- Email: [email protected]
Acute recurrent biliary pancreatitis associated with the ABCB4 gene mutation
© 2007. Elsevier Masson SAS. Tous droits réservés
CASE REPORT
Gastroenterol Clin Biol 2007;31:106-109
Acute recurrent biliary pancreatitis associated with the ABCB4 gene mutation
Francine FEIN (1), Brigitte HERMELIN (2), Marie-Claude BECKER (3), Sophie FELIX (4), Franck CARBONNEL (1) (1) Services de Gastroentérologie ; (2) Service de Biochimie, CHU Saint-Antoine, 75012 Paris ; (3) Hépatologie ; (4) Anatomopathologie, CHU Jean Minjoz, 25000 Besançon.
RÉSUMÉ
SUMMARY
The ABCB4 gene codes for a protein involved in the transport of phosphatidylcholine across the canalicular membrane of the hepatocyte. ABCB4 gene defects have been associated with progressive familial intrahepatic cholestasis type 3, intrahepatic cholestasis of pregnancy, adult biliary cirrhosis and the more recently described low phospholipid associated cholelithiasis syndrome. The present paper describes 2 probands with a long history of recurrent pancreatitis and cholelithiasis and the same heterozygous, as yet undescribed del 3683>3688 within exon 28 of the ABCB4 gene resulting in a loss of function. This report shows that ABCB4 mutations may cause acute recurrent biliary pancreatitis.
Pancréatites aiguës biliaires récidivantes associées à une mutation du gène ABCB4
Introduction
old at the onset of symptoms [10, 11]. This syndrome has been referred to as low phospholipid associated cholelithiasis (LPAC). We describe 2 patients, 1 brother and 1 sister with acute recurrent pancreatitis who relapsed after cholecystectomy but responded to oral ursodesoxycholic acid. Both had the same, as yet undescribed, heterozygous mutation of the ABCB4 gene that led to loss of function. This report shows that ABCB4 mutations may cause acute recurrent pancreatitis.
Francine FEIN, Brigitte HERMELIN, Marie-Claude BECKER, Sophie FELIX, Franck CARBONNEL
(Gastroenterol Clin Biol 2007;31:106-109)
Le gène ABCB4 code pour une protéine impliquée dans le transport de la phosphatidylcholine à travers la membrane canaliculaire de l’hépatocyte. Des anomalies du gène ABCB4 ont été associées à la cholestase intrahépatique progressive familiale de type 3, la cholestase intrahépatique de la grossesse, les cirrhoses biliaires de l’adulte et le syndrome récemment décrit sous le nom de « low phospholipid associated cholelithiasis ». Le présent article décrit deux malades, frère et sœur, atteints de pancréatites aiguës récidivantes et de lithiase biliaire, porteurs de la même délétion (jusqu’à présent non décrite) 3 683 > 3 688 de l’exon 28 du gène ABCB4, résultant en une perte de fonction. Ces observations montrent que les mutations du gène ABCB4 peuvent être à l’origine de pancréatites biliaires récidivantes.
Acute pancreatitis is a severe complication of biliary stones or sludge. Cholelithiasis is thought to account for 35-43% of all cases of acute pancreatitis [1-3]. After routine investigations, no obvious aetiology is identified in 16-30% of the cases [1, 3]. After intensive biliary investigations (such as ERCP or endoscopic ultrasonography) or follow up 21-73% of patients with unexplained acute pancreatitis are shown to have cholelithiasis [3, 4]. Previous studies have shown that patients with acute recurrent pancreatitis and biliary sludge have a low phospholipid concentrations in bile [5].
