwide, including the two most important serogroups, O1 and O139. Non-O1/non-O139 V. cholerae serogroups generally do not produce the cholera-causing toxin but do sporadically cause gastroenteritis and extra-intestinal infections. Recently, however, bloodstream infections caused by non-O1/non-O139 V. cholerae are being increasingly reported, and these infections are associated with high mortality in immunocompromised hosts. We describe a case of non-O1/non-O139 V. cholerae bacteremia in a patient with autoimmune pancreatitis and stenosis of the intra- and extrahepatic bile ducts. The clinical manifestations of bacteremia were fever and mild digestive symptoms. The blood cultures showed V. cholerae, which was identified as a non-O1, non-O139 serogroup by slide agglutination tests and PCR. The bloodstream infection of the patient was likely caused by the consumption of contaminated seafood at a banquet. The patient recovered after the administration of a third-generation cephalosporin. Non-O1/non-O139 V. cholerae infection presents with or without gastrointestinal manifestations; close attention should be paid to the possibility of disseminated non-O1/non-O139 V. cholerae infection in high-risk patients.

[Autoimmune pancreatitis versus pancreatic cancer]

CLINICAL ISSUE

Autoimmune pancreatitis (AIP) is classified as a distinct form of pancreatitis according to the guidelines. It is characterized by imaging morphologic and histologic features and is associated with extrapancreatic manifestations in type 1 IgG 4-associated disease. Symptoms and findings almost always improve with administration of steroids. Differentiation from pancreatic ductal adenocarcinoma is required, particularly in the presence of AIP with focal parenchymal involvement.

STANDARD RADIOLOGIC PROCEDURES

If AIP is suspected, abdominal ultrasound and/or endosonography, computed tomography (CT), and preferably magnetic resonance imaging (MRI) are indicated. A distinction is made between parenchymal and ductal changes that specifically indicate the presence of AIP.

METHODOLOGICAL INNOVATIONS AND EVALUATION

The diagnosis of autoimmune pancreatitis should be made based on the International Consensus Criteria (ICDC), in which the five main features (imaging, serology, histology, other organ involvement, response to steroid medication) are assessed. In type 1 AIP, typical imaging changes are sufficient to establish the diagnosis even with negative histology, whereas for type 2 AIP, histologic evidence is required. Imaging changes help in the differential diagnosis from pancreatic cancer.

PRACTICAL RECOMMENDATIONS

The following article addresses and evaluates crucial imaging diagnostic CT and MRI criteria for correct classification of findings, description of results, and differentiation of autoimmune pancreatitis from pancreatic cancer.

CT Radiomics Features in Differentiation of Focal-Type Autoimmune Pancreatitis from Pancreatic Ductal Adenocarcinoma: A Propensity Score Analysis

PURPOSE

To evaluate the diagnostic performance of the radiomics score (rad-score) for differentiating focal-type autoimmune pancreatitis (fAIP) from pancreatic ductal adenocarcinoma (PDAC).

METHODS

This retrospective review included 42 consecutive patients with fAIP diagnosed according to the International Consensus Diagnostic Criteria between January 2011 and December 2018. Furthermore, 334 consecutive patients with PDAC confirmed by pathology were also reviewed during the same period. Patients with PDAC and fAIP were matched via propensity score matching (PSM). All patients underwent multidetector computed tomography (MDCT). For each patient, 1409 radiomics features of the portal phase were extracted and reduced using the least absolute shrinkage and selection operator (LASSO) logistic regression algorithm. The portal rad-score performance was assessed based on its discriminative ability.

RESULTS

After PSM, we matched 55 patients with PDAC to 42 patients with fAIP, based on clinical and CT characteristics (e.g., patient age, sex, body mass index, location, size, enhanced mode). A rad-score for discriminating fAIP from PDAC, which contained four CT derived radiomic features, was developed (area under the curve = 0.97). The sensitivity, specificity, and accuracy of the radiomics model were 95.24%, 92.73% and 0.94, respectively.

CONCLUSION

The portal rad-score can accurately and noninvasively differentiate fAIP from PDAC.

