Pancreatic Ductal Changes Research Articles

Diagnosis of autoimmune pancreatitis with computed tomography

Objective To investigate the computed tomography (CT) features of autoimmune pancreatitis (AIP). Methods The CT imaging data of 33 patients with AIP confirmed by pathology and/or steroid therapy were retrospectively analyzed. Image analysis including the shape of pancreas, density of lesion, contrast enhancement, the changes of pancreatic duct and biliary duct, peripancreatic appearances and adjacent organ involvement. T test was performed for statistical analysis. Results Among 33 patients with AIP, 23 cases (70%) with pancreatic parenchyma diffuse enlargement, eight cases (24%) with partial enlargement and two cases (6%) with normal pancreas. The lesions appeared hypoattenuating or isoattenuating on plain CT scan. After contrast-enhanced scan, the average CT values of lesions were (75.7±17.0) Hu at arterial phase, which was lower than that of venous phase (90.7±12.0) Hu, and the difference was statistically significant (t=3.378, P=0.002). The lesions demonstrated as progressive enhancement at venous phase. Among 33 patients, the main pancreatic duct was visible in six patients (18%). Sixteen patients (48%) presented with intrahepatic and extrahepatic biliary tract dilatation caused by intrapancreatic common bile duct stenosis. Thickened envelope-like structure around the lesions, presenting as capsule sign was seen in 14 patients (42%). Extra-pancreatic organ involvement was found in seven patients including three cases of kidney involvement. After treated with steroid, seven patients repeated CT which showed different degrees of improvement. Conclusion The main CT findings of AIP are diffuse and partial enlargement of pancreas with progressive enhancement at venous phase, envelope-like structure around pancreas, and stenosis of intrapancreatic common bile duct, which are important in the diagnosis and differential diagnosis of AIP. Key words: Pancreatitis; Autoimmune diseases; Tomography, X-ray computed

Age-dependent peculiarities of pancreatic exocrine apparatus morphometric changes

The peculiarities of pancreas exocrine components structural change in white rats of different age groups were determined by means of morphometric methods. It was found out that parenchyma density decreases and stromal component specific gravity increases with age. The size and area of acini, the area of nucleus surface and the nucleoplasmic ratio in exocrine cells decrease with age. Due to age-dependent changes of pancreatic excretory ducts, the ductile constriction, in­terlobular and intralobular ducts’ dilations are observed. It proves different adaptive capacity of the ductal system in general.

Imaging features of intestinal-type and pancreaticobiliary-type invasive adenocarcinoma of the ampullary region

