Top

Langenbeck's Archives of Surgery

Published in:

01-02-2005 | Original Article

T cell lymphoplasmacellular and eosinophilic infiltration of the pancreas with involvement of the gallbladder and duodenum in non-alcoholic duct-destructive chronic pancreatitis

Authors: N. Alexakis, F. Campbell, N. Eardley, H. L. Smart, C. Garvey, J. P. Neoptolemos

Published in: Langenbeck's Archives of Surgery | Issue 1/2005

Abstract

Background

Non-alcoholic duct destructive chronic pancreatitis is a rare entity with specific pathological features. The majority of the patients are from Japan. We report a case with involvement of the distal bile duct, the gallbladder, the duodenum and the ampulla, and present a review of patients from Europe and the USA since 1997.

Case presentation

A 56-year-old man presented with a 3-month history of mild acute pancreatitis and obstructive jaundice, followed by increasing weight loss, lethargy and epigastric pain. CT showed a mass in the head of the pancreas. ERCP demonstrated a smooth stricture of the intra-pancreatic main bile duct and an irregular, incomplete, stricture in the main pancreatic duct. A pancreatic cancer could not be reliably excluded, and, therefore, he underwent a pylorus-preserving Kausch–Whipple’s pancreatoduodenectomy.

Results

Histopathology showed typical peri-ductal T cell-rich lymphoplasmacellular and eosinophilic infiltration of the pancreas, with involvement of the distal bile duct but, also, unusual inflammatory infiltration of the gallbladder, the duodenum and the ampulla.

Conclusion

The inflammatory process in non-alcoholic duct-destructive chronic pancreatitis can affect the entire pancreato-biliary region and mimics pancreatic cancer. Currently, there are no definitive criteria for pre-operative diagnosis, so it is very difficult for one to avoid resection.

Horiuchi A, Kawa S, Hamano H, Hayashi Y, Kiyosawa K (2001) Does a lack of reactivity to alpha-fodrin indicate the existence of primary autoimmune pancreatitis? Am J Gastroenterol 97:1275–1277CrossRef

Kawa S, Ota M, Yoshizawa K, Horiuchi A, Hamano H, Ochi Y, Nakayama K, Tokutabe Y, Katsuyama Y, Saito S, Hasebe O, Kiyosawa K (2002) HLA DRB10405-DQB10401 haplotype is associated with autoimmune pancreatitis in the Japanese population. Gastroenterology 122:1264–1269PubMed

Okazaki K, Uchida K, Chiba T (2001) Recent concept of autoimmune-related pancreatitis. J Gastroenterol 36:293–302CrossRefPubMed

Okazaki K, Chiba T (2002) Autoimmune related pancreatitis. Gut 51:1–4CrossRefPubMed

Yoshida K, Toki F, Takeuchi T, Watanabe S, Shiratori K, Hayashi N (1995) Chronic pancreatitis caused by an autoimmune abnormality. Proposal of the concept of autoimmune pancreatitis. Dig Dis Sci 40:1561–1568

Ectors N, Maillet B, Aerts R, Geboes K, Donner A, Borchard F, Lankisch P, Stolte M, Luttges J, Kremer B, Kloppel G (1997) Non-alcoholic duct destructive chronic pancreatitis. Gut 41:263–268PubMed

Hardacre J, Iacobuzio-Donahue C, Sohn T, Abraham S, Yeo C, Lillemoe K, Choti M, Campbell K, et al (2003) Results of pancreaticoduodenectomy for lymphoplasmacytic sclerosing pancreatitis. Ann Surg 237:853–859CrossRefPubMed

Weber S, Cubukcu-Dimopulo O, Palesty A, Suriawinata A, Klimstra D, Brennan M, Conlon K (2003) Lymphoplasmacytic sclerosing pancreatitis: inflammatory mimic of pancreatic carcinoma. J Gastrointest Surg 7:129–139CrossRefPubMed

Okazaki K, Uchida K, Ohana M, Nakase H, Uose S, Inai M, Matsushima Y, Katamura K, Ohmori K, Chiba T (2000) Autoimmune-related pancreatitis is associated with autoantibodies and a Th1/Th2-type cellular immune response. Gastroenterology 118:573–581PubMed

10.

Ichimura T, Kondo S, Ambo Y, Hirano S, Ohmi M, Okushiba S, Morikawa T, Shimizu M, Katoh H (2002) Primary sclerosing cholangitis associated with autoimmune pancreatitis. Hepatogastroenterology 49:1221–1224PubMed

11.

Sheikh S, Shaw-Stiffel T (1995) The gastrointestinal manifestations of Sjögren’s syndrome. Am J Gastroenterol 90:9–14PubMed

12.