Solid pancreatic masses in children: A review of current evidence and clinical challenges

Pancreatic tumors in children are infrequently encountered in clinical practice. Their non-specific clinical presentation and overlapping imaging characteristics often make an accurate preoperative diagnosis difficult. Tumors are categorized as epithelial or non-epithelial, with epithelial tumors further classified as tumors of the exocrine or endocrine pancreas. Although both are tumors of the exocrine pancreas, solid pseudopapillary neoplasm is the most prevalent solid pancreatic tumor in children, while pancreatoblastoma is the most common malignant tumor. Insulinoma is the most common pediatric pancreatic tumor of the endocrine pancreas. Malignant tumors require a complete, often radical, surgical resection. However, pancreatic parenchyma-sparing surgical procedures are utilized for benign tumors and low-grade malignancy to preserve gland function. This review will discuss the epidemiology, pathophysiology, clinical and diagnostic characteristics, and management options associated with both common and rare solid pancreatic masses in children. We will also discuss current challenges encountered in their evaluation and treatment.

Autoimmune pancreatitis: What we know so far

Autoimmune pancreatitis (AIP) is a rare, often‐missed disease that involves inflammation of the pancreas and strictures of the pancreatic duct. Its prevalence and incidence in the United States remain scarce. The disease has a varied presentation and often mimics pancreatic malignancy, which can make the diagnosis challenging. Most patients have an excellent response to corticosteroid therapy. Immunomodulators may be used in some cases. Rituximab is an effective, emerging treatment in steroid‐refractory cases. This study aims to review the two distinct types of AIP and provide a detailed analysis of the diagnostic approach and treatment modalities.

QNZ alleviated hepatocellular carcinoma by targeting inflammatory pathways in a rat model

The pathogenicity of HCC could be enhanced by TNF-α and NFκB, which are crucial parts of the inflammatory pathway inside the HCC microenvironment. Therefore, we aimed to discover the therapeutic effects of QNZ, an inhibitor of both TNF-α and NFκB, in an experimental model of HCC in rats. HCC was experimentally induced in rats by thioacetamide, and some of the rats were treated with QNZ. The expression levels of nuclear factor (NF)κB, tumor necrosis factor (TNF)-α, apoptosis signal regulating kinase (ASK)-1, β-catenin, glycogen synthase kinase (GSK)-3 and TNF receptor-associated factor (TRAF) were examined in hepatic samples. In addition, hepatic tissues were stained with hematoxylin/eosin and anti-TNF-α antibodies. QNZ blocked HCC-induced expression of both NFκB and TNF-α. It significantly reduced both α-fetoprotein and the average number of nodules and increased the survival rate of the HCC rats. Moreover, hematoxylin and eosin liver sections from the HCC rats showed vacuolated cytoplasm and necrotic nodules. All of these effects were alleviated by QNZ treatment. Finally, treating HCC rats with QNZ resulted in a reduction in the expression of TRAF, ASK-1 and β-catenin, as well as increased expression of GSK-3. In conclusion, inhibition of the inflammatory pathway in HCC with QNZ produced therapeutic effects, as indicated by an increased survival rate, reduced serum α-fetoprotein levels, decreased liver nodules and improved the hepatocyte structure. In addition, QNZ significantly reduced the expression of TRAF, ASK-1 and β-catenin that were associated with increased expression of GSK-3.

Imaging of inflammatory disease of the pancreas

Increasingly acute and chronic pancreatitis (AP and CP) are considered a continuum of a single entity. Nonetheless, if, after flare-up, the pancreas shows no residual inflammation, it is classified as AP. CP is characterised by a long cycle of worsening and waning glandular inflammation without the pancreas ever returning to its baseline structure or function. According to the International Consensus Guidelines on Early Chronic Pancreatitis, pancreatic inflammation must last at least 6 months before it can be labelled CP. The distinction is important because, unlike AP, CP can destroy endocrine and exocrine pancreatic function, emphasising the importance of early diagnosis. As typical AP can be diagnosed by clinical symptoms plus laboratory tests, imaging is usually reserved for those with recurrent, complicated or CP. Imaging typically starts with ultrasound and more frequently with contrast-enhanced computed tomography (CECT). MRI and/or MR cholangiopancreatography can be used as a problem-solving tool to confirm indirect signs of pancreatic mass, differentiate between solid and cystic lesions, and to exclude pancreatic duct anomalies, as may occur with recurrent AP, or to visualise early signs of CP. MR cholangiopancreatography has replaced diagnostic endoscopic retrograde cholangiopancreatography (ERCP). However, ERCP, and/or endoscopic ultrasound (EUS) remain necessary for transpapillary biliary or pancreatic duct stenting and transgastric cystic fluid drainage or pancreatic tissue sampling, respectively. Finally, positron emission tomography-MRI or positron emission tomography-CT are usually reserved for complicated cases and/or to search for extra pancreatic systemic manifestations. In this article, we discuss a broad spectrum of inflammatory pancreatic disorders and the utility of various modalities in diagnosing acute and chronic pancreatitis.

