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ESSENTIALS OF DIAGNOSIS

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ESSENTIALS OF DIAGNOSIS

  • Presentation with obstructive jaundice in 50-65% of patients.

  • Diffuse swelling and enlargement of the pancreas, especially the head, the latter mimicking carcinoma of the pancreas.

  • Diffuse irregular narrowing of the pancreatic duct on endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP).

  • Elevated serum immunoglobulin G4 (IgG4) level.

  • Extrapancreatic and intrahepatic bile duct strictures.

  • Resolution or marked improvement in pancreatic and extrapancreatic manifestations after corticosteroid treatment.

  • Pancreatic biopsies reveal extensive fibrosis and lymphoplasmacytic infiltration.

  • HISORT criteria used to establish the diagnosis.

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GENERAL CONSIDERATIONS

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Autoimmune pancreatitis is a rare disorder of presumed autoimmune causation with characteristic chemical, histologic, and morphologic findings. It is referred to by various names, including nonalcoholic destructive pancreatitis, tumefactive pancreatitis, and sclerosing pancreatitis, depending in part on specific pathologic findings and on the presence of extrapancreatic manifestations. However, it is believed that the pathologic heterogeneity may reflect different stages or manifestations of the same disease.

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Autoimmune pancreatitis has been described as a primary pancreatic disorder and is also associated with other disorders of presumed autoimmune etiology, including primary sclerosing cholangitis, primary biliary sclerosis, retroperitoneal fibrosis, rheumatoid arthritis, and Sjögren syndrome. As a result, it has been proposed that autoimmune pancreatitis represents a systemic autoimmune disease.

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Finkelberg  DL, Sahani  D, Deshpande  V  et al.. Autoimmune pancreatitis. N Engl J Med. 2006;355:2670–2676.
[PubMed: 17182992]  

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CLINICAL FINDINGS

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A. Symptoms and Signs

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Mild symptoms, usually abdominal pain, are present but attacks of acute pancreatitis are unusual. Furthermore, autoimmune pancreatitis is not a common cause of idiopathic recurrent pancreatitis. In the United States, 50–65% of patients with autoimmune pancreatitis present with obstructive jaundice. Weight loss and new onset of diabetes may also occur. Patients who have associated autoimmune conditions have corresponding clinical features. In this regard, Sjögren syndrome, rheumatoid arthritis, retroperitoneal fibrosis, ulcerative colitis, autoimmune thyroiditis, tubulointerstitial nephritis, and mediastinal adenopathy have all been reported in patients with autoimmune pancreatitis (Tables 28–1 and 28–2).

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Table Graphic Jump Location
Table 28–1.Clinical features of autoimmune pancreatitis.

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