[IgG4-related systemic disease with autoimmune pancreatitis and lung involvement primarily presenting as pancreatic cancer with pulmonary metastases]. / IgG4-assoziierte Autoimmunpankreatitis und Lungenerkrankung mit der primären, klinischen Präsentation eines pulmonal metastasierten Pankreaskarzinoms.

BACKGROUND: After the first case publication using the term "autoimmune pancreatitis" in 1995 and the successful treatment with steroids we now can distinguish between two clinical und histopathological forms of autoimmune pancreatitis. Type 1 autoimmune pancreatitis (AIP) is usually part of an IgG4-related systemic disease. AIP Typ 2 is an IgG4-independent pancreatic disease. For both entities pancreas cancer is the most important differential diagnosis. CASE REPORT: We report the case of an 82-year-old male patient who primarily presented with obstructive jaundice. Computed tomography (CT) revealed the typical image of a small cancer of the head of the pancreas with pulmonary metastases. After endoscopic drainage of the bile duct a CT-guided biopsy of a pulmonary nodule was performed in which cancer was ruled out. Next the patient was treated with steroids because of "tumour-associated cachexia". In the follow-up the mass in the head of the pancreas like the lung nodules had surprisingly disappeared. In the complete work-up the immune histochemical staining of the lung biopsy revealed subsequently a typical IgG4-associated inflammation. After termination of the therapy the disease relapsed as sclerosing cholangitis. CONCLUSION: The IgG4-related systemic disease with AIP can present as cancer of the pancreas with lung metastases. Extrapancreatic IgG4-positive histopathology and response to therapy with steroids can help to diagnose the disease in complex clinical presentations.

Duplex ultrasonography versus arteriography in the diagnosis of arterial injury: an experimental study.

Duplex ultrasonography (DUS) and arteriography (ART) were evaluated using an experimental model of arterial trauma in order to determine the accuracy of DUS compared with ART and to define the characteristic ultrasonographic features of arterial injuries. Occlusions (n = 19), blunt injuries (n = 24), lacerations (n = 25), arteriovenous fistulae (n = 13), or no injuries (sham, n = 19) were surgically created in the femoral and carotid arteries of 25 dogs. Following closure of the incisions, DUS was performed and interpreted by a staff vascular surgeon without knowledge of the presence or type of injury. Biplane selective ART was evaluated by an independent staff radiologist. Although DUS and ART were equally accurate in evaluating arterial injuries, DUS was more sensitive (90.1% +/- 3.3% versus 80.2% +/- 4.4%, p = 0.002) and better at identifying lacerated arteries (p = 0.01). However, ART had greater specificity (94.7% +/- 5.1% versus 68.4% +/- 10.7%, p = 0.04) and was more accurate for identifying normal arteries (p = 0.04). The validity of DUS increased in the latter half of the study, thus demonstrating a learning curve. Duplex ultrasonography was a more sensitive screening modality than ART for evaluating arterial injuries in our experimental model, thereby supporting its use in clinical trials to evaluate its accuracy, reliability, and cost effectiveness in the trauma setting. Furthermore, management decisions can be based on the specific type of injury, pathologic condition of the arterial wall, and hemodynamic factors identified by DUS. Clinically occult arterial injuries can be followed by repeat DUS to define the natural history of these injuries.

The efficacy of palliative and definitive percutaneous versus surgical drainage of pancreatic abscesses and pseudocysts: a prospective study of 85 patients.

We compared the efficacy of percutaneous to surgical drainage in a prospective study in 85 patients with pancreatic abscesses and pseudocysts. Percutaneous drainage of pancreatic abscesses in 18 patients cured three and palliated 12 who were eventually cured by elective surgical ablation; three patients died. This compares well to our 15 surgical patients, of whom four were cured by surgery alone and six were palliated. All were subsequently cured by additional computerized tomography-guided or ultrasound-guided percutaneous drainage and medical management or surgery. Five of the 15 died. Percutaneous drainage cured 11 of 14 infected pseudocysts and palliated two, which were subsequently cured by surgery; one was palliated but the patient was lost to follow-up. Surgical drainage cured six of 12 infected pseudocysts and palliated the other six, of which four were cured by further surgery and the other two were cured by secondary percutaneous drainage. Nine of 12 noninfected pseudocysts were cured by percutaneous aspiration, and two were palliated and later cured. In one patient, disease progressed, and he was ultimately lost to follow-up. Thirteen of 14 noninfected pseudocysts were cured by surgical drainage. The other patient died of pulmonary embolus. In patients treated by percutaneous techniques, there were four major complications. Our study established distinct advantages of percutaneous drainage under computerized tomographic and ultrasonic guidance: (1) the procedures can be carried out under ultrasonic guidance in an intensive care unit on critically ill patients, (2) the technique proved highly effective for initial palliation, with defervescence and stabilization occurring in most critically ill patients within 48 hours, (3) findings from fine needle aspiration provided valuable information as to microorganisms and antibiotic sensitivities and differed in 29 of 85 patients from those of concomitant blood cultures, and (4) definitive eradication of the process (surgical ablation of residual necrotic material) can be elected after the patient's clinical condition stabilizes.

Optimizing renal DMSA-scintigraphy with 7-pinhole collimator.

Multiple pinhole emission tomographic imaging techniques are currently being applied to imaging of organs of a limited size. The purpose of this study was to evaluate the feasibility of this technique in kidney imaging with Tc99m-DMSA. A 7-pinhole collimator having 4.5 mm. pinhole apertures was used in conjunction with a widefield camera. Left and right kidney were imaged separately. Twelve small renal cysts with a diameter of 1 to 3.5 cm. verified by US or CAT were investigated by 7-pinhole and planar scintigraphy. Eight of 12 renal cysts were identified by 7-pinhole scintigraphy whereas only one cyst was seen by planar scintigraphy. The borderline of cysts detection was 1.5 cm. in 7-pinhole tomography. Basing on these comparative studies and experiences on many patient investigations it seems reasonable to perform renal scintigraphy with 7-pinhole tomography in a routine manner.