1
|
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.
Collapse
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.
| |
Collapse
|
2
|
Paleti S, Yarlagadda B, Gremida A, Aziz M, Hanson J, McCarthy D. Colitis and Pancreatitis in a Patient with Systemic Lupus Erythematosus: Due to Disease or to Drug? Dig Dis Sci 2018; 63:2206-2209. [PMID: 30069857 DOI: 10.1007/s10620-018-5225-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Swathi Paleti
- Division of Gastroenterology and Hepatology, Department of Medicine, University of New Mexico School of Medicine, MSC10-5550, Albuquerque, NM, 87131, USA.
| | - Bharath Yarlagadda
- Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Anas Gremida
- Division of Gastroenterology and Hepatology, Department of Medicine, University of New Mexico School of Medicine, MSC10-5550, Albuquerque, NM, 87131, USA
| | - Muhammad Aziz
- Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Joshua Hanson
- Department of Pathology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Denis McCarthy
- Division of Gastroenterology and Hepatology, Department of Medicine, University of New Mexico School of Medicine, MSC10-5550, Albuquerque, NM, 87131, USA
| |
Collapse
|
3
|
Wang Y, Li K, Gao D, Luo G, Zhao Y, Wang X, Zhang J, Jin J, Zhao Z, Yang C, Zhu J, Zhang J, Huang F. Combination therapy of leflunomide and glucocorticoids for the maintenance of remission in patients with IgG4-related disease: a retrospective study and literature review. Intern Med J 2017; 47:680-689. [PMID: 28321964 DOI: 10.1111/imj.13430] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 02/07/2017] [Accepted: 03/08/2017] [Indexed: 12/24/2022]
Affiliation(s)
- Yiwen Wang
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Kunpeng Li
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Dai Gao
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Gui Luo
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Yurong Zhao
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Xiuru Wang
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Jie Zhang
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Jingyu Jin
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Zheng Zhao
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Chunhua Yang
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Jian Zhu
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Jianglin Zhang
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Feng Huang
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| |
Collapse
|
4
|
|
5
|
Abstract
Autoimmune pancreatitis (AIP) was recognized as a clinical entity, at least in the West little more than 10 years ago. Since then, studies globally, and international collaboration, have led to important advances in our understanding of its clinical features, disease course, and management, although the aetiopathogenesis of this curious disease remains to be fully elucidated. Types 1 and 2 AIP have been described, of which type 1 is the commonest form, and best defined. International consensus now recognizes it as one of the many clinical manifestations of IgG4-related disease, and is now termed IgG4-related pancreatitis (IgG4-RP). The disease is not confined to a particular race, gender, or age, but often presents after the fifth decade in men. A common presentation is with jaundice due to low bile duct obstruction related to diffuse pancreatic enlargement (historically often leading to a misdiagnosis of cancer). Acute pancreatitis is unusual. Other organ involvement is a particular feature, including biliary disease, retroperitoneal fibrosis, generalized lymphadenopathy, renal, and lung involvement. No single test makes the diagnosis, and diagnostic criteria for type 1 AIP/IgG4-RP, which incorporate clinical, laboratory, radiological, pathological, and therapeutic parameters should be applied. A particular attempt should be made to make a histological diagnosis, which is characterized by an IgG4-positive lymphoplasmacytic infiltrate. Management is not based on randomized studies, but corticosteroids are the mainstay of treatment, providing rapid clinical and radiological benefit. However, clinical relapse is common (particularly in type 1 AIP, and in those with associated other organ involvement). Additional immunosuppression may be required, including azathioprine, and rituximab may play an emerging role. The disease course is variable, but loss of organ function (especially pancreatic exocrine failure and pancreatic atrophy) may occur.
Collapse
Affiliation(s)
- George J Webster
- Pancreaticobiliary Medicine Unit, University College London Hospitals, London, UK
| |
Collapse
|
6
|
|
7
|
Grados A, Ebbo M, Jean E, Bernit E, Harlé JR, Schleinitz N. [IgG4-related disease treatment in 2014: Update and literature review]. Rev Med Interne 2015; 36:395-404. [PMID: 25595874 DOI: 10.1016/j.revmed.2014.11.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 10/27/2014] [Accepted: 11/23/2014] [Indexed: 02/08/2023]
Abstract
IgG4-related disease is an inflammatory disorder characterized by a polyclonal lymphoplasmacytic tissue infiltrate, with numerous IgG4+ plasmocytes, evolving toward fibrosis. The disease is heterogeneous and affects several tissues and organs synchroneously or metachroneously. Both the fibrosis and the tumor forming characteristics of the disease can be responsible of irreversible tissue damage. For these reasons treatment is usually necessary. A dramatic response is usually observed with steroid treatment but relapses are frequent. Immunosuppressive agents and rituximab are used as second line treatments. We review here previous studies on treatment and suggest general recommendations for the treatment and follow up of patients with IgG4-related disease.
