- Email: [email protected]
P.17.20 EUS AND S-MRCP FINDINGS IN ASYMPTOMATIC SUBJECTS WITH CHRONIC PANCREATIC HYPERENZIMEMIA
Abstracts of the 20th National Congress of Digestive Diseases / Digestive and Liver Disease 46S (2014) S1–S144 centimeter in size with small internal cysts, vascular infiltration and main pancreatic duct dilation. Percutaneous biopsy shows cohesive groups of plasmacytoid cells with round-to oval, mildly enlarged nuclei staining positively for synaptophysin and chromogranin at IHC. Patient was not suitable for surgery and started chemiotherapic treatment. Case 2: A 74 year-old man reach our Institution for abdominal pain and weight loss. An abdominal computer tomography shows a cyst with multiple internal micro-cystic spaces located in the head of the pancreas. During contrast-enanched EUS with intravenous Sonovue we described an enanchement of cystic wall and at FNA we shown low levels of CEA and amylase in cystic fluid but was negative for neoplastic cells. Percutaneous biopsy of the lesion shown cohesive groups of plasmacytoid cells with round-to oval, mildly enlarged nuclei. IHC staining was positive for synaptophysin and chromogranin. Conclusions: Pancreatic neuroendocrine tumors usually present as solid, homogeneous mass lesion with a well-defined margin on EUS. However, about 10% of neuroendocrine tumors are cystic. Cystic neuroendocrine tumors are pre-malignant or malignant lesions and require surgical intervention. Cyst Fluid from a cystic NET typically have low CEA and amylase levels. Cytology from the cyst Fluid or the solid component shows cohesive groups of plasmacytoid cells with round-to oval, mildly enlarged nuclei. IHC staining is positive for synaptophysin and chromogranin.
P.17.20 EUS AND S-MRCP FINDINGS IN ASYMPTOMATIC SUBJECTS WITH CHRONIC PANCREATIC HYPERENZIMEMIA R.A. Zuppardo ∗ , M. Di Leo, A. Mariani, M.C. Petrone, G.M. Cavestro, P.G. Arcidiacono, P.A. Testoni Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, Milan, Italy Background and aim: A long-standing increase of serum pancreatic enzymes in asymptomatic subjects is considered a benign idiopathic condition called “non-pathological chronic pancreatic hyperenzymemia” (CPH). However, recent studies showed secretin-MRCP (s-MRCP) has brought to light abnormal pancreatic findings in a significant proportion of these subjects. Aim: To evaluate pancreatic morphological abnormalities using S-MRCP and EUS in CPH patients. Material and methods: 55 consecutive subjects with CPH were investigated with S-MRCP and EUS. EUS findings were compared with 55 consecutive age and sex matched controls who underwent EUS investigation for unrelated to pancreaticobiliary disease (CTR). Results: Abnormal S-MRCP pancreatic findings were present in 23 CPH cases (41.8%): 10 chronic pancreatitis, according to Cambridge classification; 5 pancreas divisum; 3 pancreatic cyst; 5 Vater’s papilla dysfunction. Pathological EUS pancreatic findings were present in 28 CPH cases (50.9%): 7 pancreatic cystic lesion, 5 pancreas divisum, 1 papillitis, 1 NET, 14 chronic pancreatitis (defined by presence of “consistent with CP” or “suggestive of CP” findings using Rosemont criteria). All cases of CP who undergone s-MRCP had pathological EUS findings suggestive for CP too. Normal EUS findings were more significantly frequent in control patients (45) than CPH patient (27) (p<0.05). The two groups have same frequencies in detection of Cystic lesions, pancreas, divisum, papillitis, NET, but chronic pancreatitis was more common in CPH (25.5% vs 7.3%; p<0.05). Conclusions: About half of the patients with asymptomatic chronic pancreatic hyperenzymemia had some pancreatic abnormalities using s-MRCP and EUS. Both these procedures should characterize the diagnostic work-up of these subjects before the hyperenzymemia can be defined with certainly as non-pathological or benign.
