Kamraan Madhani

Autoimmune Pancreatitis: An Update on Diagnosis and Management

There is an evolving understanding that autoimmune pancreatitis (AIP) is an immunoglobulin (Ig) G4 systemic disease. It can manifest as primarily a pancreatic disorder or in association with other disorders of presumed autoimmune cause. Classic clinical characteristics include obstructive jaundice, abdominal pain, and acute pancreatitis. Thus, AIP can be difficult to distinguish from pancreatic malignancy. However, AIP may respond to therapy with corticosteroids, and has a strong association with other immune mediated diseases. Although primarily a pathologic diagnosis, attempts have been made to reliably diagnose AIP clinically. AIP can be classified as either type 1 or type 2.

Zollinger-Ellison Syndrome: A Rare Case of Chronic Diarrhea.

Zollinger-Ellison syndrome (ZES) is caused by hypersecretion of gastrin from duodenal or pancreatic gastrinomas. We report a case of a 57-year-old female who presented with chronic diarrhea. CT abdomen showed multiple liver masses. Liver biopsy suggested metastatic well-differentiated neuroendocrine tumor. Serum gastrin level was markedly elevated. MRI abdomen, somatostatin receptor scintigraphy and endoscopic ultrasound failed to reveal primary site of the tumor. Upper gastrointestinal endoscopy showed hyperplastic gastric folds and multiple duodenal ulcers consistent with ZES. Patient was started on high-dose omeprazole and octreotide resulting in improvement in diarrhea.

Management of Autoimmune Pancreatitis

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.

Whipple's Disease Manifested as Recurrent Ascites

Whipple’s disease commonly presents as chronic diarrhea and abdominal pain. Ascites is an uncommon presentation of Whipple’s disease. Here, we report a rare case of a 47-year-old male who presented with diarrhea and abdominal distention for three months. The physical examination was significant for ascites. Serum albumin was low and serum-to-ascites albumin gradient was < 1.1 g/dl. This suggested that ascites was less likely to be present due to portal hypertension. Enteroscopy showed erythematous duodenum and jejunum; biopsy was suggestive of periodic acid-Schiff stain (PAS) positive macrophages consistent with Whipple’s disease. During the hospital course, the patient improved with intravenous (IV) ceftriaxone.

Hepatitis C Screening: The Downstream Dissemination of Evolving Guidelines in a Resident Continuity Clinic

Background In 2012, the Centers for Disease Control and Prevention (CDC) published guidelines supporting one-time screening for hepatitis C (HCV) in all persons born between 1945 and 1965. It is estimated that 75% of adults infected with HCV fall within this cohort. Furthermore, it is projected that this preventative health intervention would lead to the diagnosis of 800,000 unknown cases and the prevention of 120,000 deaths. Objectives The primary objectives are to measure adherence to HCV screening in a continuity practice staffed by internal medicine residents and attending physicians and to measure the effect of educational interventions to enhance HCV screening. The secondary objectives include finding whether insurance or provider status affects adherence to HCV screening. Methods In 2015, we performed a retrospective chart review of asymptomatic patients born between 1945 and 1965 to estimate the rate of HCV screening. In order to meet inclusion criteria, the patients must have had an HCV status that was unknown and must have been seen by a primary care provider ≥ 2 times between January 1 and December 31, 2013. The data extracted included whether HCV testing was ordered, whether testing was performed primarily for screening purposes, demographic information, insurance status, number of clinic visits, and whether the primary provider was a resident or attending physician. Subsequently, in 2016 we implemented an educational intervention aimed at improving these rates. Afterwards, we repeated the chart review to determine if screening rates had improved. Results Out of 294 patients reviewed pre-intervention, 200 patients were eligible for inclusion, of which 17 (8.5%) patients were offered screening for HCV, of which 13 (76.5%) patients completed testing. Following an educational intervention, 484 patients were reviewed and 100 patients were included, of which 34 (34%) patients were screened. Compared to a pre-intervention screening rate of 8.5%, post-intervention screening had improved to 34%, a 300% increase (p<0.001). Conclusions Educational interventions are feasible and can lead to significant improvements in clinical practice enabling for the rapid dissemination of evolving guidelines.

Tu1468 Evaluation of International Consensus Diagnostic Criteria in the Diagnosis of Autoimmune Pancreatitis: A Single Center North American Cohort Study

Context In 2011, an international symposium on Autoimmune Pancreatitis produced the International Consensus Diagnostic Criteria, which can be used to stratify patients with autoimmune pancreatitis as having type 1, type 2, or autoimmune pancreatitis – not otherwise specified. There are few studies examining the application of International Consensus Diagnostic Criteria to a cohort of North American patients with autoimmune pancreatitis. Objectives To apply International Consensus Diagnostic Criteria to a cohort of 51 patients with autoimmune pancreatitis followed at a North American medical center. To compare International Consensus Diagnostic Criteria with other guidelines with emphasis on patients who were unclassifiable using International Consensus Diagnostic Criteria. Design We applied International Consensus Diagnostic Criteria using clinical-radiological-pathological features. We reevaluated patients who were unclassifiable per ICDC with Japanese Pancreatic Society-2006, HISORt, Korean, Asian, and JPS-2011 guidelines. We statistically compared type 1, type 2, and unclassifiable patients based on demographic and clinical presentation. T-test and chi-square analysis was used for statistical analysis. Results 37 patients were categorized as definitive type 1 or type 2 autoimmune pancreatitis, 1 patient as probable type 1 autoimmune pancreatitis, and 13 were unclassifiable. Unclassifiable patients had indeterminate/atypical parenchymal imaging or none at all, and 6 patients had elevated serology. Diagnostic endoscopic retrograde cholangio-pancreatography was performed on 6 patients and 1 patient had persistent waxing and waning of clinical and radiologic features. 6 patients could be diagnosed with autoimmune pancreatitis using JPS-2006, Korean, or Asian Criteria, and 4 patients using either HISORt or JPS-2011. There was no statistically significant difference between classifiable and unclassifiable patients based on demographics or clinical presentation. Conclusions The ICDC’s dependence on histology, diagnostic endoscopic retrograde cholangio-pancreatography, and lack of acknowledgment of waxing-waning features limits applicability. Our cohort evolved during routine practice and we identify discrepancies amongst guidelines.