Case reports Patient 1
The ABCB4 gene codes for a protein involved in the transport of phosphatidylcholine across the canalicular membrane of the hepatocyte. Phospholipids transported from the hepatocyte into the bile keep cholesterol in solution. It has been shown that the gene defect associated with progressive familial intrahepatic cholestasis type 3 lies in ABCB4 [6]. Intrahepatic cholestasis of pregnancy [7] and adult biliary cirrhosis [8, 9] have also been associated with ABCB4 mutations. It has also been reported that gene defects in ABCB4 may be associated with peculiar forms of gallstone disease characterized by low phospholipid concentrations in bile, recurrent symptoms after cholecystectomy, intrahepatic hyperechoic foci or sludge in patients less than 40 years
This patient was born in 1961. She has a brother (case 2) and 2 sisters. Her aunt (her mother’s dizygotic twin sister) had cholelithiasis for which she underwent a cholecystectomy (figure 1). She had been treated with oral contraceptives (Adepal® from 1979 to 1982 and Diane 35® from 1982 to 1989). In 1981 she had severe epigastric pain for 15 days that resolved spontaneously. From 1981 to 1985, she was symptomfree. In 1983, she had her first pregnancy which was uneventful. In February 1985, a diagnosis of acute pancreatitis was made on the basis of prolonged, severe epigastric pain and increased serum amylase levels, 30 times above the upper limit of normal values. Serum ALAT and ASAT activity was increased 6 times above the upper limit of normal values. Abdominal CT scan was normal and an ultrasound examination showed biliary sludge within the gallbladder. A cholecystectomy was performed in March 1985; the intraoperative cholangiography was normal. Between 1985 and 1993 she had several bouts of acute epigastric pain with or without increased serum amylase and transaminase activity. Her second pregnancy in 1989 was uneventful. Oral contraceptives (Diane 35®) were prescribed for 3 months after delivery; and were replaced by an intrauterine device for 3 years during which she was symptom-free. Then, oral contraceptives were prescribed from 1992 to 2003 (Diane 35® from 1992 to 2001; Melodia® from 2001 to 2003).
Reprints: F. CARBONNEL, Service de Gastroentérologie et Nutrition, CHU de Besançon, 25030 Besançon. E-mail : [email protected]
106
Acute recurrent biliary pancreatitis associated with the ABCB4 gene mutation
abdominal pain and fever recurred and resolved with the same antibiotics. Liver ultrasound showed that the intrahepatic bile ducts of the left lobe were enlarged. Biliary and pancreatic endoscopic ultrasonography were normal, a liver biopsy showed intrahepatic cholestasis. Several abdominal ultrasound examinations were performed and showed intrahepatic hyperechoic foci within the liver parenchyma and the intrahepatic bile ducts (figure 2). Treatment with ursodesoxycholic acid at a dose of 10 mg/kg/d was started in 1995. Acute epigastric pain recurred in November 1996 while the patient was being treated with ursodesoxycholic acid at a dose of 15 mg/kg/d. In February 1998 while she was still receving ursodesoxycholic acid at a dose of 15 mg/kg/d, she had acute epigastric pain. A stone was found in the common bile duct and removed during an ERCP. Liver function tests returned to normal values. Ursodesoxycholic acid was maintained at a dose of 10 mg/kg. In 2001, a liver ultrasound examination showed an intrahepatic hyperechoic foci in segment VI. The patient was seen in July 2004, she was in good health, and symptom-free.
? 45 II-7
+
+
24
34
Pt 1
Pt 2
? III-14
-
Patient 2
IV-2
Fig. 1 – Pedigree of family of the 2 patients studied. Four members of this family had a history of cholelithiasis. Patient II-7 had a cholecystectomy at 45 for biliary colic, search for ABCB4 was not performed. Patient 1 had her first biliary symptoms at 24 and was found to be mutated for ABCB4. Patient 2 had his first biliary symptoms at 34 and was found to be mutated for ABCB4. Patient III-14 had his first biliary symptoms at 30; search for ABCB4 mutation has not been performed. Arbre généalogique des 2 malades présentés. Quatre membres de cette famille ont présenté un ou plusieurs épisodes en rapport avec une lithiase biliaire. Le malade II-7 a eu une cholécystectomie à l’âge de 45 ans pour colique hépatique, la recherche du gène ABCB4 n’a pas été effectué. La malade 1 a eu ses premiers symptômes à l’âge de 24 ans et présentait une mutation du gène ABCB4. Le malade 2 a eu ses premiers symptômes biliaires à l’âge de 34 ans et présentait une mutation du gène ABCB4. Le malade III-14 a eu les premières manifestations biliaires à l’âge de 30 ans; la recherche de la mutation n’a pas été réalisée.