[Chronic pancreatitis : Characterization and differentiation from pancreatic cancer]

Klinisches/methodisches Problem

Bei der chronischen Pankreatitis (CP) handelt es sich um eine langanhaltende Entzündung der Bauchspeicheldrüse, welche die normale Struktur und Funktion des Organs schädigt. Das breite Spektrum an entzündlichen Pankreaserkrankungen umfasst einzelne Entitäten, wie die fokale Pankreatitis (FP) oder den Pseudotumor („mass-forming pancreatitis“), welche radiomorphologisch ein Adenokarzinom der Bauchspeicheldrüse (PDAC) nachahmen können. In weiterer Folge kann eine Fehldiagnose zu einem vermeidbaren und unnötigen operativen Eingriff oder zu einer Therapieverzögerung führen.

Radiologische Standardverfahren

Der Ultraschall (US) ist das primäre bildgebende Verfahren zur Abklärung von Pankreaserkrankungen, gefolgt von kontrastmittelverstärkter Computertomographie (KM-CT), die als meistverwendete Methode bei der diagnostischen Abklärung von Bauchspeicheldrüsenerkrankungen gilt. Die Magnetresonanztomographie (MRT) und/oder die MR-Cholangiopankreatographie (MRCP) können als Problemlöser eingesetzt werden, um zwischen soliden und zystischen Läsionen zu unterscheiden sowie auch Anomalien der Pankreasgänge auszuschließen, welche bei rezidivierender akuter Pankreatitis (AP) vorhanden sein können, oder um frühe Anzeichen einer CP zu visualisieren. Die MRCP hat dabei die diagnostische endoskopische retrograde Cholangiopankreatographie (ERCP) in der Abklärung von therapeutischen Interventionen im Wesentlichen ersetzt.

Empfehlung für die Praxis

Folgender Übersichtsartikel fasst die relevanten Merkmale in der Computertomographie (CT) und MRT zusammen, um eine akkurate, frühzeitige Diagnose einer CP zu stellen und eine Differenzierung zwischen FP und Pankreaskarzinom zu ermöglichen, um somit – auch in schwierigen Fällen – ein adäquates Therapiemanagement zu gewährleisten.

Therapeutic effects of blocking β-catenin against hepatocellular carcinoma-induced activation of inflammation, fibrosis and tumor invasion

Destructive effects of hepatocellular carcinoma (HCC) is enhanced by many cellular mechanisms including activation of fibrosis, inflammation and tumor invasion. Therefore, this study was conducted to investigate the therapeutic effects of iCRT14, β-catenin blocker, on HCC. In addition, the molecular effects of iCRT14 will be investigated on inflammation, fibrosis and tumor invasion pathways. After inducting HCC in rats, hepatic tissues were used for determination of the expression of β-catenin, nuclear factor (NF)κB, tumor necrosis factor (TNF)-α, interleukin (IL)-1β, matrix metalloproteinase (MMP)9, transforming growth factor (TGF)-β1, fibroblast growth factor (FGF)-2 and integrin-β6. Hepatic tissues were stained with hematoxylin/eosin and with anti-Ki67. Results revealed that iCRT14 significantly increased the survival percent of HCC rats, reduced both α-fetoprotein and average number of nodules. In parallel, hepatic sections from HCC rats stained with hematoxylin/eosin revealed vacuolated cytoplasm and necrotic nodules, which were attenuated by treatment with iCRT14. Finally, treating HCC rats with iCRT14 resulted in reduction of the expression of NFκB, TNF-α, IL-1β, TGF-β1, MMP9, FGF-2 and integrin-β6. In conclusion, iCRT14 treatment exhibited antitumor effects against HCC through impairing β-catenin signaling pathway. iCRT14 suppressed liver tissue inflammation, fibrosis and angiogenesis, possibly via reducing expression of NFκB, TNF-α, IL-1β, TGF-β1, MMP-9, FGF-2.