Objective To analyze the computed tomography (CT) and magnetic resonance imaging (MRI) features of intestinal-type and pancreaticobiliary-type invasive adenocarcinomas of the ampullary region (IAARs) and investigate the value of the differential diagnosis. Methods The retrospective cross-sectional study was adopted. The clinicopathological data of 33 patients with IAAR who were admitted to the Lanzhou University Second Hospital (20 patients) and Affiliated Hospital of Ningbo University (13 patients) between September 2013 and August 2015 were collected. The patients underwent plain and enhanced scans of CT and MRI. (1) Observation indictors included tumor size, shape, growth pattern, boundary, internal structure, density and/or signal, style and/or degree of contrast enhancement, changes of bile and/or pancreatic duct, invasion and metastasis. (2) The clinical and imaging features of intestinal-type and pancreaticobiliary-type IAARs were compared. (3) Operation was performed after preoperative examinations, and patients received the postoperative pathological examination and immunohistochemistry. Measurement data with normal distribution were presented as ±s. Comparison between groups was evaluated with an independent sample t test, and count data were analyzed using the chi-square test. Results (1) Of 33 patients with IAAR, 19 received plain scan of CT, including 17 receiving simultaneous enhanced scan of CT. Fourteen patients [9 receiving diffussion-weighted imaging (DWI) sequence of MRI] received plain scan of MRI, including 12 receiving simultaneous enhanced scan of MRI. The maximum diameter of IAAR in 33 patients was (2.8±1.4)cm. Fourteen tumors were round-like or oval shape and 19 tumors were irregular shape. The intracavity type, extracavity type and mixed type of tumors were detected in 24, 6 and 3 patients, respectively. There were clear boundary of tumors in 17 patients and fuzzy boundary of tumors in 16 patients. Tumors of 5 patients had appeared necrotic and/or cystic, no hemorrhage or calcification was found in tumors of 33 patients. Density and signal of tumors were homogeneous in 18 patients and inhomogeneous in 15 patients. Of 29 patients receiving enhanced scan of CT or MRI, homogeneous enhancement and inhomogeneous enhancement were respectively detected in 14 and 15 patients, and mild enhancement, moderate enhancement and no enhancement were respectively detected in 15, 14 and 0 patients. Tumors of 9 patients in DWI showed slightly high or high signal. Thirty patients had secondary bile duct dilatation (3 with mild dilatation, 6 with moderate dilatation and 21 with severe dilatation), and 3 patients had no changes of bile duct. Twenty-six patients had secondary pancreatic duct dilatation and 7 had no changes of pancreatic duct. Sixteen patients had tumor invasion to pancreatic tissues and 7 had lymph node metastases. (2) Of 33 patients with IAAR, 19 had intestinal-type IAAR (8 males and 11 females) and 14 had pancreaticobiliary-type IAAR (11 males and 3 females). There was statistically significant difference in the gender between the 2 types of IAAR (χ2=4.388, P<0.05). The intracavity type, extracavity type and mixed type of tumors, clear boundary and fuzzy boundary of tumors, homogeneous and inhomogeneous density and/or signal of tumors, with and without tumor invasion to pancreatic tissues were respectively detected in 17, 0, 2, 13, 6, 14, 5, 6, 13 patients with intestinal-type IAAR and 7, 6, 1, 4, 10, 4, 10, 10, 4 patients with pancreaticobiliary-type IAAR, with statistically significant differences between the 2 types of IAAR (χ2=9.971, 5.125, 6.617, 5.125, P<0.05). (3) All the patients underwent surgery and received comprehensive diagnosis and tumor classification after pathological examination and immunohistochemistry. Conclusion There are certain characteristics of CT and MRI in intestinal-type and pancreaticobiliary-type IAARs, and gender, tumor growth pattern, boundary, density and/or signal, tumor invasion to pancreatic tissues have certain reference values for the differential diagnosis of intestinal- type and pancreaticobiliary-type IAARs. Key words: Ampullary neoplasms; Invasive adenocareinoma; Tomography, X-ray computed; Magne-tic resonance imaging

Diabetes Mellitus Is Associated With an Exocrine Pancreatopathy: Conclusions From a Review of Literature.

Abnormalities in exocrine pancreatic function have been reported in diabetes mellitus (DM). We reviewed published literature to determine the nature of structural and functional alterations in the exocrine pancreas in DM. We identified and abstracted data from original studies (n = 50) describing morphological, structural, and functional changes in the exocrine pancreas in types 1 and 2 DM. Pancreatic weight and volume are markedly lower in type 1 DM (P < 0.005) with insignificant decrease in type 2 DM compared with age-, sex-, and body mass index-matched controls. Pancreatic histopathological changes seen in most subjects with DM at autopsy (n = 7 studies, 1272 autopsies) include mild-to-marked interacinar fibrosis, scant inflammatory infiltrate, no pancreatic ductal changes, and hyalinization of arteries. In subjects with DM, pooled prevalence of decreased fecal elastase 1 (<200 μg/g) is higher, coefficient of fat absorption is near normal (mean, 91%-94%), and pancreatic exocrine dysfunction is nonprogressive over time. Diabetes mellitus is asymptomatic in regard to the exocrine pancreas. In types 1 and 2 DM, moderate-to-severe subclinical pancreatic fibrosis and modest exocrine dysfunction occurs in the absence of clinical or histopathological evidence of chronic pancreatitis. We call this novel entity "diabetic exocrine pancreatopathy."

