Skip to main content
SpringerLink
Log in
SpringerLink
Log in

EUS Features

  • Chapter
  • First Online:
Autoimmune (IgG4-related) Pancreatitis and Cholangitis

  • 890 Accesses

Abstract

Autoimmune pancreatitis (AIP) is a form of pancreatitis that often demonstrates distinct clinical, serological, histological, and imaging features. A hallmark of this disorder is a rapid and dramatic response to steroid therapy. Following the first description by Sarles [1] in 1961, subsequent reports included only patients with florid disease manifestations [2–4]. As initially described, patients presented with jaundice and a pancreatic head mass that was often incorrectly diagnosed as carcinoma, thereby leading to unnecessary operative intervention. Over time there has been a greater understanding of the diverse clinical, laboratory, and histological manifestations, leading to a more comprehensive set of diagnostic criteria that now allow diagnosis of a broader spectrum of AIP patients while maintaining diagnostic specificity. It is now recognized that AIP represents only one component of a systemic fibroinflammatory disease process termed IgG4-related diseases (IgG4-RD) that also afflicts other organs including the bile duct, lungs, thyroid, retroperitoneum, lymph nodes, salivary glands, and kidneys [5–11]}. These non-pancreatic sites of disease also demonstrate lymphoplasmacytic infiltration with IgG4-positive cells and often storiform fibrosis.

The purpose of this chapter is to review the breadth of endoscopic ultrasound (EUS) findings associated with AIP and to consider the EUS features in the context of clinical, imaging, histological, and laboratory data. We also suggest a role for EUS imaging and guided tissue sampling within the diagnostic algorithm.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 89.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 119.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 169.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Sarles H, Sarles JC, Muratore R, Guien C. Chronic inflammatory sclerosis of the pancreas–an autonomous pancreatic disease? Am J Dig Dis. 1961;6: 688–98.

    Article  PubMed  CAS  Google Scholar 

  2. Yoshida K, Toki F, Takeuchi T, Watanabe S, Shiratori K, Hayashi N. Chronic pancreatitis caused by an autoimmune abnormality. Proposal of the concept of autoimmune pancreatitis. Dig Dis Sci. 1995;40:1561–8.

    Article  PubMed  CAS  Google Scholar 

  3. Ito T, Nakano I, Koyanagi S, Miyahara T, Migita Y, Ogoshi K, Sakai H, Matsunaga S, Yasuda O, Sumii T, Nawata H. Autoimmune pancreatitis as a new clinical entity. Three cases of autoimmune pancreatitis with effective steroid therapy. Dig Dis Sci. 1997;42:1458–68.

    Article  PubMed  CAS  Google Scholar 

  4. Okazaki K, Chiba T. Autoimmune related pancreatitis. Gut. 2002;51:1–4.

    Article  PubMed  CAS  Google Scholar 

  5. Zhang L, Smyrk TC. Autoimmune pancreatitis and IgG4-related systemic diseases. Int J Clin Exp Pathol. 2010;3:491–504.

    PubMed  Google Scholar 

  6. Maire F, Le Baleur Y, Rebours V, Vullierme MP, Couvelard A, Voitot H, Sauvanet A, Hentic O, Levy P, Ruszniewski P, Hammel P. Outcome of patients with type 1 or 2 autoimmune pancreatitis. Am J Gastroenterol. 2010;106:151–6.

    Article  PubMed  Google Scholar 

  7. Takuma K, Kamisawa T, Tabata T, Inaba Y, Egawa N, Igarashi Y. Short-term and long-term outcomes of autoimmune pancreatitis. Eur J Gastroenterol Hepatol. 2011;23:146–52.

    Article  PubMed  CAS  Google Scholar 

  8. Takuma K, Kamisawa T, Igarashi Y. Autoimmune pancreatitis and IgG4-related sclerosing cholangitis. Curr Opin Rheumatol. 2011;23:80–7.

    Article  PubMed  CAS  Google Scholar 

  9. Sah RP, Chari ST. Clinical hypothyroidism in autoimmune pancreatitis. Pancreas. 2010;39:1114–6.

    Article  PubMed  Google Scholar 

  10. Goldsmith PJ, Cockbain AJ, Smith AM. Spontaneous resolution of pulmonary nodules in autoimmune pancreatitis. Jop: J Pancreas [Electronic Resource]. 2010; 11:630–2.