Meta-analysis of CT and MRI for differentiation of autoimmune pancreatitis from pancreatic adenocarcinoma

OBJECTIVES

To systematically determine the diagnostic performance of computed tomography (CT) and magnetic resonance imaging (MRI) for differentiating autoimmune pancreatitis (AIP) from pancreatic ductal adenocarcinoma (PDAC), with a comparison between the two imaging modalities.

METHODS

Literature search was conducted using PubMed and EMBASE databases to identify original articles published between 2009 and 2019 reporting the diagnostic performance of CT and MRI for differentiating AIP from PDAC. The meta-analytic sensitivity and specificity of CT and MRI were calculated, and compared using a bivariate random effects model. Subgroup analysis for differentiating focal AIP from PDAC was performed.

RESULTS

Of the 856 articles screened, 11 eligible articles are remained, i.e., five studies for CT, four for MRI, and two for both. The meta-analytic summary sensitivity and specificity of CT were 59% (95% confidence interval [CI], 41-75%) and 99% (95% CI, 88-100%), respectively, while those of MRI were 84% (95% CI, 68-93%) and 97% (95% CI, 87-99%). MRI had a significantly higher meta-analytic summary sensitivity than CT (84% vs. 59%, p = 0.02) but a similar specificity (97% vs. 99%, p = 0.18). In the subgroup analysis for focal AIP, the sensitivity for distinguishing between focal AIP and PDAC was lower than that for the overall analysis. MRI had a higher sensitivity than CT (76% vs. 50%, p = 0.28) but a similar specificity (97% vs. 98%, p = 0.07).

CONCLUSION

MRI might be clinically more useful to evaluate patients with AIP, particularly for differentiating AIP from PDAC.

KEY POINTS

• MRI had an overall good diagnostic performance to differentiate AIP from PDAC with a meta-analytic summary estimate of 83% for sensitivity and of 97% for specificity. • CT had a very high specificity (99%), but a suboptimal sensitivity (59%) for differentiating AIP from PDAC. • Compared with CT, MRI had a higher sensitivity, but a similar specificity.

Pancreatitis and PDAC: association and differentiation

The discrimination of mass-forming chronic pancreatitis (MFCP) from pancreatic ductal adenocarcinoma (PDAC) is a central diagnostic dilemma. It is important to differentiate these entities since they have markedly different prognoses and management. Importantly, the appearance of these two entities significantly overlaps on a variety of imaging modalities. However, there are imaging features that may be suggestive of one entity more than the other. MFCP and PDAC may show different enhancement patterns on perfusion computed tomography (CT) and/or dynamic contrast-enhanced MRI (DCE-MRI). The duct-penetrating sign on magnetic resonance cholangiopancreatography (MRCP) is more often associated with MFCP, whereas abrupt cutoff with upstream dilatation of the main pancreatic duct and the double-duct sign (obstruction/cutoff of both the common bile duct and pancreatic duct) are more often associated with PDAC. Nevertheless, tissue sampling is the most reliable method to differentiate between these entities and is currently generally necessary for management.

Differentiation of focal autoimmune pancreatitis from pancreatic ductal adenocarcinoma

Autoimmune pancreatitis (AIP) is an inflammatory process of the pancreas that occurs most commonly in elderly males and clinically can mimic pancreatic adenocarcinoma and present with jaundice, weight loss, and abdominal pain. Mass-forming lesions in the pancreas are seen in the focal form of AIP and both clinical and imaging findings can overlap those of pancreatic cancer. The accurate distinction of AIP from pancreatic cancer is of utmost importance as it means avoiding unnecessary surgery in AIP cases or inaccurate steroid treatment in patients with pancreatic cancer. Imaging concomitantly with serological examinations (IgG4 and Ca 19-9) plays an important role in the distinction between these entities. Characteristic extra-pancreatic manifestations as well as favorable good response to treatment with steroids are characteristic of AIP. This paper will review current diagnostic parameters useful in differentiating between focal AIP and pancreatic adenocarcinoma.

Autoimmune pancreatitis: an update

OBJECTIVE

Since the time of inception of autoimmune pancreatitis (AIP), our knowledge of autoimmune pancreatitis has expanded significantly. The aim of this review is to provide an update on clinical manifestations, diagnosis, imaging features, and treatment of AIP.

