Autoimmune pancreatitis

Case contributed by Vasily Cherepanov
Diagnosis certain

Presentation

Recent diagnosis of ulcerative colitis, presenting to ED with sudden onset of jaundice , nausea and epigastric discomfort.

Patient Data

Age: 20 years
Gender: Female
ultrasound
  • pancreas
    • rounded/swollen, hypoechoic parenchyma (even for a young patient) with distinct lobulations at the head of the pancreas. No visible mass or stone and no pancreatic ductal dilation.
  • common bile duct
    • the CBD is distended to 15 mm with sludge in the distal CBD and an abrupt transition as it enters the pancreatic head.
  • gallbladder
    • echogenic bile sludge is present without acoustic shadowing to indicate the presence of stone. No localized tenderness. No wall thickening or pericholecystic fluid. Negative Murphy.
  • intrahepatic ducts
    • moderate dilatation of the intrahepatic ducts measuring up to 6 mm centrally on the right and left side. No obstructing lesion identified at the porta hepatis
mri

Pancreas

The pancreas is enlarged and bulky in appearance, particularly through the head and body segments. The tail is slightly atrophied in appearance. The pancreatic duct is not dilated measuring under 2 mm but appears slightly irregular through its course. There is loss of surface lobulation, delayed parenchymal enhancement and increased signal on diffusion imaging. The overall constellation of features raises concern of autoimmune pancreatitis.

Gallbladder

The gallbladder is bile-filled and contains layering sludge.
Bile ducts: The CBD is dilated tapering to the level of the pancreatic head. The CBD channel through the pancreatic head appears small in caliber and incompletely visualized through its course. The intrahepatic ducts are dilated.

Case Discussion

The cause of obstruction was not clearly delineated on ultrasound and MRCP was recommended which showed a constellation of features most in keeping with autoimmune pancreatitis. 

CBD was stented during ERCP and a biopsy showed prominent IgG4 positive lymphocytic infiltration. 

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