S127
P.18.1 RETROSPECTIVE COMPARISON BETWEEN INTERNATIONAL CONSENSUS DIAGNOSTIC CRITERIA (ICDC) WITHOUT HISTOLOGY VS HISTOLOGICAL DIAGNOSIS IN SURGICAL PATIENTS WITH FOCAL AUTOIMMUNE PANCREATITIS T. Ikeura ∗,1 , S. Detlefsen 2 , G. Zamboni 3 , A. Amodio 4 , A. Gabbrielli 4 , L. Benini 4 , K. Okazaki 1 , L. Frulloni 4 1 Third
Department of Internal Medicine, Kansai Medical University, Osaka, Japan; 2 Department of Pathology, Odense University Hospital, Odense, Denmark; 3 Dipartimento di Patologia e Diagnostica, University of Verona, Verona, Italy; 4 Dipartimento di Medicina, University of Verona, Verona, Italy Background and aim: International Consensus Diagnostic Criteria (ICDC) for autoimmune pancreatitis (AIP) have been proposed to diagnose type 1 AIP, type 2 AIP and AIP-not otherwise specified (AIP-NOS). The aim of this international multicenter study was to evaluate the possibility of correctly diagnosing AIP itself and its subtype by ICDC in focal AIP patients. Material and methods: Thirty patients (type 1 AIP in 23 and type 2 AIP in 7) diagnosed as AIP based on histology of surgical specimens were classified according to ICDC based on their preoperative data. Results: Pancreatic core biopsies and diagnostic steroid trial were not preoperatively performed in any of the patients. Based on preoperative data, ICDC diagnosed 6 patients (20%) as type 1 AIP and 24 (80%) as probable AIP. Assuming all patients had responded to a steroid trial preoperatively, ICDC would have diagnosed 8 patients (27%) as type 1 AIP, 4 (13%) as type 2 AIP, 10 as AIP-not otherwise specified (33%) and 8 (27%) as probable AIP. In the hypothetical situation, 7 of 8 type 1 AIP patients and 3 of 3 type 2 AIP patients would have been classified into the correct subtype of AIP. Conclusions: In this retrospective study, the accuracy of ICDC without preoperative histology was quite low. A steroid trial enhances the possibility of correctly diagnosing AIP by ICDC despite of the lack of histology. However, some patients cannot be diagnosed as having AIP or be classified into the correct subtype without histology.
P.18.2 PARADUODENAL PANCREATITIS: VERONA EXPERIENCE ON 112 PATIENTS N. De Pretis, A. Amodio ∗ , A. Granato, G. De Marchi, N. De Pretis, O. Messina, L. Benini, L. Frulloni Dipartimento di Medicina, Univerity of Verona, Verona, Italy Background and aim: Paraduodenal pancreatitis (PP) is a special form of chronic pancreatitis, called also groove pancreatitis or cystic dystrophy of the duodenal wall, defined on surgical specimens. Characteristic findings at CT, MR and EUS has been published. The aim of the study was to evaluate the clinical and radiological features of PP, and the clinical outcome in a mixed clinical and surgical series. Material and methods: All patients with a final diagnosis of PP in Gastroenterology unit and Surgical Department and has been enrolled. Clinical, radiological and pathological data have been collected. The diagnosis was based on surgical specimens in operated pts and on imaging in non operated pts. Results: We studied 112 pts (108 males, 4 females, mean age 41.4±10 yrs), 96.4% of them were drinkers (mean daily alcohol intake: 129.3±65.4 g) and 97.3% smokers (29.2±13.6 cigarettes/day). The clinical onset was acute pancreatitis in 70 pts (63%) and continuous pain in 42 (38%). Other symptoms at onset were vomiting (42 pts – 38%), weight loss (26 pts – 23%) and jaundice (13 pts – 12%). Cystic variant was diagnosed in 79 pts (70%) and solid in 33 (30%). Pure form involving only the groove area was observed in 22 pts (20%) and diffuse form involving all pancreas in 90 (80%). Pancreatic calcifications were diagnosed in 68 pts (61%). 74 pts (70%) underwent surgery, resective in 57 and derivative in 17. The indication for surgery were pain (67 pts – 86%), suspicion of cancer (5 – 6%) and duodenal obstruction (6 – 8%). Mean follow-up time was 5±7 yrs. Diabetes was diagnosed in 28% and steatorrhea in 25%. 10 pts (9%) died.
P.17.20 EUS AND S-MRCP FINDINGS IN ASYMPTOMATIC SUBJECTS WITH CHRONIC PANCREATIC HYPERENZIMEMIA R.A. Zuppardo ∗ , M. Di Leo, A. Mariani, M.C. Petrone, G.M. Cavestro, P.G. Arcidiacono, P.A. Testoni Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, Milan, Italy Background and aim: A long-standing increase of serum pancreatic enzymes in asymptomatic subjects is considered a benign idiopathic condition called “non-pathological chronic pancreatic hyperenzymemia” (CPH). However, recent studies showed secretin-MRCP (s-MRCP) has brought to light abnormal pancreatic findings in a significant proportion of these subjects. Aim: To evaluate pancreatic morphological abnormalities using S-MRCP and EUS in CPH patients. Material and methods: 55 consecutive subjects with CPH were investigated with S-MRCP and EUS. EUS findings were compared with 55 consecutive age and sex matched controls who underwent EUS investigation for unrelated to pancreaticobiliary disease (CTR). Results: Abnormal S-MRCP pancreatic findings were present in 23 CPH cases (41.8%): 10 chronic pancreatitis, according to Cambridge classification; 5 pancreas divisum; 3 pancreatic cyst; 5 Vater’s papilla dysfunction. Pathological EUS pancreatic findings were present in 28 CPH cases (50.9%): 7 pancreatic cystic lesion, 5 pancreas divisum, 1 papillitis, 1 NET, 14 chronic pancreatitis (defined by presence of “consistent with CP” or “suggestive of CP” findings using Rosemont criteria). All cases of CP who undergone s-MRCP had pathological EUS findings suggestive for CP too. Normal EUS findings were more significantly frequent in control patients (45) than CPH patient (27) (p<0.05). The two groups have same frequencies in detection of Cystic lesions, pancreas, divisum, papillitis, NET, but chronic pancreatitis was more common in CPH (25.5% vs 7.3%; p<0.05). Conclusions: About half of the patients with asymptomatic chronic pancreatic hyperenzymemia had some pancreatic abnormalities using s-MRCP and EUS. Both these procedures should characterize the diagnostic work-up of these subjects before the hyperenzymemia can be defined with certainly as non-pathological or benign.