BACKGROUND AND CLINICAL SIGNIFICANCE

Type 1 AIP is the pancreatic manifestation of IgG4-related systemic disease, which can be diagnosed using a combination of clinical, histopathological, pancreatic imaging findings in conjunction with manifestation in other organs, as well of responsiveness to steroid treatment. It is vital to differentiate AIP from pancreatic cancer since both can mimic each other clinically and radiologically. Type 2 AIP is a rare but distinct subtype of AIP which occurs mostly in the younger patient.

CONCLUSION

AIP is steroid-responsive chronic pancreatitis with distinct manifestations on imaging.

Pictorial Review of Rare Pancreatic Tumors and Tumor-Like Lesions

췌장에는 다양한 종류의 종양 및 종양 유사 병변들이 생길 수 있다. 이 가운데, 췌장선암은 췌장의 가장 흔한 종양으로서 일반적으로 췌장암이라고 하면 이 종양을 가리킨다. 최근에는 영상 검사의 기술적 진보와 이용이 증가하면서 췌장의 희귀 종양 및 종양 유사 병변들의 발견 빈도가 증가하고 있다. 췌장의 드문 종양 및 종양과 유사한 병변들은 치료 방침과 예후가 췌장선암과 다르기 때문에 이들 질환의 감별은 임상적으로 중요한 의의가 있다. 영상 검사는 포상세포암이나 신경초종 등의 희귀 종양 및 자가면역 췌장염 또는 염증성 거짓종양과 같은 종양 유사 병변들과 췌장선암의 감별 진단에 중요한 역할을 하지만 영상 소견만으로 이들 질환을 정확히 구분하는 것은 한계가 있다. 이 논문에서는 췌장에서 생길 수 있는 희귀 종양 및 종양 유사 병변들의 다양한 영상 소견들과 췌장선암과의 감별에 있어 도움이 되는 특징들을 제시하고자 한다.

IgG4-related disease: Is rituximab the best therapeutic strategy for cases refractory to conventional therapy? Results of a systematic review

INTRODUCTION

IgG4 related disease is a fibroinflammatory condition characterised by lymphoplasmocytic infiltration with predominance of IgG4+ plasma cells, fibrosis, and in most cases elevated IgG4 serum levels. It can affect any organ and result in varying clinical manifestations. Steroids are the cornerstone of treatment, however there is a high percentage of relapse. Recent studies have demonstrated favourable effects with rituximab.

OBJECTIVE

To evaluate effectiveness related to the response to treatment with rituximab in patients with IgG4 related disease refractory to steroids and other immunosuppressant therapies.

MATERIALS AND METHODS

We undertook a systematic search of the specialist databases EMBASE, LILACS, PUBMED and OVID-Cochrane for publications up until December 2017.

RESULTS

After the quality analysis, we selected 27 articles (264 patients in total) for the final review, of which 23 were case reports and case series (105 patients), 3 were observational follow-up cohort studies (129 patients), and there was one clinical trial (30 patients). IgG4 related disease presents predominantly in male patients aged between 50 and 70 years on average. Multiple organs are compromised with an average of 3.5 compromised organs. Orbital, glandular and lymph-node compromise is most frequent. Patients in the different studies we included had received various treatments prior to starting rituximab, including glucocorticoids and disease-modifying anti-rheumatic drugs. There was 90.7% response in the cases where rituximab was used as second line therapy; rituximab was used as first line treatment for 10% of the patients with a 100% response rate.

CONCLUSION

The use of rituximab for patients refractory to first-line treatments was associated with a high response percentage and less dependence on glucocorticoids.

Imaging in Autoimmune Pancreatitis and Immunoglobulin G4-Related Disease of the Abdomen

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.

Beyond the Bowel: Extraintestinal Manifestations of Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a chronic, relapsing immune-mediated inflammation of the gastrointestinal tract. IBD includes two major disease entities: Crohn disease and ulcerative colitis. Imaging plays an important role in the diagnosis and surveillance of these complex disorders. Computed tomographic and magnetic resonance enterographic techniques have been refined in recent years to provide a superb means of evaluating the gastrointestinal tract for suspected IBD. Although the intestinal imaging manifestations of IBD have been extensively discussed in the radiology literature, extraintestinal imaging manifestations of IBD have received less attention. Multiple extraintestinal manifestations may be seen in IBD, including those of gastrointestinal (hepatobiliary and pancreatic), genitourinary, musculoskeletal, pulmonary, cardiac, ocular, and dermatologic disorders. Although many associations between IBD and extraintestinal organ systems have been well established, other associations have not been fully elucidated. Some extraintestinal disorders may share a common pathogenesis with IBD. Other extraintestinal disorders may occur as a result of unintended treatment-related complications of IBD. Although extraintestinal disorders within the abdomen and pelvis may be well depicted with cross-sectional enterography, other musculoskeletal and thoracic disorders may be less evident with such examinations and may warrant further investigation with additional imaging examinations or may be readily apparent from the findings at physical examination. Radiologists involved in the interpretation of IBD imaging examinations must be aware of potential extraintestinal manifestations, to provide referring clinicians with an accurate and comprehensive profile of patients with these complex disorders. ^© RSNA, 2017.