    Google Scholar 

  11. Triantopoulou C, Malachias G, Maniatis P, Anastopoulos J, Siafas I, Papailiou J. Renal lesions associated with autoimmune pancreatitis: CT findings. Acta Radiol. 2010;51:702–7.

    Article  PubMed  Google Scholar 

  12. Ryu JK, Chung JB, Park SW, Lee JK, Lee KT, Lee WJ, Moon JH, Cho KB, Kang DW, Hwang J-H, Yoo K-S, Yoo BM, Lee DH, Kim HK, Moon YS, Lee J, Lee HS, Choi HS, Lee SK, Kim Y-T, Kim CD, Kim SJ, Hahm JS, Yoon YB. Review of 67 patients with autoimmune pancreatitis in Korea: a multicenter nationwide study. Pancreas. 2008;37:377–85.

    Article  PubMed  Google Scholar 

  13. Okazaki K, Kawa S, Kamisawa T, Naruse S, Tanaka S, Nishimori I, Ohara H, Ito T, Kiriyama S, Inui K, Shimosegawa T, Koizumi M, Suda K, Shiratori K, Yamaguchi K, Yamaguchi T, Sugiyama M, Otsuki M, Research Committee of Intractable Diseases of the P. Clinical diagnostic criteria of autoimmune pancreatitis: revised proposal. J Gastroenterol. 2006;41:626–31.

    Article  PubMed  Google Scholar 

  14. Chari ST, Smyrk TC, Levy MJ, Topazian MD, Takahashi N, Zhang L, Clain JE, Pearson RK, Petersen BT, Vege SS, Farnell MB. Diagnosis of autoimmune pancreatitis: the Mayo Clinic experience. Clin Gastroenterol Hepatol. 2006;4:1010–6. quiz 934.

    Article  PubMed  Google Scholar 

  15. Pearson RK, Longnecker DS, Chari ST, Smyrk TC, Okazaki K, Frulloni L, Cavallini G. Controversies in clinical pancreatology: autoimmune pancreatitis: does it exist? Pancreas. 2003;27:1–13.

    Article  PubMed  Google Scholar 

  16. Society JP. Diagnostic criteria for autoimmune pancreatitis by the Japan Pancreas Society. J Jpn Pancreas Soc. 2002;17:585–7.

    Google Scholar 

  17. Kloppel G, Luttges J, Lohr M, Zamboni G, Longnecker D. Autoimmune pancreatitis: pathological, clinical, and immunological features. Pancreas. 2003;27:14–9.

    Article  PubMed  Google Scholar 

  18. Chari ST, Smyrk TC, Levy MJ, Topazian MD, Takahashi N, Clain JE, Pearson RK, Petersen BT, Swaroop VS, Farnell MB. Autoimmune pancreatitis: diagnosis using histology, imaging, serology, other organ involvement and response to steroids. 2006: Pending publication.

    Google Scholar 

  19. Ghazale A, Chari ST, Smyrk TC, Levy MJ, Topazian MD, Takahashi N, Clain JE, Pearson RK, Pelaez-Luna M, Petersen BT, Vege SS, Farnell MB. Value of serum IgG4 in the diagnosis of autoimmune pancreatitis and in distinguishing it from pancreatic cancer. Am J Gastroenterol. 2007;102:1646–53.

    Article  PubMed  CAS  Google Scholar 

  20. Notohara K, Burgart LJ, Yadav D, Chari S, Smyrk TC. Idiopathic chronic pancreatitis with periductal lymphoplasmacytic infiltration: clinicopathologic features of 35 cases.[see comment]. Am J Surg Pathol. 2003;27:1119–27.

    Article  PubMed  Google Scholar 

  21. Takahashi N, Kawashima A, Fletcher JG, Chari ST. Renal involvement in patients with autoimmune pancreatitis: CT and MR imaging findings. Radiology. 2007;242:791–801.

    Article  PubMed  Google Scholar 

  22. Zhang L, Notohara K, Levy MJ, Chari ST, Smyrk TC. IgG4-positive plasma cell infiltration in the diagnosis of autoimmune pancreatitis. Mod Pathol. 2007;20: 23–8.