The patient was born in 1965. In 1999, he was admitted for severe epigastric pain and increased transaminase levels. Biliary sludge and dilatation of the intra and extrahepatic bile ducts were found on abdominal ultrasound. A cholecystectomy was performed, intraoperative cholangiography was found to be normal. Liver biopsy was normal. One week after the cholecystectomy he had loss of vision in the left eye. A posterior uveitis and thrombosis of the central retinal vein were found. Corticosteroids and cyclosporine were started in February 2001. In May 2001 an increase in serum alkaline phosphatase (4 times above the upper limit of normal), γGT (13 times above the upper limit of normal), ASAT (4 times above the upper limit of normal) and ALAT (5 times above the upper limit of normal) were discovered. A liver biopsy was performed and showed pericentrolobular cholestasis and eosinophils within the portal space (figure 3). Biliary and pancreatic endoscopic ultrasonography examination was normal. Cyclosporine was discontinued, liver function tests improved and returned to normal values in July 2001. Azathioprine was started in April 2002. In October 2002, the patient had severe and prolonged epigastric pain. Serum lipase levels were above 1500 IU/liter (Normal values 114-286) and serum amylase levels were 9.5 times above the upper limit of normal, ASAT and ALAT were also increased (4 and 2.5 times above the upper limit of normal). A new abdominal ultrasound examination showed intrahepatic hyperechoic foci. Abdominal CT scan and MR cholangiography were normal. Oral intake was resumed and pain did not recur. Ursodesoxycholic acid was begun at a dose of 10 mg/kg and azathioprine was
In May 1993 she was admitted for acute pancreatitis. An ERCP was performed and was found to be normal; an endoscopic sphincterotomy was performed. She developed septicaemia from Pseudomonas Aeruginosa. Jaundice and cholestasis appeared. Fever and cholestasis resolved with vancomycine, amikacine and imipenem intravenously. In October 1993,
A B Fig. 2 – Liver ultrasound in patient 1 showing hyperechoic foci within the liver parenchyma (arrow, panel A) and the intrahepatic bile ducts (arrow, panel B). Échographie hépatique du malade 1 montrant une calcification intrahépatique (flèche image A) et la présence d’un calcul dans une voie biliaire intrahépatique (flèche, image B).
107
F. Fein et al.
a b Fig. 3 – Liver biopsy in patient 2 showing intrahepatic cholestasis within the cytoplasm of the hepatocytes. These abnormalities predominate in the centrolobular space (arrow panel a). Liver biopsy in patient 2 showing eosinophils within the portal space (PS) suggesting drug-induced liver injury (arrow panel b). Biopsie du foie chez le malade 2 montrant un cholestase intrahépatique, intracytoplasmique à prédominance centrolobulaire (flèche image a). Chez le même malade, on note la présence d’éosinophiles dans l’espace porte (PS), suggérant l’origine médicamenteuse de la cholestase (flèche, image b).
was treated with azathioprine, a drug that can induce pancreatitis. However, azathioprine-induced pancreatitis generally occurs within 6 weeks after the drug is begun whereas 6 months elapsed between the start of azathioprine and pancreatitis and it did not recur even though azathioprine was continued.
continued. After twenty four months of follow up, the patient is in good health and symptom-free.
Mutation screening Mutations were screened as previously described [10, 11]. Briefly, genomic DNA was obtained using standard procedures. Polymerase chain reaction was performed using specific primers of exons and splice junctions. PCR reaction products were purified on a Sephadex (Pharmacia) column and sequenced with Big Dye Terminator chemistry (Applied Biosystems, Applera France SA, Courtaboeuf, France). Identification and localization of ABCB4 gene mutations and SNPs were assessed by sequence comparisons with Seqscape Software (version 1; Applied Biosystems). Patients gave informed consent to search for mutations within the ABCB4 gene. Both were found to have a mutation 1769G>A within exon 15 and del 3683>3688 within exon 28.