Uchida K, Okazaki K, Konishi Y, Ohana M, Takakuwa H, Hajiro K, Chiba T (2000) Clinical analysis of autoimmune-related pancreatitis. Am J Gastroenterol 95:2788–2794CrossRefPubMed

13.

Irie H, Honda H, Baba S, Kuroiwa T, Yoshimitsu K, Tajima T, Jimi M, Sumjj T, Masuda K (1998) Autoimmune pancreatitis: CT and MR characteristics. AJR Am J Roentgenol 170:1323–1327

14.

Procacci C, Carbognin G, Biasiutti C, Frulloni L, Bicego E, Spoto E, El-Khaldi M, Bassi C, Pagnotta N, Talamini G, Cavallini G (2001) Autoimmune pancreatitis: possibilities of CT characterization. Pancreatology 1:246–253CrossRefPubMed

15.

Van Hoe L, Gryspeerdt S, Ectors N, Van Steenbergen W, Aerts R, Baert A, Marchal G (1998) Non-alcoholic duct destructive chronic pancreatitis: imaging findings. AJR Am J Roentgenol 170:643–647

16.

Eerens I, Vanbeckevoort D, Vansteenbergen W, Van Hoe L (2001) Autoimmune pancreatitis associated with primary sclerosing cholangitis: MR imaging findings. Eur Radiol 11:1401–1404CrossRefPubMed

17.

Horiuchi A, Kawa S, Hamano H, Hayama M, Ota H, Kiyosawa K (2002) ERCP features in 27 patients with autoimmune pancreatitis. Gastrointest Endosc 55:494–499CrossRefPubMed

18.

Bogomoletz W (1997) Duct destructive chronic pancreatitis. A new insight into the pathology of idiopathic non-alcoholic chronic pancreatitis. Gut 41:272–273PubMed

19.

Scully K, Li S, Hebert J, Trainer T (2000) The characteristic appearance of non-alcoholic duct destructive chronic pancreatitis: a report of 2 cases. Arch Pathol Lab Med 124:1535–1538PubMed

20.

Kamisawa T, Funata N, Hayashi Y, Tsuruta K, Okamoto A, Amemiya K, Egawa N, Nakajima H (2003) Close relationship between autoimmune pancreatitis and multifocal fibrosclerosis. Gut 52:683–687CrossRefPubMed

21.

Notohara K, Burgart L, Yadav D, Chari S, Smyrk T (2003) Idiopathic chronic pancreatitis with periductal lymphoplasmacytic infiltration. Am J Surg Pathol 27:1119–1127CrossRefPubMed

22.

Kloppel G, Maillet B (1993) Pathology of acute and chronic pancreatitis. Pancreas 8:659–670PubMed

23.

Chung J, Na S, Park Y, Yu J, Yoon D, Lee S, Song S, Lee K, Chung J, Lee S, Kang J (1999) Non alcoholic duct destructive chronic pancreatitis: recognition before definitive treatment. Yonsei Med J 40:518–522PubMed

24.

Horiuchi A, Kaneko T, Yamamura N, Nagata A, Nakamura T, Akamatsu T, Mukawa K, Kawa S, Kiyosawa K (1996) Autoimmune chronic pancreatitis simulating pancreatic lymphoma. Am J Gastroenterol 91:2607–2609PubMed

25.

Koga Y, Yamaguchi K, Sugitani A, Chijiiwa K, Tanaka M (2002) Autoimmune pancreatitis starting as a localized form. J Gastroenterol 37:133–137CrossRef

26.

Ohana M, Okazaki K, Hajiro K, Kobashi Y (1998) Multiple pancreatic masses associated with autoimmunity. Am J Gastroenterol 93:99–102CrossRefPubMed

27.

Servais A, Pestieau S, Detry O, Honore P, Belaiche J, Boniver J, Jacquet N (2001) Autoimmune pancreatitis mimicking cancer of the head of pancreas: report of two cases. Acta Gastroenterol Belg 64:227–230PubMed

28.

Taniguchi T, Seko S, Azuma K, Tamegai M, Nishida O, Inoue F, Okamoto M, Mizumoto T, Kobayashi H (2000) Autoimmune pancreatitis detected as a mass in the tail of the pancreas. J Gastroenterol Hepatol 15:461–464CrossRefPubMed

29.

Taniguchi T, Seko S, Azuma K, Tamegai M, Nishida O, Inoue F, Okamoto M, Mizumoto T, Kobayashi H (2001) Autoimmune pancreatitis detected as a mass in the head of the pancreas with contiguous fibrosis around the superior mesenteric artery. Dig Dis Sci 46:187–191CrossRefPubMed

30.

