Viktória Terzin

Autoimmune pancreatitis in Hungary: A multicenter nationwide study

Background: To date, most cases of autoimmune pancreatitis (AIP) have been reported from Japan. The aim of the present study was to assess the clinical features and management of AIP cases in Hungary. Methods: The demographics, clinical presentation, laboratory and imaging findings, extrapancreatic involvement, treatment response and recurrence were evaluated in the first 17 patients diagnosed with AIP in Hungary. Results: The mean age at presentation was 42.7 years (range: 16–74); 47% of the patients were women. New-onset mild abdominal pain (76%), weight loss (41%) and jaundice (41%) were the most common symptoms, with inflammatory bowel disease being the most frequent (36%) extrapancreatic manifestation. Diffuse pancreatic swelling was seen in 7 patients (41%) and a focal pancreatic mass in 8 (47%). Endoscopic retrograde cholangiopancreatography revealed pancreatic duct strictures in all study patients. The serum IgG4 level at presentation was elevated in 62% of the 8 patients in whom it was measured. All the percutaneous core biopsies (5 patients) and surgical specimens (2 patients), and 2 of the 4 biopsies of the papilla of Vater revealed the typical characteristic findings of AIP: a diffuse lymphoplasmacytic infiltration, marked interstitial fibrosis and obliterative phlebitis. Immunostaining indicated IgG4-positive plasma cells in 62% of the 8 patients in whom it was performed. Granulocytic epithelial lesions (GEL) were present in 3 patients. The patients without GELs were older (mean age 59 years), while those with GEL were younger (mean age 34 years), and 2 of 3 were female and had ulcerative colitis. A complete response to steroid treatment was achieved in all 15 patients. Because of the suspicion of a pancreatic tumor, 2 patients with focal AIP underwent partial pancreatectomy. One patient relapsed, but responded to azathioprine. Conclusions: This first Hungarian series has confirmed several previously reported findings on AIP. AIP with GEL was relatively frequent among our patients: these patients tended to be younger than in earlier studies and displayed a female preponderance with a high coincidence of ulcerative colitis. Performance of a percutaneous biopsy is strongly recommended. The response to immunosuppressive therapy was excellent.

Hypertriglyceridemia causes more severe course of acute pancreatitis

Abstract Aim: To assess the clinical features and management of hypertriglyceridemia (HTG)-induced acute pancreatitis(AP). Patients & methods: Patients with AP and serum triglyceride levels of >11.3 mmol/l were included.Results: HTG-induced AP accounted for 6.28% of the total number of AP cases. HTG-induced AP patients were significantly younger and there was a male preponderance compared with non-HTG-induced pancreatitic patients.Antilipemic therapy lowered triglyceride levels from 44.78 ± 6.26 to 3.59 ± 0.3 mmol/l in the HTG-induced APgroup. Amylase levels were elevated three-times over normal levels in only 23.1% of HTG-induced AP patients.Severe prognosis, pancreatic necrosis, sepsis and local complications were more frequent and the length ofhospitalization was significantly longer in the HTG-induced AP compared with AP with other etiologies. Conclusion:HTG-induced AP seems to be more severe than AP of other causes. Levels of serum amylase may be normal oronly minimally elevated.

Association between autoimmune pancreatitis and systemic autoimmune diseases

AIM To investigate the association between autoimmune pancreatitis (AIP) and systemic autoimmune diseases (SAIDs) by measurement of serum immunoglobulin G4 (IgG4). METHODS The serum level of IgG4 was measured in 61 patients with SAIDs of different types who had not yet participated in glucocorticosteroid treatment. Patients with an elevated IgG4 level were examined by abdominal ultrasonography (US) and, in some cases, by computer tomography (CT). RESULTS Elevated serum IgG4 levels (919 ± 996 mg/L) were detected in 17 (28%) of the 61 SAID patients. 10 patients had Sjögrens syndrome (SS) (IgG4: 590 ± 232 mg/L), 2 of them in association with Hashimotos thyroiditis, and 7 patients (IgG4: 1388 ± 985.5 mg/L) had systemic lupus erythematosus (SLE). The IgG4 level in the SLE patients and that in patients with SS were not significantly different from that in AIP patients (783 ± 522 mg/L). Abdominal US and CT did not reveal any characteristic features of AIP among the SAID patients with an elevated IgG4 level. CONCLUSION The serum IgG4 level may be elevated in SAIDs without the presence of AIP. The determination of serum IgG4 does not seem to be suitable for the differentiation between IgG4-related diseases and SAIDs.