It can be hypothesized that, in patient 1, oral contraceptives contributed to cholelithiasis and in patient 2 cyclosporine contributed to cholestasis. ABCB4 mutations and drugs may have both contributed to cholelithiasis and cholestatic liver disease. However, the role of ABCB4 mutations in drug-induced cholestasis deserves further study. In conclusion, the present paper shows that acute biliary pancreatitis should be added to the clinical spectrum of diseases associated with the ABCB4 gene defect. The ABCB4 gene defect should be added to the list of causes of acute recurrent pancreatitis of a biliary origin. The search for mutations should be performed in patients with acute biliary pancreatitis who exhibit other features of the LPAC syndrome.
Discussion
REFERENCES
These two probands have a longstanding history of recurrent pancreatitis and cholelithiasis and the same mutation in the ABCB4 gene. The1769G>A within exon 15 is a polymorphism and does not seem to have functional consequences. In contrast, the as yet undescribed, del 3683>3688 within exon 28 leads to a deletion in the ATP binding site of the protein resulting in a loss of function. These 2 case reports confirm the results reported by Rosmorduc et al. who found that ABCB4 gene mutation-associated cholelithiasis (including cholangitis and pancreatitis) recurred after cholecystectomy, was associated with intrahepatic hyperechoic foci and sludge with an onset of symptoms in patients less than 40 years old [10, 11]. In our patients, acute pancreatitis was associated with, and a prominent feature of, LPAC. Acute pancreatitis had all the characteristics of a biliary origin and was associated with the other typical features of LPAC.
1. Di Magno EP, Chari S. Acute pancreatitis in Sleisenger and Fordtran’s Gastrointestinal disease. Philadelphia: WB Saunders 2002.
2. Appelros S, Borgstrom A. Incidence, aetiology and mortality rate of acute pancreatitis over 10 years in a defined urban population in Sweden. Br J Surg 1999;86:465-70.
3. Maes B, Hastier P, Buckley MJ, Peten EP, Paolini O, Staccini P, et al.
Extensive aetiological investigations in acute pancreatitis: results of a 1-year prospective study. Eur J Gastroenterol Hepatol 1999;11:891-6.
4. Ros E, Navarro S, Bru C, Garcia-Puges A, Valderrama R. Occult mi-
crolithiasis in ‘idiopathic’ acute pancreatitis: prevention of relapses by cholecystectomy or ursodeoxycholic acid therapy. Gastroenterology 1991;101:1701-9.
5. Fracchia M, Pellegrino S, Secreto P, Gallo L, Masoero G, Pera A,
et al. Biliary lipid composition in cholesterol microlithiasis. Gut 2001; 48:702-6.
Other causes of acute pancreatitis were eliminated in these 2 patients. In case 1, sphincter of Oddi dysfunction was not consistent with other features of the case such as intrahepatic cholestasis and hyperechoic foci; moreover, endoscopic sphincterotomy did not improve the patient’s condition. In case 2, the presence of posterior uveitis suggested associated primary sclerosing cholangitis. This diagnosis was eliminated by the normal MR cholangiography findings and liver biopsy results. Patient 2
6. de Vree JM, Jacquemin E, Sturm E, Cresteil D, Bosma PJ, Aten J,
et al. Mutations in the MDR3 gene cause progressive familial intrahepatic cholestasis. Proc Natl Acad Sci USA 1998;95:282-7.
7. Jacquemin E, Cresteil D, Manouvrier S, Boute O, Hadchouel M.
Heterozygous non-sense mutation of the MDR3 gene in familial intrahepatic cholestasis of pregnancy. Lancet 1999;353:210-1.
8. Jacquemin E, de Vree JM, Cresteil D, Sokal EM, Sturm E, Dumont M, et al. The wide spectrum of multidrug resistance 3 deficiency: from
108
Acute recurrent biliary pancreatitis associated with the ABCB4 gene mutation
10. Rosmorduc O, Hermelin B, Poupon R. MDR3 gene defect in adults
neonatal cholestasis to cirrhosis of adulthood. Gastroenterology 2001;120:1448-58.
with symptomatic intrahepatic and gallbladder cholesterol cholelithiasis. Gastroenterology 2001;120:1459-67.
