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IgG4 Autoimmune Pancreatitis and associated anomalies

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Sausage shaped pancreas with a hypo-attenuating halo suggestive of autoimmune pancreatitis.
Sausage shaped pancreas with a hypo-attenuating halo suggestive of autoimmune pancreatitis.

What is an IgG4 Autoimmune Pancreatitis ?

Auto-immune pancreatitis is a chronic immune-mediated fibroinflammatory disease primarily involving pancreas responding to steroid therapy.

What are the diagnostic criteria for autoimmune IgG4 pancreatitis?

The Mayo Clinic HISORt Criteria are used for confirming the diagnosis. Here are the details:

Mayo Clinic HISORt Criteria for IgG4 Autoimmune Pancreatitis

Histology:

(1) Periductal lymphoplasmacytic infiltrate with obliterative phlebitis and storiform fibrosis (LPSP) OR

(2) Lymphoplasmacytic infiltrate with storiform fibrosis showing abundant (210 cells/HPF) IgG4-positive cells

Imaging:

Typical: diffusely enlarged gland with delayed (rim) enhancement; diffusely irregular, attenuated main pancreatic duct

Others: Focal pancreatic mass/enlargement; focal pancreatic duct stricture; pancreatic atrophy; pancreatic calcification; or pancreatitis

Serology: Elevated serum IgG4 level (>135 mg/dL)

Other Organ Involvement.

Response to steroids.

What are the two subtypes of autoimmune pancreatitis?

Type 1 (lymphoplasmacytic sclerosing pancreatitis) and type 2 (idiopathic duct-centric chronic pancreatitis).

  • Type 1 autoimmune pancreatitis is the pancreatic manifestation of IgG4-related disease.
  • Type 2 has a distinctly different histologic and clinical profile, with no elevation of serum IgG4 concentrations or presence of autoantibodies.
AIP type 1AIP type 2
Geographical distributionAsia > United States, EuropeEurope > United States > Asia
Age at presentation60-70 s40-50 s
GenderMale >> FemaleMale = Female
SymptomsJaundice, Abdominal painJaundice, Abdominal pain
SerologyIgG4, IgG,
Autoantibodies
Usually negative
Pancreatic imagesEnlarged
(focal, diffuse)
Enlarged
(focal, diffuse)
Pancreatic histologyLymphoplasmacytic sclerosingIdiopathic duct-centritic pancreatitis with
granulocyte epithelial lesion.
Extrapancreatic
lesions
Sclerosing cholangitis,
sialoadenitis,
retroperitoneal fibrosis,
interstitional nephritis,
Inflammatory bowel
disease
Steroid responseExcellentExcellent
RRelapseHighRare
Type 1 IgG4 vs type 2 Autoimmune Pancreatitis

What are the other anomalies associated with IgG4 Pancreatitis?

IgG4 disease is a multi-system disorder. Following disorders have been described (Common disorders are highlighted):

  • CNS:
    • Hypertrophic pachymeningitis
    • Autoimmune hypophysitis
    • Orbital pseudotumor
  • Salviay / lacrimal glands:
    • Mikulicz’s disease
    • Kuttner’s tumor
  • Thyroid
    • Riedel’s thyroiditis
    • Hashimoto’s thyroiditis
  • Lungs
    • Pulmonary pseudotumor
    • Interstitial pneumoniaLymphadenopathy
  • Hepatobiliary:
    • Autoimmune pancreatitis
    • Sclerosing cholangitis
    • Liver pseudotumor
  • Retroperitoneal fibrosis
  • Tubulointerstitial nephritis
  • Inflammatory aortic aneurysm
  • Prostatitis, testicular involvement
  • Cutaneous pseudolymphoma

What is the management for IgG4 Autoimmune Pancreatitis?

IgG4 pancreatitis responds well to corticosteroids.

PACS Based Case Images (Arterial and Portal Venous Phase)

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Detailed discussion with video:

References:

  1. Head to toe IgG4 Autoimmune Pancreatitis
  2. Grainger & Allison’s Diagnostic Radiology

More radiology cases:

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