Fumitake Toki

Chronic pancreatitis caused by an autoimmune abnormality. Proposal of the concept of autoimmune pancreatitis.

SummarySeveral authors have reported a case of chronic pancreatitis associated with Sjögrens syndrome in which an autoimmune mechanism may have been involved in the etrology and in which steroid therapy was effective. We recently encountered a patient with pancreatitis who had hyperglobulinemia, was autoantibody-positive, and responded to steroid therapy. This patient, however, failed to show any evidence of association with Sjögrens syndrome or other collagen diseases. Although the concept of autoimmune hepatitis and the criteria for diagnosing it have been established, autoimmune pancreatitis has not yet been defined as a clinical entity. We report a case of chronic pancreatitis in which an autoimmune mechanism is involved in the etiology and summarize the cases of pancreatitis suspected of being caused by an autoimmune mechanism in the Japanese and English literature.

Pancreatic diseases : Evaluation with MR cholangiopancreatography

Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive diagnostic modality capable of producing high-quality images of the biliary tree and pancreatic duct. We evaluated the MRCP capability of depicting the normal pancreatic duct and, based on data achieved, studied the usefulness in the pathologic pancreatic duct. MRCP was performed in 42 patients without any pancreatic lesion and in 162 patients with pancreatic diseases, including congenital anomalies of biliary tree and pancreatic duct. Results were compared with endoscopic retrograde cholangiopancreatography (ERCP) in 93 patients. The visualization of the pancreatic duct and its branches and the presence or absence of dilatation, stenosis, and filling defects were recorded. All images were interpreted retrospectively and blindly by three radiologists. Among control patients, the main pancreatic duct (MPD) was depicted in the head, body, and tail of the pancreas in 41 (98%), 39 (93%), and 31 (74%), and accessory pancreatic duct and secondary branches in the head, body, and tail of the pancreas were depicted in 11 (26%), eight (19%), four (10%), and two (5%) of these patients. Compared with ERCP, MRCP overestimated the stenosis of MPD and underestimated the dilatation of the branches and filling defects in the pancreatic duct in pancreatic diseases, especially pancreatitis. However, MRCP was distinctly advantageous over ERCP in diagnosing mucin-producing tumor of the pancreas, cystic lesions, and depicting the whole, including the part distal to the obstructed site. Four of the eight cases of pancreas divisum, and 10 of the 12 cases of anomalous pancreaticobiliary duct union also were demonstrated. MRCP can accurately demonstrate the normal pancreatic duct as well as various pancreatic duct abnormalities, including congenital anomalies of the biliary tree and pancreatic duct.

Continuous endoscopic pancreatocholedochal catheterization

The authors describe their technique and experience of inserting and maintaining peroral catheters, placed by endoscopic guidance, in the pancreatic and bile ducts. Such indwelling catheters have permitted extended chemical and cytologic examinations. Further, such catheters have been used for therapeutic lavage and drainage.

Prevalence of pancreatic and biliary tract tumors in pancreas divisum.

BackgroundThe present study was undertaken to evaluate the prevalence of pancreatic and biliary tract tumors in pancreas divisum (PD).MethodsA retrospective single-center study was performed, and a total of 118 cases of complete PD and 7850 cases of fused pancreas were identified among the 8537 consecutive new endoscopic retrograde cholangiopancreatography (ERCP) examinations performed between 1980 and 2002. The prevalence of pancreatic cancer (PCA), intraductal papillary mucinous neoplasms (IPMNs), other pancreatic tumors, and biliary tract cancer in the patients with PD and the patients with a fused pancreas were compared.ResultsThe prevalence of the pancreatic tumors in the PD patients was: PCA, 10%; IPMN, 5.1%; other pancreatic tumors, 2.5%. The prevalence of pancreatic tumors in the patients with a fused pancreas was: PCA, 4.8%; IPMN, 2.6%; and other pancreatic tumors, 1.1%. The prevalence of PCA was significantly higher in the patients with PD than in those with a fused pancreas (P = 0.008; OR, 2.24). The percentages of PD patients with PCA who had pancreatic-type pain and a serum pancreatic enzyme elevation were significantly higher than among the PD patients without PCA. The prevalence of biliary tract cancer was 0.8% in the PD group and 5.3% in the fused pancreas group, and it was significantly lower in PD than in fused pancreas (P = 0.031).ConclusionsThe results of this study showed a significantly higher prevalence of PCA in PD than in fused pancreas. We concluded that patients with PD, especially patients presenting with pancreatic-type pain and pancreatic enzyme elevation, should be carefully followed up because of the risk of developing PCA.