9. Lucena JF, Herrero JI, Quiroga J, Sangro B, Garcia-Foncillas J,
11. Rosmorduc O, Hermelin B, Boelle PY, Parc R, Taboury J, Poupon R.
Zabalegui N, et al. A multidrug resistance 3 gene mutation causing cholelithiasis, cholestasis of pregnancy, and adulthood biliary cirrhosis. Gastroenterology 2003;124:1037-42.
ABCB4 gene mutation-associated cholelithiasis in adults. Gastroenterology 2003;125:452-9.
109
CASE REPORT
Gastroenterol Clin Biol 2007;31:106-109
Acute recurrent biliary pancreatitis associated with the ABCB4 gene mutation
Francine FEIN (1), Brigitte HERMELIN (2), Marie-Claude BECKER (3), Sophie FELIX (4), Franck CARBONNEL (1) (1) Services de Gastroentérologie ; (2) Service de Biochimie, CHU Saint-Antoine, 75012 Paris ; (3) Hépatologie ; (4) Anatomopathologie, CHU Jean Minjoz, 25000 Besançon.
RÉSUMÉ
SUMMARY
The ABCB4 gene codes for a protein involved in the transport of phosphatidylcholine across the canalicular membrane of the hepatocyte. ABCB4 gene defects have been associated with progressive familial intrahepatic cholestasis type 3, intrahepatic cholestasis of pregnancy, adult biliary cirrhosis and the more recently described low phospholipid associated cholelithiasis syndrome. The present paper describes 2 probands with a long history of recurrent pancreatitis and cholelithiasis and the same heterozygous, as yet undescribed del 3683>3688 within exon 28 of the ABCB4 gene resulting in a loss of function. This report shows that ABCB4 mutations may cause acute recurrent biliary pancreatitis.
Pancréatites aiguës biliaires récidivantes associées à une mutation du gène ABCB4
Introduction
old at the onset of symptoms [10, 11]. This syndrome has been referred to as low phospholipid associated cholelithiasis (LPAC). We describe 2 patients, 1 brother and 1 sister with acute recurrent pancreatitis who relapsed after cholecystectomy but responded to oral ursodesoxycholic acid. Both had the same, as yet undescribed, heterozygous mutation of the ABCB4 gene that led to loss of function. This report shows that ABCB4 mutations may cause acute recurrent pancreatitis.
Francine FEIN, Brigitte HERMELIN, Marie-Claude BECKER, Sophie FELIX, Franck CARBONNEL
(Gastroenterol Clin Biol 2007;31:106-109)
Le gène ABCB4 code pour une protéine impliquée dans le transport de la phosphatidylcholine à travers la membrane canaliculaire de l’hépatocyte. Des anomalies du gène ABCB4 ont été associées à la cholestase intrahépatique progressive familiale de type 3, la cholestase intrahépatique de la grossesse, les cirrhoses biliaires de l’adulte et le syndrome récemment décrit sous le nom de « low phospholipid associated cholelithiasis ». Le présent article décrit deux malades, frère et sœur, atteints de pancréatites aiguës récidivantes et de lithiase biliaire, porteurs de la même délétion (jusqu’à présent non décrite) 3 683 > 3 688 de l’exon 28 du gène ABCB4, résultant en une perte de fonction. Ces observations montrent que les mutations du gène ABCB4 peuvent être à l’origine de pancréatites biliaires récidivantes.
Acute pancreatitis is a severe complication of biliary stones or sludge. Cholelithiasis is thought to account for 35-43% of all cases of acute pancreatitis [1-3]. After routine investigations, no obvious aetiology is identified in 16-30% of the cases [1, 3]. After intensive biliary investigations (such as ERCP or endoscopic ultrasonography) or follow up 21-73% of patients with unexplained acute pancreatitis are shown to have cholelithiasis [3, 4]. Previous studies have shown that patients with acute recurrent pancreatitis and biliary sludge have a low phospholipid concentrations in bile [5].