Pancreas divisum: correlation between anatomical abnormalities and bile precipitation in the gallbladder in seven patients.

Pancreas divisum is a genetic defect associated with recurrent acute pancreatitis due to insufficient drainage of the accessory pancreatic duct. Seven young patients diagnosed with pancreatic divisum and thickening of the gallbladder bile as shown on magnetic resonance cholangio-pancreatography without pancreatic ductal changes underwent laparoscopic cholecystectomy. During the mean follow-up of 32 months no episode of pancreatitis was reported. There is an association between PD and higher concentration of bile in the gallbladder. Cholecystectomy can be considered curative in patients with PD in the absence of indications for major surgery.

Evolution of pancreas in aging: degenerative variation or early changes of disease?

Pancreatic changes in aging have been described for many decades. They involve not only pancreatic parenchyma but also pancreatic ductal, microscopic, and exocrine functional changes. There have been many studies of these changes based on pathology and various imaging modalities, as well as functional studies. The pancreatic volume was found to decrease with advancing age, with a higher incidence of pancreatic steatosis, as demonstrated in autopsy and imaging studies. The pancreatic ductal structure has been described with wide ranges of normal variation, but many studies have shown a tendency toward enlargement with advancing age. By endoscopic ultrasound imaging, the aging pancreas may exhibit abnormal findings similar to chronic pancreatitis. Microscopically, there has been evidence of patchy lobular fibrosis and papillary hyperplasia and demonstrable k-ras mutation in both normal and dysplastic ductal mucosa. The evidence of pancreatic exocrine insufficiency has yielded conflicting results, but most studies have shown a tendency toward decreased pancreatic exocrine function in the elderly. Differentiating pancreatic change in the elderly from early chronic pancreatitis may be difficult as there are limited studies to compare these two conditions in terms of structural and functional changes.

Elevated DNA damage response in pancreatic cancer.

Pancreatic cancer is one of the most aggressive and intractable human malignant tumors and a leading cause of cancer-related death across the world, with incidence equaling mortality. Because of the extremely high malignance, this disease is usually diagnosed at its advanced stage and recurs even after surgical excision. Pancreatic adenocarcinoma is generally thought to arise from pathological changes of pancreatic duct, and the pancreatic ductal adenocarcinoma accounts for more than 90 % of malignant neoplasms of the pancreas. To date, scientists have revealed several risk factors for pancreatic cancer, including smoking, family history, and aging. However, the underlying molecular mechanism remains unclear. Meanwhile, more mutations of DNA damage response factors have been identified in familial pancreatic cancers, implying a potential link between DNA damage and pancreatic cancer. DNA damage is a recurring phenomenon in our bodies which could be induced by exogenous agents and endogenous metabolism. Accumulated DNA lesions cause genomic instability which eventually results in tumorigenesis. In this study, we showed obvious DNA damages existed in human pancreatic cancer, which activated DNA damage response and the DNA repair pathway including ataxia-telangiectasia mutated, DNA-PK, CHK1, and CHK2. The persistent DNA damage in pancreatic tissue may be the source for its tumorigenesis.

Endoscopic Ultrasound and Histology in Chronic Pancreatitis

This study aimed to correlate endoscopic ultrasound (EUS) criteria and pathology in patients with chronic pancreatitis (CP). Endoscopic ultrasound reports and pathology specimens were reviewed from patients with known or suspected CP who underwent surgery within 1 year of EUS. The following information was abstracted: EUS criteria for CP, corresponding pathology results, and histologic features. The EUS and pathology results were correlated. One hundred patients (55 men; mean age, 54 years) underwent a pancreatic resection, median of 50 days (range, 1-363 days). The mean (SD) fibrosis scores in the head and body/tail specimens were 7.9 (3.0) and 6.4 (3.8), respectively (P = 0.02). The main pancreatic duct (MPD) dilation and irregularity were associated with moderate and severe fibrosis. Lobularity with honeycombing was associated with intralobular and interlobular fibrosis. Severe CP was associated with the following: lobularity with honeycombing, hyperechoic foci with shadowing, hyperechoic foci without shadowing, MPD dilation, MPD irregularity, and dilated side branches. Endoscopic ultrasound of the pancreas head may be considered in the evaluation of CP. The EUS criteria that were associated with severe CP included the following: lobularity with honeycombing, hyperechoic foci with shadowing, dilated MPD, irregular MPD, and dilated side branches. The importance of pancreatic ductal changes should not be minimized in the evaluation of CP.

