Endoscopy 2007; 39: E63
DOI: 10.1055/s-2006-944597
Unusual cases and technical notes

© Georg Thieme Verlag KG Stuttgart · New York

Pseudotumor of the bile duct associated with autoimmune pancreatitis

T. Kurihara1 , T. Itoi1 , A. Sofuni1 , F. Itokawa1 , T. Tsuchiya1 , F. Moriyasu1
  • 1 Fourth Department of Internal Medicine, Tokyo Medical University, Tokyo, Japan
Further Information

T. Itoi, M. D.

Fourth Department of Internal Medicine

Tokyo Medical University
Shinjuku-ku
Nishishinjuku 6-7-1
Tokyo
Japan

Fax: +81-3-5381-6654

Email: itoi@tokyo-med.ac.jp

Publication History

Publication Date:
26 February 2007 (online)

Table of Contents

Autoimmune pancreatitis is a well-established entity that can be associated with biliary abnormalities [1]. Peroral cholangioscopic images of such biliary lesions are rarely available, however. We report here a patient with autoimmune pancreatitis who was found to have a pseudotumor in the bile duct.

A 69-year-old man with epigastric pain and general fatigue underwent transabdominal ultrasonography and computed tomography, which revealed a swollen pancreas and dilatation of the common bile duct. Though he did not have obstructive jaundice and had normal levels of gamma-immunoglobulin, endoscopic retrograde cholangiopancreatography (ERCP) showed that he had a stricture in the lower bile duct and an irregular main pancreatic duct (Figure [1]). Although the results of the imaging studies were suspicious of autoimmune pancreatitis, the patient was observed without medication.

Eight months later he was hospitalized because he had developed obstructive jaundice. ERCP showed a polypoid lesion in upper bile duct, without a stricture of either the pancreatic duct or the distal bile duct (Figure [2]). Peroral cholangioscopy revealed a tumor-like lesion with a thick vessel in the bile duct (Figure [3]). The level of immunogloblin G subclass 4 (IgG4) was measured this time and was found to be high (857 mg/dl). A biopsy specimen from the lesion showed non-neoplastic bile-duct mucosa with fibrosis and lymphocyte and plasma cell infiltrations (Figure [4]). We made a diagnosis of autoimmune pancreatitis with pseudotumor in the bile duct. The patient was treated with oral prednisolone (40 mg/day), and the jaundice improved immediately. Six months later, ERCP showed improvement in the narrowing of the bile duct, and peroral cholangioscopy revealed that the pseudotumor had disappeared. Three years after starting treatment, he is now on 5 mg prednisolone daily.

Endoscopy_UCTN_Code_CCL_1AZ_2AC
Endoscopy_UCTN_Code_TTT_1AO_2AI

Zoom Image

Figure 1 The initial endoscopic retrograde cholangiopancreatogram (ERCP) showed narrowing of the main pancreatic duct and a stricture in the lower bile duct.

Zoom Image

Figure 2 On re-admission 8 months later, the patient underwent another ERCP, which showed an upper bile duct stricture without a stricture of the distal bile duct.

Zoom Image

Figure 3 Peroral cholecystoscopy revealed a submucosal tumor and a tumor-like vessel in the bile duct.

Zoom Image

Figure 4 Histological examination of the biopsy specimens showed fibrosis with chronic inflammatory cell infiltrates (hematoxylin & eosin stain, × 200 magnification).

#

References

T. Itoi, M. D.

Fourth Department of Internal Medicine

Tokyo Medical University
Shinjuku-ku
Nishishinjuku 6-7-1
Tokyo
Japan

Fax: +81-3-5381-6654

Email: itoi@tokyo-med.ac.jp

#

References

T. Itoi, M. D.

Fourth Department of Internal Medicine

Tokyo Medical University
Shinjuku-ku
Nishishinjuku 6-7-1
Tokyo
Japan

Fax: +81-3-5381-6654

Email: itoi@tokyo-med.ac.jp

Zoom Image

Figure 1 The initial endoscopic retrograde cholangiopancreatogram (ERCP) showed narrowing of the main pancreatic duct and a stricture in the lower bile duct.

Zoom Image

Figure 2 On re-admission 8 months later, the patient underwent another ERCP, which showed an upper bile duct stricture without a stricture of the distal bile duct.

Zoom Image

Figure 3 Peroral cholecystoscopy revealed a submucosal tumor and a tumor-like vessel in the bile duct.

Zoom Image

Figure 4 Histological examination of the biopsy specimens showed fibrosis with chronic inflammatory cell infiltrates (hematoxylin & eosin stain, × 200 magnification).