Case Report: Nonfunctioning Islet Cell Tumor with a Unique Pattern of Tumor Growth

Pancreatic endocrine tumors are re lative ly rare . Unlike peptide -hormone-producing tumors, nonfunctioning isle t ce ll tumors are dif® cult to detect until they are large enough to cause symptoms such as abdominal pain, jaundice , and abdominal mass (1± 4) . As nonfunctioning isle t cell tumors have a highe r incide nce of malignanc y, patients tend to be found at more advance d stage s, with metastase s in the live r and lymph node s. They are usually diagnose d by abdominal ultrasound (US) and compute d tomography (CT) scanning as a solitary, solid mass in the pancreas (5) . Although compre ssion, stricture , or obstruction of the pancreatic duct by tumors has sometimes be en obse rved during endoscopic re trograde cholangiopancre atography (ERCP), approxim ate ly 50% of patients with nonfunctioning isle t ce ll tumors have normal pancre atic ducts (6, 7). However, a few case s of isle t cell tumors growing into the main pancreatic duct (MPD) have been reported (8) . We present a case of nonfunc tioning isle t ce ll tumor unique ly growing within the entire lumen of the MPD and describe the re sults of the histological studie s to identify the origin of the tumor.

Embryological Fusion Between the Ducts of the Ventral and Dorsal Primordia of the Pancreas Occurs in Two Manners

The junction between the main pancreatic duct and the accessory duct has been thought to be the site of fusion between the ducts of the ventral and the dorsal primordia of the pancreas. The aim of this study was to investigate the fusion point between the ventral and the dorsal pancreatic ducts and to determine whether there is any relationship between the configuration of the pancreatic ducts and the manner of embryological fusion. Pancrea-tography was performed at 22 consecutive autopsies. Immunohistochemical staining of pancreatic polypeptide (PP) was performed because PP cells were rich in the ventral pancreas but poor in the dorsal pancreas. We identified two types of fusion. In one type, the ventral and the dorsal pancreatic ducts fuse at their junction (one-point fusion). In the other type, the two ducts fuse not only at the proximal site but at a second, more distal site (two-point fusion). Analysis of the pancreatograms showed that the distance between the junction and the major papilla in two-point fusion is significantly shorter than in one-point fusion (p < 0.01). These results indicate a close correlation between the pattern seen on pancreatograms and the manner of embryological fusion.

MORE ACCURATE PREDICTION OF POST‐ERCP PANCREATITIS BY 4‐H SERUM LIPASE LEVELS THAN AMYLASE LEVELS

Background:  The aim of the present study was to evaluate and compare 4‐h post‐endoscopic retrograde cholangiopancreatography (ERCP) hyperamylasemia and hyperlipasemia as predictors of post‐ERCP pancreatitis.

Pancreatogram of Unfused Pancreatic Duct Systems

Abstract: The aim of this study was to indirectly evaluate functional aspects of the accessory papilla, by measuring the diameter of the dorsal duct in non‐fusion (pancreas divisum). In 56 patients with definite non‐fusion, the diameter of the duct on ERCP was measured with a caliper rule, in the ventral duct (V1, V2), in the head of the dorsal duct (Dh1, Dh2), the body (Dbl, Db2), and the tail (Dt1, Dt2). The controls were 61 consecutive patients with a normally fused pancreatic duct system. The mean value ± SD were V1:2.0±1.1, V2:1.7±0.8, Dh1:2.5±0.6, Dh2:2.6±0.8, Dbl:2.7±0.8, Db2: 2.1 ±0.5, Dt1: 1.7±0.5, Dt2: 0.9±0.2 in the non‐fusion group. The values in the control group were 3.4±0.9, 3.0±0.8, 1.0±0.3, 1.3±0.4, 2.6±0.6, 2.3±0.6, 1.6 ± 0.3, 0.9 ± 0.2, respectively. Results showed that the diameter of the pancreatic duct was significantly related to the age of the patient in the body and tail of the non‐fusion group but not in the controls (p<0.05). The diameter of the ventral duct in the control group was related to the age but not in the non‐fusion group (p<0.0001).

Prediction of Post-ERCP Pancreatitis

Diagnostic accuracy in regard to biliary and pancreatic diseases has improved markedly since the introduction of computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP)(1,2), but detection of small bile duct cancers and small pancreatic cancers is difficult even by those modalities. Endoscopic retrograde cholangiopancreatography (ERCP) remains the most accurate and reliable procedure for cytodiagnosis and precise staging of biliary and pancreatic neoplasms, and it is indispensable to the endoscopic treatment of biliary and pancreatic diseases.

Usefulness of Intraductal Ultrasonography (IDUS) for Diagnosing Mucin‐producing Pancreatic Tumors

Abstract: While it is very important to detect protruded lesions in order to determine the optimal treatment modality for mucin‐producing tumors of the pancreas (MPT), it can be very difficult to discriminate between mucinous substance and tumor. Intraductal ultrasonography (IDUS) (2.0 mm diameter, 15 or 20 MHz) was performed in five MPT cases. The sizes of the tumors were 2, 5, 12, 12 and 30 mm. Histological findings of the resected specimens demonstrated adenocarcinoma in two cases, adenoma in one, and hyperplasia in one. IDUS visualized all tumors, i. e. the visualization rate was 100%. The visualization rate for US and CT was 40% with 12 and 30 mm tumors, and that for EUS was 60% with 2, 12, and 30 mm tumors. We found IDUS to be a very useful method for visualizing small protruded lesions in MPT.