Malignant Transformation of Branch Duct–Type Intraductal Papillary Mucinous Neoplasms of the Pancreas Based on Contrast-Enhanced Endoscopic Ultrasonography Morphological Changes

The natural history of branch duct-type intraductal papillary mucinous neoplasms (BD-IPMNs) of the pancreas remains unclear. We conducted a retrospective long-term follow-up study for malignant transformation (MT) of BD-IPMNs focusing on morphological changes. The subjects consisted of 142 patients who underwent contrast-enhanced endoscopic ultrasonography for initial diagnosis from January 2001 with more than 12 months of follow-up. The MT rate, including the co-occurrence of invasive ductal cancer, was evaluated by univariate and multivariate analysis. In addition, on the basis of morphological changes in patients who underwent surgery, the predictive factors for malignant IPMNs were evaluated. Median follow-up term was 42.5 months (range, 12-105 months). Thirty patients who exhibited morphological changes underwent surgery. Malignant transformation occurred in 9 patients (6.3%), and 5-year MT rate was 10.7%. The co-occurrence of invasive ductal cancer was seen in 5 patients. Multivariate analysis showed that the existence of mural nodules at initial diagnosis and involvement of main pancreatic duct were significant predictors of MT of BD-IPMN. Malignant transformation of BD-IPMN is not rare. The observation of morphological changes of main pancreatic duct and nodules, mainly on contrast-enhanced endoscopic ultrasonography, is practical and useful for predicting MT of BD-IPMN itself.

Fatal complication after endoscopic ultrasound-guided celiac plexus neurolysis

A 57-year-old woman with a diagnosis of idiopathic recurrent pancreatitis and progressive epigastric pain radiating to her back was admitted to the hospital. Abdominal computed tomography (CT) showed a suspicious 3-cm pancreatic head mass involving the superior mesenteric artery (SMA) and vein. Endoscopic ultrasound (EUS) showed the suspicious pancreatic head mass with bile duct and main pancreatic duct dilatation and changes compatible with chronic pancreatitis. However, EUS-guided fine needle aspiration cytology was negative on three occasions. EUS-guided celiac plexus neurolysis (EUSCPN) was carried out using a 19-gauge needle. Absolute alcohol (10cc) and bupivacaine 0.5% (5cc) were injected on each side of the celiac takeoff. Color Doppler imaging after the procedure revealed the permeability of the SMA and celiac takeoff. After the procedure, the patient experienced stabbing pain radiating to the back, with nausea, hypotension, and fever. CT demonstrated complete thrombosis of the celiac takeoff, as well as wall thickening and bubble-like pneumatosis of the stomach, duodenum, jejunum, ileum loops, and ascending colon. Signs of hepatic infarction of segments I and III, and near-total right-kidney and splenic infarction were discovered. Conservative management was carried out and the patient died 8 days later. Major complications have rarely been reported using EUS-CPN or EUS-guided celiac plexus block (● Tab.1) [1–7]. The present case is the first to document a fatal outcome. The sclerosing effect of absolute ethanol, arterial embolisms after injection, and vasospasm could explain the necrosis of organs distant to the celiac takeoff [8]. All cases of major complications due to CPN, except one, were reported in the setting of chronic pancreatitis (● Tab.1). The issue of using CPN in patients with chronic pancreatitis is still a matter of debate [9]. In conclusion, major complications of CPN can include death. It may be preferable to limit EUS-guided CPN to patients with histologically proven cancers.