Sepsis and hepatitis together with herpes simplex esophagitis in an immunocompetent adult.

Herpes simplex virus (HSV)‐induced sepsis affects immunocompromised patients. We report here the case of an immunocompetent adult with sepsis, hepatitis, renal failure and esophagitis. The possibility of HSV should be considered in cases of sepsis without any evident cause, even in immunocompetent patients. The characteristic endoscopic and histological findings of the associated esophagitis may assist the etiology of sepsis.

Improved glycemic control in pancreatic diabetes through intensive conservative insulin therapy

OBJECTIVE The aim of this study was to evaluate the effectivity and safety of insulin therapy in patients with DM secondary to underlying chronic pancreatitis with initially inappropriate glycemic control. METHODS Pancreatic DM patients treated with oral antidiabetics (OAD) or pre-mixed insulin (PMI) with HbA1c ≥7.0% were recruited. Intensive conservative insulin treatment (ICT) (Group A, n = 16) or PMI (Group B, n = 8) was introduced instead of OAD, or the initial PMI therapy was switched to ICT (Group C, n = 10). The changes in HbA1c, fasting plasma glucose, body weight and hypoglycemic events from baseline to 2 years were followed. RESULTS The patients in Group A and B had been treated with oral antidiabetics for 55 ± 68 months before switching to insulin therapy. The level of HbA1c had worsened from 8.3 ± 1.5% to 9.8 ± 1.7% during this period. The ICT had reduced HbA1c significantly from 9.7 ± 1.8% to 7.6 ± 1.4% after 12 weeks, in Group A, and five patients had HbA1c<7.0%. The introduction of PMI in Group B reduced HbA1c from 10.0 ± 1.4% to 9.0 ± 0.6% by 12 weeks. None of the patients had HbA1c<7.0%. By 12 weeks, the introduction of ICT in Group C had reduced the level of HbA1c from 8.8 ± 1.7% to 7.7 ± 1.2%. Two patients reached HbA1c<7.0%. There were two severe hypoglycemic episodes during the 2 years, one-one case in Group A and B. CONCLUSIONS Oral medication becomes insufficient early in pancreatic DM. Long-term improvement of glycemic control can be achieved through intensified insulin therapy and in selected cases through PMI with a low risk of hypoglycemia.

Exocrine pancreatic insufficiency in type 1 and type 2 diabetes mellitus: do we need to treat it? A systematic review

The exocrine and endocrine pancreata are very closely linked both anatomically and physiologically. Abdominal symptoms such as nausea, bloating, diarrhea, steatorrhea, and weight loss can often occur in diabetic patients. Impairments of the exocrine pancreatic function seem to be a frequent complication of diabetes mellitus; however, they are largely overlooked. The aim of this paper is to provide an overview of the current concepts of exocrine pancreatic insufficiency (PEI) in diabetes mellitus. The prevalence and symptoms of PEI in diabetes mellitus, the pathomechanism, and difficulties of diagnosis and therapy of PEI are summarized in this systematic review.

[Pancreatic cancer or autoimmune pancreatitis: endosonography as a diagnostic reviser].

