1. Pancreatic pseudocyst in autoimmune pancreatitis
Kyung-Ae Chang
Division of Gastroenterology, Department of Internal Medicine, College of Medicine,
Yeungnam University,
Daegu, Korea

2. 53/M C/C: Abdominal discomfort for 1wk
P/I: 상기 증상으로 LMC 방문하여 Abdo.CT check 후 r/o pancreatic head ca. imp으로 본원 GS로 transfer.
PMHx: N-S
SHx: Alcohol(+); 소주 1병/회*4회/월*30년
Smoking(+); 1갑*30년
FHx: N-S

3. ROS : Abdominal discomfort(+), itching sensation (+)
P/E : Icteric sclera (+), Epigastric and RUQ mild tenderness (+)
Lab: CBC 4090/12.1/183K
AST/ALT 228/386, TB/DB 7.7/5.5
ALP/GGT 757/203, Amylase 191
TP/Alb 6.61/3.5, Glu 110
AFP,CEA,CA19-9,CA125; W.N.L
V/S: BP 110/70mmHg, BT 36.5℃
PR 72회/min, RR 20회/min

4. Abdo.CT

5. ERCP

6. ERCP

7. IMP: R/O CBD malignancy
R/O Choledochal cyst
환자 further evaluation refuse 하고 전원 원하여 CT & ERCP copy하여 transfer.

8. Outside CT

9. Outside ERCP

10. Outside ERCP

11. Outside ERCP

12. Outside ERCP

13. Outside ERCP

14. Outside ERCP

15. Outside CT

16. 2008.10.28. Abdominal pain 으로 ER 통해 Admission.
V/S: BP 100/60mmHg, BT 37.4℃,
PR 84회/min, RR 20회/min
Lab: CBC 8680/15.4/271K
TB/DB 1.26/0.26 AST/ALT 28/38
ALP/GGT 437/208,
Amylase/Lipase 400/93.8,
Glu 401

17. Abdo.CT

18. Abdo.CT

19. ERCP

20. Pancreatic pseudocyst interanl drainage시행 후 abdominal pain 점차 감소하고 PO 시작한 후에도 pain 없어 Nisolon 40mg qd and ciprobay 250mg bid 처방 후 D/C & OPD F/U.
PD 30mg PO하면서 OPD F/U 중 abdominal pain으로
ER 통해 admission.

21. V/S: BP 100/60mmHg, BT 37.4℃
PR 84회/min, RR 20회/min
Lab: CBC 18220/13.6/424K
AST/ALT 41/32, TB/DB 1.54/0.83
ALP/GGT 593/201,
Amylase/Lipase 243/26 ,
Glu 88

22. Abdo.CT

23. ERCP

24. Abdo.CT

25. ERCP

26. Autoimmune pancreatitis
The first report was in 1961,in a case report of a patient with pancreatitis and hypergammaglobulinemia.
Early reports noted chronic pancreatitis characterized by the presence of autoantibodies, elevated levels of Ig, enlargement of the pancreas(diffuse or focal), pancreatic duct strictures, and pathologic features of a dense lymphocytic infiltrate.

27. Diganotic crierias
In 1995, Yoshida et al. summarized the characteristics of AIP: 1)increased serum gammaglobulin or IgG levels, 2)presence of autoantibodies, 3)diffuse enlargement of the pancreas, 4)diffuse irregular narrowing of the main pancreatic duct on ERP, 5)fibrotic changes with lymphocytic infiltration of the pancreas on histopathological exam, 6)no sx or only mild sx, usually with no history of acute attacks of pancreatitis,

28. 7)Stenosis of the CBD in the pancreas,
with dilatation of the bile duct upstream
and frequent occurrence of cholestatic
liver dysfunction and hyperbilirubinemia,
8)no pancreatic calcification, 9)no
pancreatic cysts, 10)occasional
association with other autoimmune ds,
11)Effectives of steroid therapy.

29. Japan Pancreas Society in 2002: 1)imaging studies showing diffuse narrowing of the main pancreatic duct, with an irregular wall(more than one-third the length of the entire pancreas) and enlargement of the pancreas, 2) lab; abnl elevated levels of serum gammaglobulin and/or IgG, or the presence of autoantibodies, 3)histopathologic exam; fibrotic changes with lymphocyte and plasma cell infiltration.

30. Japan revised 2006

31. Korea 2007

32. Mayo clinic 2006

33. Asian criteria 2008

34. Presence of extrapancreatic lesion
Imaging factor(6) : CT
Delayed enhancement
Capsule like rim
ERCP
Narrowed portion of MPD > 3cm
Skipped lesions of MPD
Maximal diameter < 5mm of upstream MPD
Presence of extrapancreatic lesion
Kamisawa et al Pancreas 2008:37;e62-67

35. Consensus of Treatment in Japan

36. Rate of complete remission with or without steroid
Tetsuhido Ito et el J Gastroenterol 2007;42;50-58

37. Time necessary to complete remission
Tetsuhido Ito et el J Gastroenterol 2007;42;50-58