CP Severity Index: A Reliable Scoring System to Assess Severity and Progression of Chronic Pancreatitis

Background: Chronic pancreatitis (CP) is a syndrome characterized by structural changes in the pancreas that lead to chronic abdominal pain and varying degree of pancreatic functional failure. It has difficult to assess the severity and progression of CP based upon pancreatic duct (PD) changes alone. The aims of this study were: (1) to develop a 'CP severity index' to assess the severity of CP; and (2) correlate the 'CP severity index' with different clinical outcomes in the natural history of CP. Patients and Methods: A prospective study of subjects with established CP was performed at the Pancreatitis Center of the VCU Medical Center, Richmond, VA. Baseline clinical, laboratory and radiologic findings were recorded. Patients were followed in the pancreatitis clinic at 6-month intervals or as the clinical situation warranted. Desirability function methodology was used to develop the CP severity score which ranges between 0 (most severe) and 1 (not severe). Of the 14 recorded variables, on the a stepwise ordinal logistic regression analysis, 8 variables were selected based on a stepwise ordinal logistic regression and combined into a 'pancreatitis severity score' alcohol use, side branch size, side branch ectasia (SBE >3),main PD (MPD) irregularity, MPD stricture, MPD leak, MPD calculi, and contour abnormality of the bile duct. The key outcomes assessed included: exocrine failure, endocrine insufficiency (diabetes), presence or development of a pseudocyst and bile duct stricture. An ordinal 'response' score was created at baseline and at one-year followup, which counted the number of the above outcomes in each patient. Results: Eighty nine subjects with CP (mean age 48 yrs, 54% males) were evaluated, of whom 48 (54%) were African American and 41 (46%) were Caucasian. On independent ordinal regression analysis, only the side branch size correlated with the severity of CP (p= 0.03). The 'CP severity score' significantly correlated with the number of adverse outcomes in CP (p=0.038) and was negatively associated with the number of outcomes. The average CP severity score in subjects with none, one, two, three and four adverse outcomes was 0.74, 0.70, 0.63, 0.60 and 0.43, respectively. For each 0.1 unit increase in the CP severity score the odds of moving to more adverse outcomes decreased by 0.85 times. Conclusions: The 'CP severity score' significantly correlates with the severity of CP. The 'CP severity index' reliably predicts the progression of CP by taking into consideration both imaging changes as well as behavioral risk factors as ongoing alcohol use.

13 C-Di-Peptide Breath Test to Assess Exocrine Pancreatic Function in Chronic Pancreatitis: A Novel Non-Invasive Method

Background: Chronic pancreatitis (CP) is a syndrome characterized by structural changes in the pancreas that lead to chronic abdominal pain and varying degree of pancreatic functional failure. It has difficult to assess the severity and progression of CP based upon pancreatic duct (PD) changes alone. The aims of this study were: (1) to develop a 'CP severity index' to assess the severity of CP; and (2) correlate the 'CP severity index' with different clinical outcomes in the natural history of CP. Patients and Methods: A prospective study of subjects with established CP was performed at the Pancreatitis Center of the VCU Medical Center, Richmond, VA. Baseline clinical, laboratory and radiologic findings were recorded. Patients were followed in the pancreatitis clinic at 6-month intervals or as the clinical situation warranted. Desirability function methodology was used to develop the CP severity score which ranges between 0 (most severe) and 1 (not severe). Of the 14 recorded variables, on the a stepwise ordinal logistic regression analysis, 8 variables were selected based on a stepwise ordinal logistic regression and combined into a 'pancreatitis severity score' alcohol use, side branch size, side branch ectasia (SBE >3),main PD (MPD) irregularity, MPD stricture, MPD leak, MPD calculi, and contour abnormality of the bile duct. The key outcomes assessed included: exocrine failure, endocrine insufficiency (diabetes), presence or development of a pseudocyst and bile duct stricture. An ordinal 'response' score was created at baseline and at one-year followup, which counted the number of the above outcomes in each patient. Results: Eighty nine subjects with CP (mean age 48 yrs, 54% males) were evaluated, of whom 48 (54%) were African American and 41 (46%) were Caucasian. On independent ordinal regression analysis, only the side branch size correlated with the severity of CP (p= 0.03). The 'CP severity score' significantly correlated with the number of adverse outcomes in CP (p=0.038) and was negatively associated with the number of outcomes. The average CP severity score in subjects with none, one, two, three and four adverse outcomes was 0.74, 0.70, 0.63, 0.60 and 0.43, respectively. For each 0.1 unit increase in the CP severity score the odds of moving to more adverse outcomes decreased by 0.85 times. Conclusions: The 'CP severity score' significantly correlates with the severity of CP. The 'CP severity index' reliably predicts the progression of CP by taking into consideration both imaging changes as well as behavioral risk factors as ongoing alcohol use.