Case reports Patient 1
The ABCB4 gene codes for a protein involved in the transport of phosphatidylcholine across the canalicular membrane of the hepatocyte. Phospholipids transported from the hepatocyte into the bile keep cholesterol in solution. It has been shown that the gene defect associated with progressive familial intrahepatic cholestasis type 3 lies in ABCB4 [6]. Intrahepatic cholestasis of pregnancy [7] and adult biliary cirrhosis [8, 9] have also been associated with ABCB4 mutations. It has also been reported that gene defects in ABCB4 may be associated with peculiar forms of gallstone disease characterized by low phospholipid concentrations in bile, recurrent symptoms after cholecystectomy, intrahepatic hyperechoic foci or sludge in patients less than 40 years
This patient was born in 1961. She has a brother (case 2) and 2 sisters. Her aunt (her mother’s dizygotic twin sister) had cholelithiasis for which she underwent a cholecystectomy (figure 1). She had been treated with oral contraceptives (Adepal® from 1979 to 1982 and Diane 35® from 1982 to 1989). In 1981 she had severe epigastric pain for 15 days that resolved spontaneously. From 1981 to 1985, she was symptomfree. In 1983, she had her first pregnancy which was uneventful. In February 1985, a diagnosis of acute pancreatitis was made on the basis of prolonged, severe epigastric pain and increased serum amylase levels, 30 times above the upper limit of normal values. Serum ALAT and ASAT activity was increased 6 times above the upper limit of normal values. Abdominal CT scan was normal and an ultrasound examination showed biliary sludge within the gallbladder. A cholecystectomy was performed in March 1985; the intraoperative cholangiography was normal. Between 1985 and 1993 she had several bouts of acute epigastric pain with or without increased serum amylase and transaminase activity. Her second pregnancy in 1989 was uneventful. Oral contraceptives (Diane 35®) were prescribed for 3 months after delivery; and were replaced by an intrauterine device for 3 years during which she was symptom-free. Then, oral contraceptives were prescribed from 1992 to 2003 (Diane 35® from 1992 to 2001; Melodia® from 2001 to 2003).
Reprints: F. CARBONNEL, Service de Gastroentérologie et Nutrition, CHU de Besançon, 25030 Besançon. E-mail : [email protected]
106
Acute recurrent biliary pancreatitis associated with the ABCB4 gene mutation
abdominal pain and fever recurred and resolved with the same antibiotics. Liver ultrasound showed that the intrahepatic bile ducts of the left lobe were enlarged. Biliary and pancreatic endoscopic ultrasonography were normal, a liver biopsy showed intrahepatic cholestasis. Several abdominal ultrasound examinations were performed and showed intrahepatic hyperechoic foci within the liver parenchyma and the intrahepatic bile ducts (figure 2). Treatment with ursodesoxycholic acid at a dose of 10 mg/kg/d was started in 1995. Acute epigastric pain recurred in November 1996 while the patient was being treated with ursodesoxycholic acid at a dose of 15 mg/kg/d. In February 1998 while she was still receving ursodesoxycholic acid at a dose of 15 mg/kg/d, she had acute epigastric pain. A stone was found in the common bile duct and removed during an ERCP. Liver function tests returned to normal values. Ursodesoxycholic acid was maintained at a dose of 10 mg/kg. In 2001, a liver ultrasound examination showed an intrahepatic hyperechoic foci in segment VI. The patient was seen in July 2004, she was in good health, and symptom-free.
