Autoimmune pancreatitis - diagnosis, management and longterm follow-up.

BACKGROUND & AIMS: Autoimmune pancreatitis (AIP) is a fibroinflammatory condition affecting the pancreas and could present as a multisystem disorder. Diagnosis and management can pose a diagnostic challenge in certain groups of patients. We report our experience of managing this condition in a tertiary pancreaticobiliary centre in the North East of England. METHODS: Patients were identified from a prospectively maintained database of patients diagnosed with AIP between 2005 and 2013. Diagnosis of definite/probable AIP was based on the revised HISORt criteria. When indicated, patients were treated with steroids and relapses were treated with azathioprine. All patients have been followed up to date. RESULTS: Twenty-two patients were diagnosed with AIP during this period. All patients had pancreatic protocol CT performed while some patients had either MR or EUS as part of the work up. Fourteen out of 22 (64%) had an elevated IgG4 level (mean: 10.9 g/L; range 3.4 - 31 g/L). Four (18%) patients underwent surgery. Extrapancreatic involvement was seen in 15 (68%) patients, with biliary involvement being the commonest. Nineteen (86%) were treated with steroids and five (23%) required further immunosuppression for treatment of relapses. The mean follow up period was 36.94 months (range 7 - 94). CONCLUSION: Autoimmune pancreatitis is being increasingly recognized in the British population. Extrapancreatic involvement, particularly extrahepatic biliary involvement seems to be a frequent feature. Diagnosis should be based on accepted criteria as this significantly reduces the chances of overlooking malignancy. Awareness of this relatively rare condition and a multi-disciplinary team approach will help us to diagnose and treat this condition more effectively thereby reducing unnecessary interventions.

Does on-site adequacy assessment by cytotechnologists improve results of EUS guided FNA of solid pancreaticobiliary lesions?

CONTEXT: Rapid onsite adequacy assessment is stated to improve the diagnostic performance of EUS-FNA. OBJECTIVES: The aim of this study was to establish if the introduction of adequacy assessment performed by a biomedical scientist (cytotechnologist) to an established EUS service improved the diagnostic accuracy of EUS guided FNA of solid pancreaticobiliary lesions. DESIGN AND PATIENTS: This retrospective study includes all patients with solid pancreaticobiliary lesions who underwent EUS-FNA from April 2009 to September 2010. An in room cytotechnologist was present for 2 out of the 4 weekly EUS lists and therefore there were two groups identified: Group 1, cytotechnologist absent; and Group 2, cytotechnologist present. RESULTS: There were 82 patients in Group 1 and 97 patients in Group 2. There was no statistically significant difference in the number of passes (4.1 vs. 4.3), the inadequate aspirate rate (7.3% vs. 5.1%) or the mean size of the lesions (34.7 vs. 32.6 mm) between the groups. The accuracy, sensitivity, specificity, positive predictive value and negative predictive value in Group 1 were 89%, 88%, 100%, 100% and 50% respectively. The results in Group 2 were 91%, 90%, 100%, 100% and 69% respectively. There was no statistically significant difference between the two groups. CONCLUSIONS: In this study the adequacy assessment performed by a cytotechnologist did not improve the diagnostic accuracy of EUS-FNA. In an established EUS-FNA service with low inadequate aspirate rates, onsite adequacy assessment may not improve results of the test.

Tuberculosis and the pancreas: a diagnostic challenge solved by endoscopic ultrasound. A case series.

Pancreatic tuberculosis is a rare disease. It can be easily confused with malignancy or pancreatitis on imaging. This could result in unnecessary surgery. As this is a treatable disease it is imperative to diagnose this condition pre-operatively. We report three cases of pancreatic tuberculosis that were diagnosed by endoscopic ultrasound. In conclusion, endoscopic ultrasound is the diagnostic modality of choice for pancreatic tuberculosis facilitating high resolution imaging, as well as sampling of tissue for staining, cytology, culture and polymerase chain reaction assay.

Mucocele of the cystic duct remnant after orthotopic liver transplant: a problem revisited.

Mucocele of the cystic duct remnant is an uncommon hepatobiliary complication of a liver transplant. Current practice usually involves either excising the cystic duct, or incorporating the distal end of the transected cystic duct into the suture line of the biliary anastomosis to ensure drainage. We report a patient who developed cystic duct remnant mucocele after the latter approach was adopted. We believe that this is likely related to delayed anastomotic stricturing, which prevented draining from the remnant cystic duct. We also discuss the incidence, pathology, investigations, and treatment of this condition.