MRI of pancreatic duct changes in piglets with chronic pancreatitis

Objective To study MRI findings of pancreatic ducts of piglets with chronic pancreatitis (CP) induced by pancreatic duct ligation and analyze the relationship between pancreatic duct changes in piglets with CP and the pathological severity of CP. Methods Thirty healthy piglets were included in this study. Five piglets were randomly selected as normal control group, and the remaining 25 piglets were served as the experimental group. The duct ligation operations were performed on experimental group. After 2 to 18 weeks, pancreas and pancreatic ducts were observed on MRI. Then the pancreas was removed and graded into three types by histopathology. The relationship between the diameter of pancreatic duct or the pancreatic branch displaying rate and the severity of CP was analyzed by Spearman correlation coefficient. Results CP was found in 21 piglets( 84. 0% ) in the experimental group including mild ( n = 7 ), moderate ( n = 8 ) and severe( n = 6) pancreatitis. Pancreatic ducts were shown in mild CP and the edge of pancreatic ducts was irregular in three cases. The dilated RPD, LPD and MPD constituted the person form in moderate and severe CP. The diameter of pancreatic ducts was(0. 9 ±0. 3)mm, (2. 9 ± 1.4)mm and (4. 8 ± 1.2)mm in mild, moderate, and severe CP respectively. The expansion extent of pancreatic ducts was correlated with the severity of CP of piglets (r = 0. 837, P ＜ 0. 05). The pancreatic branch displaying rate increased with the increase of the severity of CP ( r = 0. 990, P ＜ 0. 05 ); the displaying rate was 0/7 for mild, 3/8 for moderate, and 5/6 for severe CP. Conclusions The dilated pancreatic ducts with person form in piglets with obstructive CP created by pancreatic duct ligation. The pancreatic duct changes on MRI reflect the severity of CP of piglets. Key words: Pancreatitis,chronic; Magnetic resonance imaging; Animals,laboratory

Endoscopic retrograde pancreatography criteria to diagnose autoimmune pancreatitis: an international multicentre study

BackgroundCharacteristic pancreatic duct changes on endoscopic retrograde pancreatography (ERP) have been described in autoimmune pancreatitis (AIP). The performance characteristics of ERP to diagnose AIP were determined.MethodsThe study was done in...

Diet with a low n‐6/n‐3 essential fatty acid ratio when started immediately after the onset of overt diabetes prolongs survival of type 1 diabetes model NOD mice

Type 1 diabetes is a multifactorial disease involving genetic and environmental factors and results from the destruction of pancreatic islet β cells, virtually the only source of insulin. When the majority of β cells are lost, a 'honeymoon' period of variable length follows: namely, a fleeting phase of residual endogenous insulin production, during which glycemic control is achieved with modest or no doses of insulin. However, the remaining β cells are eventually lost, causing the individual to become insulin-dependent and to require long-term insulin therapy or islet transplantation. Here we show that NOD mice, a type 1 diabetes model, survived significantly longer when their diet was changed from one chow with a high essential fatty acid (EFA) ratio (n-6/n-3, 14.5) to another with a low n-6/n-3 ratio (3.0) within 6 days after the onset of overt diabetes (i.e. the 'honeymoon' period), than mice that were continuously fed with the chow with the high n-6/n-3 ratio. This effect was not observed when the chow was changed later than 9 days after the onset. Significantly larger number of islets remained with suggestive islet neogenesis from the pancreatic duct and pathological changes in renal glomeruli were significantly milder in NOD mice fed the chow with the low n-6/n-3 ratio within 6 days after the onset of overt diabetes than those continuously fed with the high-n-6/n-3-ratio chow. These findings indicate that a diet with a low n-6/n-3 ratio prolongs the 'honeymoon' period by retaining the β cell mass, suggesting its potential therapeutic merit.