Conventional radiologic imaging (abdominal ultrasound, computer tomography) used in the differential diagnosis of post-hepatic jaundice can frequently provide inaccurate diagnosis. Inflammatory lesions may mimic neoplastic processes and malignancy may be accompanied by perifocal inflammation resulting in histological misdiagnosis. Furthermore, chronic and autoimmune pancreatitis are associated with an increased risk for pancreatic cancer. Radial endosonography has become a markedly important method in the imaging of the pancreas. It has a crucial role in the diagnosis and staging of pancreatic cancer. The authors present three cases where the diagnosis of pancreatic cancer determined by conventional imaging techniques (abdominal ultrasound, computer tomography, endoscopic retrograde cholangiopancreatography) was excluded or confirmed by the radial endosonography. The authors conclude that radial endosonography is an essential complementary method among imaging techniques of the pancreas and in tumor staging. Application of that may prevent unnecessary surgeries, which is obviously useful for patients and cost effective for health care providers.

Shall we use endoscopic submucosal dissection for every gastric neoplasia

We read with great interest the article by Kato et al. [1] validating the use of endoscopic submucosal dissection (ESD) for total incisional biopsy in gastric noninvasive neoplasia (NIN) (adenoma with lowor high-grade dysplasia, categories 3 and 4.1 according to the Vienna classification) diagnosed by endoscopic forceps biopsy. ESD revealed adenocarcinoma in 44% of the NIN cases. The largest diameter of the NIN lesions treated with ESD in the study varied between 2 and 55 mm. The rate of complications was reasonably low, and it was concluded that ESD may be a therapeutic option for gastric NIN. The standard treatment of precancerous lesions and early-stage cancers of the gastrointestinal tract is endoscopic mucosal resection (EMR), a minimally invasive technique which is safe, convenient, and efficacious, but which is insufficient for the treatment of larger lesions. ESD was developed to allow the endoscopic resection of large and ulcerative neoplastic lesions that were previously unresectable by conventional EMR [2]. In experienced hands, ESD is superior to EMR for en-bloc resection, complete resection, curative resection, and local recurrence [3]. The effectiveness of EMR for small lesions may be as good as that of ESD. The study by Nakamoto et al. [4] indicated the equivalence of EMR and ESD en-bloc and complete resection rates for intramucosal gastric cancers of B5 mm and the equivalent 5-year recurrence-free rates for intramucosal gastric cancers of B10 mm. Moreover, modification of the standard EMR technique with circumferential mucosal precutting made EMR comparable to ESD for larger lesions. The en-bloc plus R0 resection rates and the local recurrence rates for EMR after circumferential precutting and ESD for early gastric cancer of\20 mm did not differ either [5]. The rate of adenocarcinoma underdiagnosis has risen significantly for large ([21 mm) and depressed lesions [1]. Therefore, it appears logical that small and elevated gastric lesions, in which the possibility of the presence of carcinoma is low, and where the efficacies of EMR and ESD methods are comparable, should be removed by EMR. Although the rate of ESD complications such as perforation and bleeding was reported to be relatively low [1], the rate was significantly higher than that for EMR [3], and the duration of the operation was considerably longer for ESD than for EMR [3]. This raises doubts concerning the economic aspects of the use of ESD in NIN. In Japan, the medical insurance system covers the costs of ESD only for gastric cancer. Endoscopic submucosal dissection (ESD), which demands high levels of endoscopic skill and experience, has recently become available at the largest endoscopic centers in the western world. However, ESD is not generally performed outside these centers, in view of the lower incidence of gastric cancer in western countries than in the Far East. In conclusion, we strongly agree that gastric NIN should be endoscopically resected, because it is commonly a premalignant lesion, furthermore malignancy may be detected. However, EMR may be recommended for the removal of small (\5 mm), elevated lesions. For larger or depressed lesions, ESD would be preferred. An answer to this letter to the editor is available at doi: 10.1007/s00535-011-0526-3

Hypertriglyceridaemia okozta akut pancreatitis sajátosságai beteganyagunkban@@@Acute pancreatitis caused by hypertriglyceridemia