? 45 II-7
+
+
24
34
Pt 1
Pt 2
? III-14
-
Patient 2
IV-2
Fig. 1 – Pedigree of family of the 2 patients studied. Four members of this family had a history of cholelithiasis. Patient II-7 had a cholecystectomy at 45 for biliary colic, search for ABCB4 was not performed. Patient 1 had her first biliary symptoms at 24 and was found to be mutated for ABCB4. Patient 2 had his first biliary symptoms at 34 and was found to be mutated for ABCB4. Patient III-14 had his first biliary symptoms at 30; search for ABCB4 mutation has not been performed. Arbre généalogique des 2 malades présentés. Quatre membres de cette famille ont présenté un ou plusieurs épisodes en rapport avec une lithiase biliaire. Le malade II-7 a eu une cholécystectomie à l’âge de 45 ans pour colique hépatique, la recherche du gène ABCB4 n’a pas été effectué. La malade 1 a eu ses premiers symptômes à l’âge de 24 ans et présentait une mutation du gène ABCB4. Le malade 2 a eu ses premiers symptômes biliaires à l’âge de 34 ans et présentait une mutation du gène ABCB4. Le malade III-14 a eu les premières manifestations biliaires à l’âge de 30 ans; la recherche de la mutation n’a pas été réalisée.
The patient was born in 1965. In 1999, he was admitted for severe epigastric pain and increased transaminase levels. Biliary sludge and dilatation of the intra and extrahepatic bile ducts were found on abdominal ultrasound. A cholecystectomy was performed, intraoperative cholangiography was found to be normal. Liver biopsy was normal. One week after the cholecystectomy he had loss of vision in the left eye. A posterior uveitis and thrombosis of the central retinal vein were found. Corticosteroids and cyclosporine were started in February 2001. In May 2001 an increase in serum alkaline phosphatase (4 times above the upper limit of normal), γGT (13 times above the upper limit of normal), ASAT (4 times above the upper limit of normal) and ALAT (5 times above the upper limit of normal) were discovered. A liver biopsy was performed and showed pericentrolobular cholestasis and eosinophils within the portal space (figure 3). Biliary and pancreatic endoscopic ultrasonography examination was normal. Cyclosporine was discontinued, liver function tests improved and returned to normal values in July 2001. Azathioprine was started in April 2002. In October 2002, the patient had severe and prolonged epigastric pain. Serum lipase levels were above 1500 IU/liter (Normal values 114-286) and serum amylase levels were 9.5 times above the upper limit of normal, ASAT and ALAT were also increased (4 and 2.5 times above the upper limit of normal). A new abdominal ultrasound examination showed intrahepatic hyperechoic foci. Abdominal CT scan and MR cholangiography were normal. Oral intake was resumed and pain did not recur. Ursodesoxycholic acid was begun at a dose of 10 mg/kg and azathioprine was
In May 1993 she was admitted for acute pancreatitis. An ERCP was performed and was found to be normal; an endoscopic sphincterotomy was performed. She developed septicaemia from Pseudomonas Aeruginosa. Jaundice and cholestasis appeared. Fever and cholestasis resolved with vancomycine, amikacine and imipenem intravenously. In October 1993,
A B Fig. 2 – Liver ultrasound in patient 1 showing hyperechoic foci within the liver parenchyma (arrow, panel A) and the intrahepatic bile ducts (arrow, panel B). Échographie hépatique du malade 1 montrant une calcification intrahépatique (flèche image A) et la présence d’un calcul dans une voie biliaire intrahépatique (flèche, image B).
107
F. Fein et al.
a b Fig. 3 – Liver biopsy in patient 2 showing intrahepatic cholestasis within the cytoplasm of the hepatocytes. These abnormalities predominate in the centrolobular space (arrow panel a). Liver biopsy in patient 2 showing eosinophils within the portal space (PS) suggesting drug-induced liver injury (arrow panel b). Biopsie du foie chez le malade 2 montrant un cholestase intrahépatique, intracytoplasmique à prédominance centrolobulaire (flèche image a). Chez le même malade, on note la présence d’éosinophiles dans l’espace porte (PS), suggérant l’origine médicamenteuse de la cholestase (flèche, image b).
was treated with azathioprine, a drug that can induce pancreatitis. However, azathioprine-induced pancreatitis generally occurs within 6 weeks after the drug is begun whereas 6 months elapsed between the start of azathioprine and pancreatitis and it did not recur even though azathioprine was continued.
continued. After twenty four months of follow up, the patient is in good health and symptom-free.