Collapse
Affiliation(s)
- A Grados
- Service de médecine interne, hôpital de la Timone, AP-HM, Aix-Marseille université, 264, rue Saint-Pierre, 13385 Marseille, France
| | - M Ebbo
- Service de médecine interne, hôpital de la Timone, AP-HM, Aix-Marseille université, 264, rue Saint-Pierre, 13385 Marseille, France.
| | - E Jean
- Service de médecine interne, hôpital Nord, AP-HM, Aix-Marseille université, 13915 Marseille, France
| | - E Bernit
- Service de médecine interne, hôpital de la Timone, AP-HM, Aix-Marseille université, 264, rue Saint-Pierre, 13385 Marseille, France
| | - J-R Harlé
- Service de médecine interne, hôpital de la Timone, AP-HM, Aix-Marseille université, 264, rue Saint-Pierre, 13385 Marseille, France
| | - N Schleinitz
- Service de médecine interne, hôpital de la Timone, AP-HM, Aix-Marseille université, 264, rue Saint-Pierre, 13385 Marseille, France
| |
Collapse
|
8
|
Mulay K, Honavar SG. Orbital Immunoglobulin G4-Related Disease: A Systematic Review. Asia Pac J Ophthalmol (Phila) 2014; 3:322-5. [PMID: 26107919 DOI: 10.1097/apo.0000000000000077] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a clinically distinct systemic condition that can involve the orbital tissue. Characterized by a triad of a mass-forming lesion, infiltration by IgG4-positive plasma cells, and elevated serum IgG4 titers in many cases, IgG4-RD has clinicopathologic features that overlap with ocular adnexal lymphomas and orbital inflammatory conditions. Although most cases of orbital IgG4-RD respond well to steroids, it may become necessary to include supplemental immunosuppressant therapy in the management.
Collapse
Affiliation(s)
- Kaustubh Mulay
- From the *National Reporting Centre for Ophthalmic Pathology (NRCOP) and †Ophthalmic and Facial Plastic Surgery and Ocular Oncology, Centre for Sight, Hyderabad, India
| | | |
Collapse
|
9
|
Review of 43 patients with autoimmune pancreatitis based on the international consensus diagnostic criteria in China. Pancreas 2014; 43:810-1. [PMID: 24921204 DOI: 10.1097/mpa.0000000000000127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
10
|
Mulay K, Aggarwal E, Jariwala M, Honavar SG. Orbital immunoglobulin-G4-related disease: case series and literature review. Clin Exp Ophthalmol 2014; 42:682-7. [PMID: 24330202 DOI: 10.1111/ceo.12284] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 12/05/2013] [Indexed: 12/19/2022]
Abstract
Immunoglobulin-G4-related disease (IgG4-RD) is a distinct group of diseases characterized by elevated serum IgG4 titres and infiltration of affected organs by IgG4-positive plasma cells. IgG4-RD can involve any ocular adnexal tissue. They have a distinct prognosis and pattern of tissue involvement and hence need to be differentiated from orbital lesions with similar clinicopathological features. We report three cases of IgG4-RD and review the literature extensively discussing various aspects of this novel entity.
Collapse
Affiliation(s)
- Kaustubh Mulay
- National Reporting Centre for Ophthalmic Pathology (NRCOP), Centre for Sight, Hyderabad, India; Ophthalmic Pathology Service, L.V. Prasad Eye Institute, Hyderabad, India
| | | | | | | |
Collapse
|
11
|
Abstract
IgG4-associated cholangitis is the hepatobiliary manifestation of a recently characterized inflammatory systemic disease, associated with increased IgG4 serum levels and IgG4-positive lymphoplasmacytic infiltration. Often, patients present with obstructive jaundice, and imaging reveals stenoses of the extrahepatic or intrahepatic bile ducts, often in association with parenchymal pancreatic findings and irregularities of the pancreatic duct. The histologic findings include lymphoplasmacytic infiltrates, on occasion resulting in tumefactive lesions (which can mimic malignancy), obliterative phlebitis, and fibrotic changes. Steroid treatment is the mainstay of management, but relapse is common after discontinuation of therapy or during tapering of steroids and may require further treatment.
Collapse
Affiliation(s)
- Marina G Silveira
- Division of Gastroenterology and Hepatology, Louis Stokes Cleveland VAMC, Case Medical Center, 10701 East Boulevard, 111E (W), Cleveland, OH 44106, USA.
| |
Collapse
|
12
|
Liu B, Li J, Yan LN, Sun HR, Liu T, Zhang ZX. Retrospective study of steroid therapy for patients with autoimmune pancreatitis in a Chinese population. World J Gastroenterol 2013; 19:569-574. [PMID: 23382638 PMCID: PMC3558583 DOI: 10.3748/wjg.v19.i4.569] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 12/27/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To explore the optimal steroid therapeutic strategy for autoimmune pancreatitis (AIP).
METHODS: This study was conducted retrospectively in two large institutions in China. Patients with clinically, radiologically and biochemically diagnosed AIP were enrolled. The performed radiological investigations and biochemical tests, the regimen of the given steroid treatment, remission and relapse whether with and without steroid therapy were analyzed.
RESULTS: Twenty-eight patients with AIP received steroid treatment, while 40 patients were treated surgically by pancreatoduodenectomy, distal pancreatectomy and choledochojejunostomy, radiofrequency ablation for the enlarged pancreatic head, percutaneous transhepatic biliary drainage and endoscopic biliary drainage. The starting oral prednisolone dose was 30 mg/d in 18 (64.3%) patients and 40 mg/d in 10 (35.7%) patients administered for 3 wk. The remission rate of AIP patients with steroid treatment (96.4%) was significantly higher than in those without steroid treatment (75%). Maintenance therapy (oral prednisolone dose 5 mg/d) was performed after remission for at least 6-12 mo to complete the treatment course. Similarly, the relapse rate was significantly lower in AIP patients with steroid treatment (28.6%) than in those without steroid treatment (42.5%). Steroid re-treatment was effective in all relapsed patients with or without steroid therapy.
CONCLUSION: Steroid therapy should be considered in all patients with active inflammatory phase of AIP. However, the optimal regimen still should be trailed in larger numbers of patients with AIP.
Collapse
|
13
|
|