Pancreatic ductal adenocarcinoma and chronic mass-forming pancreatitis: Differentiation with dual-energy MDCT in spectral imaging mode

OBJECTIVE

To investigate the value of dual-energy MDCT in spectral imaging in the differential diagnosis of chronic mass-forming chronic pancreatitis (CMFP) and pancreatic ductal adenocarcinoma (PDAC) during the arterial phase (AP) and the pancreatic parenchymal phase (PP).

MATERIALS AND METHODS

Thirty five consecutive patients with CMFP (n=15) or PDAC (n=20) underwent dual-energy MDCT in spectral imaging during AP and PP. Iodine concentrations were derived from iodine-based material-decomposition CT images and normalized to the iodine concentration in the aorta. The difference in iodine concentration between the AP and PP, contrast-to-noise ratio (CNR) and the slope K of the spectrum curve were calculated.

RESULTS

Normalized iodine concentrations (NICs) in patients with CMFP differed significantly from those in patients with PDAC during two double phases (mean NIC, 0.26±0.04 mg/mL vs. 0.53±0.02 mg/mL, p=0.0001; 0.07±0.02 mg/mL vs. 0.28±0.04 mg/mL, p=0.0002, respectively). There were significant differences in the value of the slope K of the spectrum curve in two groups during AP and PP (K(CMFP)=3.27±0.70 vs. K(PDAC)=1.35±0.41, P=0.001, and K(CMFP)=3.70±0.17 vs. K(PDAC)=2.16±0.70, p=0.003, respectively). CNRs at low energy levels (40-70 keV) were higher than those at high energy levels (80-40 keV).

CONCLUSION

Individual patient CNR-optimized energy level images and the NIC can be used to improve the sensitivity and the specificity for differentiating CMFP from PDAC by use of dual-energy MDCT in spectral imaging with fast tube voltage switching.

Autoimmune pancreatitis mimicking Klatskin tumour on radiology

Autoimmune pancreatitis (AIP) is categorised into two distinct types, AIP type 1 and 2. Although there can be multisystem involvement, rarely, the cholangitis associated with AIP can present radiologically in a manner similar to that of Klatskin tumour. We present the case of a 65-year-old man who was almost misdiagnosed with a Klatskin tumour because of the similarity in radiological features of the two aforementioned clinical entities. The patient presented with a history of jaundice, pruritus and abdominal pain, and work up showed deranged liver function tests, elevated cancer antigen 19-9 levels and positive antinuclear antibodies. CT scan of the abdomen showed findings suggestive of Klatskin tumour but due to diffuse enlargement of the pancreas and surrounding low-attenuation halo found on a closer review, a diagnosis of AIP was performed. The patient was started on standard corticosteroid therapy and responded well, with complete resolution of the radiological findings.

Pharmacologic therapy for acute pancreatitis

While conservative management such as fluid, bowel rest, and antibiotics is the mainstay of current acute pancreatitis management, there is a lot of promise in pharmacologic therapies that target various aspects of the pathogenesis of pancreatitis. Extensive review of preclinical studies, which include assessment of therapies such as anti-secretory agents, protease inhibitors, anti-inflammatory agents, and anti-oxidants are discussed. Many of these studies have shown therapeutic benefit and improved survival in experimental models. Based on available preclinical studies, we discuss potential novel targeted pharmacologic approaches that may offer promise in the treatment of acute pancreatitis. To date a variety of clinical studies have assessed the translational potential of animal model effective experimental therapies and have shown either failure or mixed results in human studies. Despite these discouraging clinical studies, there is a great clinical need and there exist several preclinical effective therapies that await investigation in patients. Better understanding of acute pancreatitis pathophysiology and lessons learned from past clinical studies are likely to offer a great foundation upon which to expand future therapies in acute pancreatitis.