Mutation screening Mutations were screened as previously described [10, 11]. Briefly, genomic DNA was obtained using standard procedures. Polymerase chain reaction was performed using specific primers of exons and splice junctions. PCR reaction products were purified on a Sephadex (Pharmacia) column and sequenced with Big Dye Terminator chemistry (Applied Biosystems, Applera France SA, Courtaboeuf, France). Identification and localization of ABCB4 gene mutations and SNPs were assessed by sequence comparisons with Seqscape Software (version 1; Applied Biosystems). Patients gave informed consent to search for mutations within the ABCB4 gene. Both were found to have a mutation 1769G>A within exon 15 and del 3683>3688 within exon 28.
It can be hypothesized that, in patient 1, oral contraceptives contributed to cholelithiasis and in patient 2 cyclosporine contributed to cholestasis. ABCB4 mutations and drugs may have both contributed to cholelithiasis and cholestatic liver disease. However, the role of ABCB4 mutations in drug-induced cholestasis deserves further study. In conclusion, the present paper shows that acute biliary pancreatitis should be added to the clinical spectrum of diseases associated with the ABCB4 gene defect. The ABCB4 gene defect should be added to the list of causes of acute recurrent pancreatitis of a biliary origin. The search for mutations should be performed in patients with acute biliary pancreatitis who exhibit other features of the LPAC syndrome.
Discussion
REFERENCES
These two probands have a longstanding history of recurrent pancreatitis and cholelithiasis and the same mutation in the ABCB4 gene. The1769G>A within exon 15 is a polymorphism and does not seem to have functional consequences. In contrast, the as yet undescribed, del 3683>3688 within exon 28 leads to a deletion in the ATP binding site of the protein resulting in a loss of function. These 2 case reports confirm the results reported by Rosmorduc et al. who found that ABCB4 gene mutation-associated cholelithiasis (including cholangitis and pancreatitis) recurred after cholecystectomy, was associated with intrahepatic hyperechoic foci and sludge with an onset of symptoms in patients less than 40 years old [10, 11]. In our patients, acute pancreatitis was associated with, and a prominent feature of, LPAC. Acute pancreatitis had all the characteristics of a biliary origin and was associated with the other typical features of LPAC.
1. Di Magno EP, Chari S. Acute pancreatitis in Sleisenger and Fordtran’s Gastrointestinal disease. Philadelphia: WB Saunders 2002.
2. Appelros S, Borgstrom A. Incidence, aetiology and mortality rate of acute pancreatitis over 10 years in a defined urban population in Sweden. Br J Surg 1999;86:465-70.
3. Maes B, Hastier P, Buckley MJ, Peten EP, Paolini O, Staccini P, et al.
Extensive aetiological investigations in acute pancreatitis: results of a 1-year prospective study. Eur J Gastroenterol Hepatol 1999;11:891-6.
4. Ros E, Navarro S, Bru C, Garcia-Puges A, Valderrama R. Occult mi-
crolithiasis in ‘idiopathic’ acute pancreatitis: prevention of relapses by cholecystectomy or ursodeoxycholic acid therapy. Gastroenterology 1991;101:1701-9.
5. Fracchia M, Pellegrino S, Secreto P, Gallo L, Masoero G, Pera A,
et al. Biliary lipid composition in cholesterol microlithiasis. Gut 2001; 48:702-6.
Other causes of acute pancreatitis were eliminated in these 2 patients. In case 1, sphincter of Oddi dysfunction was not consistent with other features of the case such as intrahepatic cholestasis and hyperechoic foci; moreover, endoscopic sphincterotomy did not improve the patient’s condition. In case 2, the presence of posterior uveitis suggested associated primary sclerosing cholangitis. This diagnosis was eliminated by the normal MR cholangiography findings and liver biopsy results. Patient 2
6. de Vree JM, Jacquemin E, Sturm E, Cresteil D, Bosma PJ, Aten J,
et al. Mutations in the MDR3 gene cause progressive familial intrahepatic cholestasis. Proc Natl Acad Sci USA 1998;95:282-7.
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