Venu R, Radke J, Brown R, Deutsch S, Zaytsev P, Miyaji E, Nishimori E (1999) Autoimmune pancreatitis, pancreatic mass, and lower gastrointestinal bleed. J Clin Gastroenterol 28:364–367CrossRefPubMed

31.

Hamano H, Kawa S, Horiuchi A, Unno H, Furuya N, Akamatsu T, Fukushima M, Nakaido T, Nakayama K, Usuda N, Kiyosawa K High serum IgG4 concentrations in patients with sclerosing pancreatitis. N Engl J Med 344:732–738CrossRefPubMed

32.

Khalid A, Whitcomb D (2001) The importance of autoimmune pancreatitis. Gastroenterology 121:1518–1520PubMed

33.

Farell R, Jain A, Brandwein S, Wang H, Chuttani R, Pleskow D (2001) The combination of stricture dilation, endoscopic needle aspiration and biliary brushings significantly improves diagnostic yield from malignant bile duct strictures. Gastrointest Endosc 54:587–594CrossRefPubMed

34.

Pugliese V, Pujic N, Saccomanno S, et al (2001) Pancreatic intraductal sampling during ERCP in patients with chronic pancreatitis and pancreatic cancer: cytologic studies and K-ras-2 codon 12 molecular analysis in 47 cases. Gastrointest Endosc 54:595–599CrossRefPubMed

35.

Smith C, Behrns K, van Heerden J, Sarr M (1994) Radical pancreatoduodenectomy for misdiagnosed pancreatic mass. Br J Surg 81:585–589PubMed

36.

Van Gulik T, Reeders J, Bosma A, et al (1997) Incidence and clinical findings of benign, inflammatory disease in patients resected for presumed pancreatic carcinoma. Gastrointest Endosc 46:417–423PubMed

37.

Neoptolemos JP, Russell RC, Bramhall S, et al (1997) Low mortality following resection for pancreatic and periampullary tumours in 1026 patients: UK survey of specialist pancreatic units. UK pancreatic cancer group. Br J Surg 84:1370–1376CrossRefPubMed

38.

Ito T, Nakano I, Koyanagi S, Miyahara T, Migita Y, Ogoshi K, Sakai H, Matsunaga S, Yasuda O, Sumii T, Nawata H (1997) Autoimmune pancreatitis as a new clinical entity. Three cases of autoimmune pancreatitis with effective steroid therapy. Dig Dis Sci 42:1458–1468

39.

Kuroiwa T, Suda T, Takahashi T, Hirono H, Natsui M, Motoyama H, Nomoto M, Aoyagi Y (2002) Bile duct involvement in a case of autoimmune pancreatitis successfully treated with an oral steroid. Dig Dis Sci 47:1810–1816CrossRefPubMed

40.

Erkelens G, Vieggaar F, Lesterhuis W, van Buuren H, van der Werf S (1999) Sclerosing pancreato-cholangitis responsive to steroid therapy. Lancet 354:43–44CrossRefPubMed

41.

Tanaka S, Kobayashi T, Nakanishi K, Okubo M, Odawara M, Murase T, Hashimoto M, Watanabe G, Matsushita H, Inoko H, Takeuchi K (2002) Corticosteroid-responsive diabetes mellitus associated with autoimmune pancreatitis: pathological examinations of the endocrine and exocrine pancreas. Ann N Y Acad Sci 958:152–159PubMed

Title: T cell lymphoplasmacellular and eosinophilic infiltration of the pancreas with involvement of the gallbladder and duodenum in non-alcoholic duct-destructive chronic pancreatitis
Authors: N. Alexakis
F. Campbell
N. Eardley
H. L. Smart
C. Garvey
J. P. Neoptolemos
Publication date: 01-02-2005
Publisher: Springer-Verlag
Published in: Langenbeck's Archives of Surgery / Issue 1/2005
Print ISSN: 1435-2443
Electronic ISSN: 1435-2451
DOI: https://doi.org/10.1007/s00423-003-0450-y

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

T cell lymphoplasmacellular and eosinophilic infiltration of the pancreas with involvement of the gallbladder and duodenum in non-alcoholic duct-destructive chronic pancreatitis

Abstract

Background

Case presentation

Results

Conclusion

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Case presentation

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 1/2005

Management strategies for patients with nipple discharge

Rectal prolapse: which surgical option is appropriate?

Pitfalls and complications in the use of the proximal femoral nail

Safe closure technique for distal pancreatic resection

Anal fissure: the changing management of a surgical condition

Diabetes mellitus: a risk factor for pancreatic cancer?