    Article  PubMed  CAS  Google Scholar 

  23. Ghazale A, Chari ST. Optimising corticosteroid treatment for autoimmune pancreatitis. Gut. 2007;56: 1650–2.

    Article  PubMed  CAS  Google Scholar 

  24. Chari ST, Takahashi N, Levy MJ, Smyrk TC, Clain JE, Pearson RK, Petersen BT, Topazian MA, Vege SS. A diagnostic strategy to distinguish autoimmune pancreatitis from pancreatic cancer. Clin Gastroenterol Hepatol. 2009;7:1097–103.

    Article  PubMed  CAS  Google Scholar 

  25. Yadav D, Notahara K, Smyrk TC, Clain JE, Pearson RK, Farnell MB, Chari ST. Idiopathic tumefactive chronic pancreatitis: clinical profile, histology, and natural history after resection. Clin Gastroenterol Hepatol. 2003;1:129–35.

    Article  PubMed  Google Scholar 

  26. Kamisawa T, Egawa N, Nakajima H, Tsuruta K, Okamoto A, Kamata N. Clinical difficulties in the differentiation of autoimmune pancreatitis and pancreatic carcinoma. Am J Gastroenterol. 2003;98: 2694–9.

    Article  PubMed  Google Scholar 

  27. Taniguchi T, Tanio H, Seko S, Nishida O, Inoue F, Okamoto M, Ishigami S, Kobayashi H. Autoimmune pancreatitis detected as a mass in the head of the pancreas without hypergammaglobulinemia, which relapsed after surgery: case report and review of the literature. Dig Dis Sci. 2003;48:1465–71.

    Article  PubMed  Google Scholar 

  28. Kojima E, Kimura K, Noda Y, Kobayashi G, Itoh K, Fujita N. Autoimmune pancreatitis and multiple bile duct strictures treated effectively with steroid. J Gastroenterol. 2003;38:603–7.

    Article  PubMed  Google Scholar 

  29. Chari ST, Smyrk TC, Takahashi N, Clain JE, Farnell MB, Levy MJ, Pearson RK, Petersen BT, Topazian M, Vege SS. Autoimmune pancreatitis: diagnosis using histology, imaging, serology, other organ involvement and response to steroids. Pancreas. 2005;31:435–6.

    Article  Google Scholar 

  30. Sadler R, Chapman RW, Simpson D, Soonawalla ZF, Waldegrave EL, Burden JM, Misbah SA, Ferry BL. The diagnostic significance of serum IgG4 levels in patients with autoimmune pancreatitis: a UK study. Eur J Gastroenterol Hepatol. 2010;23:139–45.

    Article  Google Scholar 

  31. Park SH, Kim M-H, Kim SY, Kim HJ, Moon S-H, Lee SS, Byun JH, Lee SK, Seo DW, Lee M-G. Magnetic resonance cholangiopancreatography for the diagnostic evaluation of autoimmune pancreatitis. Pancreas. 2010;39:1191–8.

    Article  PubMed  Google Scholar 

  32. Ishigami K, Tajima T, Nishie A, Ushijima Y, Fujita N, Asayama Y, Kakihara D, Irie H, Ito T, Igarashi H, Nakamura M, Honda H. MRI findings of pancreatic lymphoma and autoimmune pancreatitis: a comparative study. Eur J Radiol. 2010;74:e22–8.

    Article  PubMed  Google Scholar 

  33. Nishino T, Oyama H, Toki F, Shiratori K. Differentiation between autoimmune pancreatitis and pancreatic carcinoma based on endoscopic retrograde cholangiopancreatography findings. J Gastroenterol. 2010;45:988–96.

    Article  PubMed  Google Scholar 

  34. Levy MJ, Wiersema MJ, Chari ST. Chronic pancreatitis: focal pancreatitis or cancer? Is there a role for FNA/biopsy? Autoimmune pancreatitis. Endoscopy. 2006;38 Suppl 1:S30–5.

    Article  PubMed  Google Scholar 

  35. Finkelberg DL, Sahani D, Deshpande V, Brugge WR. Autoimmune pancreatitis. N Eng J Med. 2006;355: 2670–6.

    Article  CAS  Google Scholar 

  36. Farrell JJ, Garber J, Sahani D, Brugge WR. EUS findings in patients with autoimmune pancreatitis. Gastrointest Endosc. 2004;60:927–36.

