Pancreatic pseudocyst in autoimmune pancreatitis Kyung-Ae Chang Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu, Korea

53/M C/C: Abdominal discomfort for 1wk P/I: 상기 증상으로 LMC 방문하여 Abdo.CT check 후 r/o pancreatic head ca. imp으로 본원 GS로 transfer. PMHx: N-S SHx: Alcohol(+); 소주 1병/회*4회/월*30년 Smoking(+); 1갑*30년 FHx: N-S

ROS : Abdominal discomfort(+), itching sensation (+) P/E : Icteric sclera (+), Epigastric and RUQ mild tenderness (+) Lab: CBC 4090/12.1/183K AST/ALT 228/386, TB/DB 7.7/5.5 ALP/GGT 757/203, Amylase 191 TP/Alb 6.61/3.5, Glu 110 AFP,CEA,CA19-9,CA125; W.N.L V/S: BP 110/70mmHg, BT 36.5℃ PR 72회/min, RR 20회/min

2004.12.21.Abdo.CT

2004.12.23. ERCP

2004.12.23.ERCP

IMP: R/O CBD malignancy R/O Choledochal cyst 환자 further evaluation refuse 하고 전원 원하여 CT & ERCP copy하여 transfer.

2005.1.6. Outside CT

2005.4.21. Outside ERCP

2005.4.21.Outside ERCP

2005.4.21. Outside ERCP

2005.6.28. Outside ERCP

2005.6.28.Outside ERCP

2005.6.28. Outside ERCP

2005.8.13. Outside CT

2008.10.28. Abdominal pain 으로 ER 통해 Admission. V/S: BP 100/60mmHg, BT 37.4℃, PR 84회/min, RR 20회/min Lab: CBC 8680/15.4/271K TB/DB 1.26/0.26 AST/ALT 28/38 ALP/GGT 437/208, Amylase/Lipase 400/93.8, Glu 401

2008.10.28.Abdo.CT

2008.10.28.Abdo.CT

2008.11.4.ERCP

Pancreatic pseudocyst interanl drainage시행 후 abdominal pain 점차 감소하고 PO 시작한 후에도 pain 없어 Nisolon 40mg qd and ciprobay 250mg bid 처방 후 D/C & OPD F/U. PD 30mg PO하면서 OPD F/U 중 2008.11.16. abdominal pain으로 ER 통해 admission.

V/S: BP 100/60mmHg, BT 37.4℃ PR 84회/min, RR 20회/min Lab: CBC 18220/13.6/424K AST/ALT 41/32, TB/DB 1.54/0.83 ALP/GGT 593/201, Amylase/Lipase 243/26 , Glu 88

2008.11.16.Abdo.CT

2008.11.18.ERCP

2009.1.19.Abdo.CT

2009.1.20.ERCP

Autoimmune pancreatitis The first report was in 1961,in a case report of a patient with pancreatitis and hypergammaglobulinemia. Early reports noted chronic pancreatitis characterized by the presence of autoantibodies, elevated levels of Ig, enlargement of the pancreas(diffuse or focal), pancreatic duct strictures, and pathologic features of a dense lymphocytic infiltrate.

Diganotic crierias In 1995, Yoshida et al. summarized the characteristics of AIP: 1)increased serum gammaglobulin or IgG levels, 2)presence of autoantibodies, 3)diffuse enlargement of the pancreas, 4)diffuse irregular narrowing of the main pancreatic duct on ERP, 5)fibrotic changes with lymphocytic infiltration of the pancreas on histopathological exam, 6)no sx or only mild sx, usually with no history of acute attacks of pancreatitis,

7)Stenosis of the CBD in the pancreas, with dilatation of the bile duct upstream and frequent occurrence of cholestatic liver dysfunction and hyperbilirubinemia, 8)no pancreatic calcification, 9)no pancreatic cysts, 10)occasional association with other autoimmune ds, 11)Effectives of steroid therapy.

Japan Pancreas Society in 2002: 1)imaging studies showing diffuse narrowing of the main pancreatic duct, with an irregular wall(more than one-third the length of the entire pancreas) and enlargement of the pancreas, 2) lab; abnl elevated levels of serum gammaglobulin and/or IgG, or the presence of autoantibodies, 3)histopathologic exam; fibrotic changes with lymphocyte and plasma cell infiltration.

Japan revised 2006

Korea 2007

Mayo clinic 2006

Asian criteria 2008

Presence of extrapancreatic lesion Imaging factor(6) : CT Delayed enhancement Capsule like rim ERCP Narrowed portion of MPD > 3cm Skipped lesions of MPD Maximal diameter < 5mm of upstream MPD Presence of extrapancreatic lesion Kamisawa et al Pancreas 2008:37;e62-67

Consensus of Treatment in Japan

Rate of complete remission with or without steroid Tetsuhido Ito et el J Gastroenterol 2007;42;50-58

Time necessary to complete remission Tetsuhido Ito et el J Gastroenterol 2007;42;50-58