S127
P.18.1 RETROSPECTIVE COMPARISON BETWEEN INTERNATIONAL CONSENSUS DIAGNOSTIC CRITERIA (ICDC) WITHOUT HISTOLOGY VS HISTOLOGICAL DIAGNOSIS IN SURGICAL PATIENTS WITH FOCAL AUTOIMMUNE PANCREATITIS T. Ikeura ∗,1 , S. Detlefsen 2 , G. Zamboni 3 , A. Amodio 4 , A. Gabbrielli 4 , L. Benini 4 , K. Okazaki 1 , L. Frulloni 4 1 Third
Department of Internal Medicine, Kansai Medical University, Osaka, Japan; 2 Department of Pathology, Odense University Hospital, Odense, Denmark; 3 Dipartimento di Patologia e Diagnostica, University of Verona, Verona, Italy; 4 Dipartimento di Medicina, University of Verona, Verona, Italy Background and aim: International Consensus Diagnostic Criteria (ICDC) for autoimmune pancreatitis (AIP) have been proposed to diagnose type 1 AIP, type 2 AIP and AIP-not otherwise specified (AIP-NOS). The aim of this international multicenter study was to evaluate the possibility of correctly diagnosing AIP itself and its subtype by ICDC in focal AIP patients. Material and methods: Thirty patients (type 1 AIP in 23 and type 2 AIP in 7) diagnosed as AIP based on histology of surgical specimens were classified according to ICDC based on their preoperative data. Results: Pancreatic core biopsies and diagnostic steroid trial were not preoperatively performed in any of the patients. Based on preoperative data, ICDC diagnosed 6 patients (20%) as type 1 AIP and 24 (80%) as probable AIP. Assuming all patients had responded to a steroid trial preoperatively, ICDC would have diagnosed 8 patients (27%) as type 1 AIP, 4 (13%) as type 2 AIP, 10 as AIP-not otherwise specified (33%) and 8 (27%) as probable AIP. In the hypothetical situation, 7 of 8 type 1 AIP patients and 3 of 3 type 2 AIP patients would have been classified into the correct subtype of AIP. Conclusions: In this retrospective study, the accuracy of ICDC without preoperative histology was quite low. A steroid trial enhances the possibility of correctly diagnosing AIP by ICDC despite of the lack of histology. However, some patients cannot be diagnosed as having AIP or be classified into the correct subtype without histology.
P.18.2 PARADUODENAL PANCREATITIS: VERONA EXPERIENCE ON 112 PATIENTS N. De Pretis, A. Amodio ∗ , A. Granato, G. De Marchi, N. De Pretis, O. Messina, L. Benini, L. Frulloni Dipartimento di Medicina, Univerity of Verona, Verona, Italy Background and aim: Paraduodenal pancreatitis (PP) is a special form of chronic pancreatitis, called also groove pancreatitis or cystic dystrophy of the duodenal wall, defined on surgical specimens. Characteristic findings at CT, MR and EUS has been published. The aim of the study was to evaluate the clinical and radiological features of PP, and the clinical outcome in a mixed clinical and surgical series. Material and methods: All patients with a final diagnosis of PP in Gastroenterology unit and Surgical Department and has been enrolled. Clinical, radiological and pathological data have been collected. The diagnosis was based on surgical specimens in operated pts and on imaging in non operated pts. Results: We studied 112 pts (108 males, 4 females, mean age 41.4±10 yrs), 96.4% of them were drinkers (mean daily alcohol intake: 129.3±65.4 g) and 97.3% smokers (29.2±13.6 cigarettes/day). The clinical onset was acute pancreatitis in 70 pts (63%) and continuous pain in 42 (38%). Other symptoms at onset were vomiting (42 pts – 38%), weight loss (26 pts – 23%) and jaundice (13 pts – 12%). Cystic variant was diagnosed in 79 pts (70%) and solid in 33 (30%). Pure form involving only the groove area was observed in 22 pts (20%) and diffuse form involving all pancreas in 90 (80%). Pancreatic calcifications were diagnosed in 68 pts (61%). 74 pts (70%) underwent surgery, resective in 57 and derivative in 17. The indication for surgery were pain (67 pts – 86%), suspicion of cancer (5 – 6%) and duodenal obstruction (6 – 8%). Mean follow-up time was 5±7 yrs. Diabetes was diagnosed in 28% and steatorrhea in 25%. 10 pts (9%) died.