    Article  PubMed  Google Scholar 

  37. Levy MJ, Reddy RP, Wiersema MJ, Smyrk TC, Clain JE, Harewood GC, Pearson RK, Rajan E, Topazian MD, Yusuf TE, Chari ST, Petersen BT. EUS-guided trucut biopsy in establishing autoimmune pancreatitis as the cause of obstructive jaundice. Gastrointest Endosc. 2005;61:467–72.

    Article  PubMed  Google Scholar 

  38. Zhang L, Chari ST, Levy MJ, SMyrk TC. Pancreatic IgG4 stain for diagnosing autoimmune pancreatitis (AIP) and for distinguishing AIP subtypes. Gastroenterology. 2005;128:A474.

    Google Scholar 

  39. Hocke M, Ignee A, Dietrich CF. Contrast-enhanced endoscopic ultrasound in the diagnosis of autoimmune pancreatitis. Endoscopy. 2011;43:163–5.

    Article  PubMed  CAS  Google Scholar 

  40. Levy MJ, Smyrk TC, Takahashi N, Zhang L, Chari ST. Idiopathic duct-centric pancreatitis: disease description and endoscopic ultrasonography-guided trucut biopsy diagnosis. Pancreatology. 2011;11: 76–80.

    Article  PubMed  Google Scholar 

  41. Mizuno N, Bhatia V, Hosoda W, Sawaki A, Hoki N, Hara K, Takagi T, Ko SBH, Yatabe Y, Goto H, Yamao K. Histological diagnosis of autoimmune pancreatitis using EUS-guided trucut biopsy: a comparison study with EUS-FNA. J Gastroenterol. 2009;44:742–50.

    Article  PubMed  CAS  Google Scholar 

  42. Deshpande V, Mino-Kenudson M, Brugge WR, Pitman MB, Fernandez-del Castillo C, Warshaw AL, Lauwers GY. Endoscopic ultrasound guided fine needle aspiration biopsy of autoimmune pancreatitis: diagnostic criteria and pitfalls. Am J Surg Pathol. 2005;29:1464–71.

    Article  PubMed  Google Scholar 

  43. Chari ST, Kloeppel G, Zhang L, Notohara K, Lerch MM, Shimosegawa T, Autoimmune Pancreatitis International Cooperative Study G. Histopathologic and clinical subtypes of autoimmune pancreatitis: the Honolulu consensus document. Pancreas. 2010;39: 549–54.

    Article  PubMed  CAS  Google Scholar 

  44. Voss M, Hammel P, Molas G, Palazzo L, Dancour A, O’Toole D, Terris B, Degott C, Bernades P, Ruszniewski P. Value of endoscopic ultrasound guided fine needle aspiration biopsy in the diagnosis of solid pancreatic masses. Gut. 2000;46:244–9.

    Article  PubMed  CAS  Google Scholar 

  45. Eloubeidi MA, Tamhane A. EUS-guided FNA of solid pancreatic masses: a learning curve with 300 consecutive procedures. Gastrointest Endosc. 2005; 61:700–8.

    Article  PubMed  Google Scholar 

  46. Mitsuhashi T, Ghafari S, Chang CY, Gu M. Endoscopic ultrasound-guided fine needle aspiration of the pancreas: cytomorphological evaluation with emphasis on adequacy assessment, diagnostic criteria and contamination from the gastrointestinal tract. Cytopathology. 2006;17:34–41.

    Article  PubMed  CAS  Google Scholar 

  47. Turner BG, Cizginer S, Agarwal D, Yang J, Pitman MB, Brugge WR. Diagnosis of pancreatic neoplasia with EUS and FNA: a report of accuracy. Gastrointest Endosc. 2009;71:91–8.

    Article  Google Scholar 

  48. Piccinino F, Sagnelli E, Pasquale G, Giusti G. Complications following percutaneous liver biopsy. A multicentre retrospective study on 68,276 biopsies. J Hepatol. 1986;2:165–73.

    Article  PubMed  CAS  Google Scholar 

  49. Kovalik EC, Schwab SJ, Gunnells JC, Bowie D, Smith SR. No change in complication rate using spring-loaded gun compared to traditional percutaneous renal allograft biopsy techniques. Clin Nephrol. 1996;45:383–5.

    PubMed  CAS  Google Scholar 

  50. Brandt KR, Charboneau JW, Stephens DH, Welch TJ, Goellner JR. CT- and US-guided biopsy of the pancreas. Radiology. 1993;187:99–104.