UNLABELLED Hypertriglyceridemia is reported to cause 1-7% of the cases of acute pancreatitis. AIM The aim of the present study was to assess the clinical features and management of pancreatitis with hypertriglyceridemia in our tertiary center. METHODS Between 1 January 2007 and 31 December 2009, patients with a diagnosis of hypertriglyceridemia-induced acute pancreatitis were reviewed. Patients with pancreatitis and serum triglyceride levels greater than 11.3 mmol/l (≈1000 mg/dl) were included. Acute pancreatitis with other etiologies was excluded. RESULTS 26 patients (2 women, 24 men; median age at presentation 42 years; range: 22-70) were diagnosed with hypertriglyceridemia‑induced acute pancreatitis; 3 patients had altogether 7 relapses. The total number of cases was 33, which accounted for 4.71% of the total number of acute pancreatitis cases in the examined period. There was a failure in diet in 30.3% and a history of regular alcohol abuse in 57.6% of the cases. A history of diabetes mellitus was present in 38.1%, and gallstones in 9.1% of the cases. Lactescent serum was described on admission in 27.3%. Mean triglyceride level was 47.24 mmol/l (≈4181 mg/dl; 12.4-103.8 mmol/l). Amylase level was elevated to three times the normal in 54.5%, and that of lipase to three times the normal in 58.8%. Necrotizing acute pancreatitis was diagnosed in 7 patients (26.9%), and pseudocyst in 8 patients (30.7%). Administration of insulin, heparin, plasmapheresis and fibrates lowered the triglyceride to 3.71 mmol/l (≈328 mg/dl). CONCLUSION The clinical course of acute pancreatitis with hypertriglyceridemia does not differ from acute pancreatitis of other causes. Interestingly, levels of serum pancreatic enzymes may be normal or only minimally elevated. Insulin, heparin, plasmapheresis and fibrates effectively reduce lipid levels and relieve symptoms. A low triglyceride level is necessary to prevent relapses.

Hypertriglyceridaemia okozta akut pancreatitis sajátosságai beteganyagunkban

UNLABELLED Hypertriglyceridemia is reported to cause 1-7% of the cases of acute pancreatitis. AIM The aim of the present study was to assess the clinical features and management of pancreatitis with hypertriglyceridemia in our tertiary center. METHODS Between 1 January 2007 and 31 December 2009, patients with a diagnosis of hypertriglyceridemia-induced acute pancreatitis were reviewed. Patients with pancreatitis and serum triglyceride levels greater than 11.3 mmol/l (≈1000 mg/dl) were included. Acute pancreatitis with other etiologies was excluded. RESULTS 26 patients (2 women, 24 men; median age at presentation 42 years; range: 22-70) were diagnosed with hypertriglyceridemia‑induced acute pancreatitis; 3 patients had altogether 7 relapses. The total number of cases was 33, which accounted for 4.71% of the total number of acute pancreatitis cases in the examined period. There was a failure in diet in 30.3% and a history of regular alcohol abuse in 57.6% of the cases. A history of diabetes mellitus was present in 38.1%, and gallstones in 9.1% of the cases. Lactescent serum was described on admission in 27.3%. Mean triglyceride level was 47.24 mmol/l (≈4181 mg/dl; 12.4-103.8 mmol/l). Amylase level was elevated to three times the normal in 54.5%, and that of lipase to three times the normal in 58.8%. Necrotizing acute pancreatitis was diagnosed in 7 patients (26.9%), and pseudocyst in 8 patients (30.7%). Administration of insulin, heparin, plasmapheresis and fibrates lowered the triglyceride to 3.71 mmol/l (≈328 mg/dl). CONCLUSION The clinical course of acute pancreatitis with hypertriglyceridemia does not differ from acute pancreatitis of other causes. Interestingly, levels of serum pancreatic enzymes may be normal or only minimally elevated. Insulin, heparin, plasmapheresis and fibrates effectively reduce lipid levels and relieve symptoms. A low triglyceride level is necessary to prevent relapses.