Pancreatic duct changes are not associated with early signs of chronic pancreatitis at magnetic resonance imaging (MRI) in patients with primary sclerosing cholangitis

Objective. The association between chronic pancreatitis (CP) and primary sclerosing cholangitis (PSC) has been reported previously. The aims of the present study were to evaluate the presence of early pancreatic abnormalities and duct changes, using MRCP/MRI in PSC and to evaluate possible risk factors for these changes and their clinical importance. Materials and methods. One hundred and three patients with PSC were identified among all MRI liver/pancreas referrals in 2001–2005. MRCP was used to grade pancreatic duct changes in three groups: grade 0 (normal), grade 1 (mild) and grade 2 (severe). For detection of early MRI signs of CP, the pancreas-spleen signal intensity ratio (SIR), the arterial and early venous phase ratio (A/PV ratio) and the age-related size of the pancreas were evaluated. Results. Pancreatic duct changes were found in 24% of the PSC patients. The pancreatic duct changes were associated with extrahepatic biliary involvement and long duration of PSC but not associated with pancreas-spleen SIR, A/PV ratio, pancreas size, previous post-ERCP or acute pancreatitis. Severe pancreatic duct changes were significantly associated to abdominal pain. Clinically significant CP was seen in one PSC patient (1%). Conclusions. Pancreatic duct changes are associated with extrahepatic bile duct strictures and not with the early MRI signs of CP. Therefore, pancreatic duct changes seem to be part of the spectrum of PSC and should not be defined as CP. Pancreatic duct changes are of limited clinical importance but may contribute to abdominal pain in PSC.

Clinical Significance of Extrapancreatic Lesions in Autoimmune Pancreatitis

To clarify the frequency and clinical significance of extrapancreatic lesions in autoimmune pancreatitis (AIP). The frequency and clinical characteristics of extrapancreatic lesions during the clinical course of AIP were investigated retrospectively in 64 patients with AIP. The predictive factors for relapse of AIP at clinical onset were also examined. Extrapancreatic lesions occurred in 95% (61/64) during the clinical course of AIP. The frequencies of sclerosing cholangitis, sclerosing sialadenitis, retroperitoneal fibrosis, and mediastinal or hilar lymphadenopathy were 84% (54/64), 23% (15/64), 16% (10/64), and 77% (27/35), respectively. Patients with sclerosing sialadenitis or extrapancreatic bile duct sclerosing cholangitis had a significantly higher serum immunoglobulin G concentration than those without (P = 0.005 and P = 0.016, respectively). Univariate analysis revealed that sclerosing sialadenitis (P = 0.005), diffuse pancreatic ductal changes (P = 0.028), and a high serum immunoglobulin G concentration (P = 0.030) at clinical onset of AIP were significant predictive factors for relapse. Multivariate analysis revealed that diffuse pancreatic ductal changes (P = 0.005) and sclerosing sialadenitis (P = 0.012) were significant independent predictive factors for relapse of AIP. The frequency of extrapancreatic lesions with AIP during the clinical course was high. The presence of sclerosing sialadenitis at clinical onset is a significant predictive factor for relapse of AIP.

Lateral anastomosis techniques

Characteristic symptoms of chronic pancreatitis are difficult to manage conservatively. They include severe pain and endocrine and exocrine insufficiency. Surgical treatment with simple and extended draining procedures addresses pain relief and the management of chronic pancreatitis-associated complications of adjacent organs. Following the assumption that pancreatic duct changes with intraductal hypertension are the reason for pain, simple drainage procedures have reduced pain in up to 80% of patients, with low morbidity and mortality. In case of complications involving adjacent organs with inflammatory pancreatic head tumor and stenosis of the distal bile duct, extended drainage procedures with limited pancreatic head resection according to Frey and V-shaped excision of the ventral aspect of the pancreas have been performed successfully.

