Controversies in Clinical Pancreatology

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ArticlePlus Click on the links below to access all the ArticlePlus for this article. Please note that ArticlePlus files may launch a viewer application outside of your web browser. https://links.lww.com/MPA/A1 INTRODUCTION Dr. William M. Steinberg The term “autoimmune pancreatitis” (AIP) has been used to define a relatively new syndrome of clinical and histologic findings. This entity has been described in several articles published in Europe and Japan, yet few cases have been seen or reported in the United States. Therefore, it was thought that this was a timely topic for discussion at our Controversies in Clinical Pancreatology session at the American Pancreatic Association meetings on November 14, 2002. Five discussants participated in this session. Dr. Randall Pearson of the Gastroenterology Section, Mayo Clinic presented a case, and Dr. Dan Longnecker of the Department of Pathology, Dartmouth-Hitchcock Medical Center discussed the pathology. Dr. Suresh Chari of the Gastroenterology Section, Mayo Clinic, Dr. Kazuichi Okazaki of the Gastroenterology Section, Kyoto University, and Dr. Luca Frulloni of the Gastroenterology Section, University of Verona then proceeded with reports of the Mayo Clinic, Japanese, and Italian experiences with this syndrome. Finally, the discussants kindly submitted the following manuscripts for this article. BACKGROUND INDETERMINANT PANCREATIC MASS Dr. Randall K. Pearson A 53-year-old white woman in generally good health (postcholecystectomy) felt vaguely unwell for nearly 4 months with dyspeptic symptoms, two episodes of nausea and diarrhea characterized as “flu,” and a 20-pound weight loss. Two weeks prior, she noted dark urine, pale stools, and scleral icterus. She had no known history of pancreatitis, drank minimal amounts of alcohol, and had no family history of chronic pancreatitis. Biochemical studies confirmed jaundice, and computed tomography (CT) of the abdomen showed dilatation of the biliary tree down to the level of the pancreas. The pancreas was generally enlarged, but the cause of the obstruction was not obvious. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a distal bile duct stricture that was stented, and she was referred to the Mayo Clinic. After endoscopic stenting, she felt progressively better and was essentially without complaints. Her physical examination was normal. Laboratory studies were consistent with resolving obstructive jaundice. A CA 19-9 level was mildly elevated at 91.4 U/mL (normal, <40 U/mL). Repeat triple-phase contrast CT with thin cuts through the pancreas failed to reveal a mass or cause for biliary obstruction. Endoscopic ultrasound findings were suspicious for malignancy; a 3-cm mixed echogenicity region in the head was prominently seen in the setting of diffuse alteration in the parenchyma consistent with pancreatitis. Fine-needle aspiration of the mass and peripancreatic lymph nodes was negative. ERCP (Fig. 1) confirmed the distal bile duct stricture; a limited pancreatogram showed a normal duct in the head with slight narrowing at the neck of the pancreas and irregularity in the tail (Fig. 2).FIGURE 1.: Retrograde cholangiogram demonstrating a distal common bile duct stricture with proximal dilatation.FIGURE 2.: Mildly irregular pancreatic duct observed with endoscopic pancreatography.The patient underwent laparotomy, and a pancreaticoduodenectomy (Whipple resection) was performed. PATHOLOGY OF AUTOIMMUNE PANCREATITIS Dr. Daniel Longnecker The pathologic changes found in cases of pancreatitis associated with other autoimmune diseases, such as Sjögren disease and extrahepatic sclerosing cholangitis, 1 can be divided into two groups. The first group includes constant features characteristic and suggestive of AIP, i.e., found in all cases, and the second group comprises variable features seen in a fraction of cases that, when present, provide additional support for the diagnosis. On gross examination, the involved pancreas is firm or

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