Autoimmune Pancreatitis: Disease Evolution, Staging, Response Assessment, and CT Features That Predict Response to Corticosteroid Therapy

To evaluate the evolution of morphologic features of autoimmune pancreatitis (AIP) at computed tomography (CT) and to identify imaging features that can predict AIP response to corticosteroid therapy (CST). This HIPAA-compliant retrospective study had institutional review board approval. From among a cohort of 63 patients with AIP, 15 patients (12 men, three women; mean age, 64.7 years; age range, 30-84 years) who underwent sequential CT examinations before treatment were included to assess the evolution of disease by reviewing pancreatic, peripancreatic, and ductal changes. Of these patients, 13 received CST and underwent posttreatment CT; these CT studies were evaluated to determine if there were imaging features that could predict response to CST. The disease evolved from changes of diffuse (14 of 15 patients) or focal (one of 15 patients) parenchymal swelling, peripancreatic stranding (10 of 15 patients), "halo" (nine of 15 patients), pancreatic duct changes (15 of 15 patients), and distal common bile duct narrowing (12 of 15 patients) to either resolution or development of ductal strictures and/or focal masslike swelling. In 13 patients treated with CST, favorable response to treatment was seen in those with diffuse pancreatic and peripancreatic changes. Suboptimal response was seen in patients with ductal stricture formation (two of 13 patients) and in those in whom focal masslike swellings persisted after resolution of diffuse changes (seven of 13 patients). CT features like diffuse swelling and halo respond favorably to CST and likely reflect an early inflammatory phase, whereas features like ductal strictures and focal masslike swelling are predictive of a suboptimal response and symbolize a late stage with predominance of fibrosis.

Clinical outcomes and nonendoscopic interventions after minor papilla endotherapy in patients with symptomatic pancreas divisum

Long-term outcomes of minor papilla endotherapy (MPE) in pancreas divisum are limited. To determine the efficacy of MPE in symptomatic pancreas divisum subgroups. This was a retrospective study of patients from an endoscopy database. The data collection instrument included preprocedure and postprocedure pain score, narcotic use, acute pancreatitis episodes, emergency department visits, and hospitalizations. A follow-up was obtained by chart review and telephone contact with a questionnaire. A tertiary-referral center. (1) Clinical improvement defined as a > or = 50% reduction in the evaluated data points and (2) non-MPE interventions for pain. Between January 2000 and April 2006, 57 patients were identified. Indications were recurrent acute pancreatitis (RAP) (n = 27 [47%]), abdominal pain and chronic pancreatitis (CP) (n = 20 [35%]), abdominal pain alone (n = 8 [14%]), other (n = 2 [4%]). Successful MPE occurred in 49 of 57 patients (86%). Initial MPE entailed minor papilla sphincterotomy (n = 46), stenting without sphincterotomy (n = 2), and tamponade of bleeding (n = 1). Follow-up was obtained in 56 of 57 patients (98%) for a median of 20 months (interquartile range 12-39 months); 28 of 48 patients (58%) with successful MPE had clinical improvement: 16 of 21 (76%) with RAP, 8 of 19 (42%) with CP, and 2 of 6 (33%) with pain alone (RAP vs non-RAP; P = .019). Two patients had resolution of a dorsal-duct leak and bleeding, respectively. Twelve of 57 patients (21%) underwent 16 additional interventions for incomplete response: celiac plexus block (4), intrathecal narcotic pump (2), sphincteroplasty (7), bilateral thoracic splanchnicectomy (2), and Puestow procedure (1); 7 of 12 patients (58%) clinically improved. This was a retrospective study. (1) MPE is most effective in patients with pancreas divisum and with RAP with or without pancreatic ductal changes, (2) although patients with chronic pain and pancreas divisum respond poorly to MPE, the majority will have clinical improvement after additional nonendoscopic interventions for pain management.