    PubMed  CAS  Google Scholar 

  51. Welch TJ, Sheedy 2nd PF, Johnson CD, Johnson CM, Stephens DH. CT-guided biopsy: prospective analysis of 1,000 procedures. Radiology. 1989;171:493–6.

    PubMed  CAS  Google Scholar 

  52. Harrison BD, Thorpe RS, Kitchener PG, McCann BG, Pilling JR. Percutaneous Trucut lung biopsy in the diagnosis of localised pulmonary lesions. Thorax. 1984;39:493–9.

    Article  PubMed  CAS  Google Scholar 

  53. Ingram DM, Sheiner HJ, Shilkin KB. Operative biopsy of the pancreas using the Trucut needle. Aust N Z J Surg. 1978;48:203–6.

    Article  PubMed  CAS  Google Scholar 

  54. Lavelle MA, O’Toole A. Trucut biopsy of the prostate. Br J Urol. 1994;73:600.

    PubMed  CAS  Google Scholar 

  55. Ball AB, Fisher C, Pittam M, Watkins RM, Westbury G. Diagnosis of soft tissue tumours by Tru-Cut biopsy. Br J Surg. 1990;77:756–8.

    Article  PubMed  CAS  Google Scholar 

  56. Wiersema MJ, Levy MJ, Harewood GC, Vazquez-Sequeiros E, Jondal ML, Wiersema LM. Initial experience with EUS-guided trucut needle biopsies of perigastric organs. Gastrointest Endosc. 2002;56: 275–8.

    Article  PubMed  Google Scholar 

  57. Levy MJ, Jondal ML, Clain J, Wiersema MJ. Preliminary experience with an EUS-guided trucut biopsy needle compared with EUS-guided FNA. Gastrointest Endosc. 2003;57:101–6.

    Article  PubMed  Google Scholar 

  58. Levy MJ, Wiersema MJ. EUS-guided trucut biopsy. Gastrointest Endosc. 2005;62:417–26.

    Article  PubMed  Google Scholar 

  59. Levy MJ, Smyrk TC, Reddy RP, Clain JE, Harewood GC, Kendrick ML, Pearson RK, Petersen BT, Rajan E, Topazian MD, Wang KK, Wiersema MJ, Yusuf TE, Chari ST. Endoscopic ultrasound-guided trucut biopsy of the cyst wall for diagnosing cystic pancreatic tumors. Clin Gastroenterol Hepatol. 2005;3: 974–9.

    Article  PubMed  Google Scholar 

  60. Gines A, Wiersema MJ, Clain JE, Pochron NL, Rajan E, Levy MJ. Prospective study of a Trucut needle for performing EUS-guided biopsy with EUS-guided FNA rescue. Gastrointest Endosc;62.

    Google Scholar 

  61. Abraham SC, Wilentz RE, Yeo CJ, Sohn TA, Cameron JL, Boitnott JK, Hruban RH. Pancreaticoduodenectomy (Whipple resection) in patients without malignancy: are they all chronic pancreatitis? Am J Surg Pathol. 2003;27:110–20.

    Article  PubMed  Google Scholar 

  62. Kloppel G, Luttges J, Sipos B, Capelli P, Zamboni G. Autoimmune pancreatitis: pathological findings. Jop: J Pancreas [Electronic Resource]. 2005;6:97–101.

    Google Scholar 

  63. Zamboni G, Luttges J, Capelli P, Frulloni L, Cavallini G, Pederzoli P, Leins A, Longnecker D, Kloppel G. Histopathological features of diagnostic and clinical relevance in autoimmune pancreatitis: a study on 53 resection specimens and 9 biopsy specimens. Virchows Arch. 2004;445:552–63.

    Article  PubMed  Google Scholar 

  64. Suda K, Takase M, Fukumura Y, Ogura K, Ueda A, Matsuda T, Suzuki F. Histopathologic characteristics of autoimmune pancreatitis based on comparison with chronic pancreatitis. Pancreas. 2005;30:355–8.

    Article  PubMed  Google Scholar 

  65. Kamisawa T. IgG4-positive plasma cells specifically infiltrate various organs in autoimmune pancreatitis. Pancreas. 2004;29:167–8.

    Article  PubMed  Google Scholar 

  66. Kawaguchi K, Koike M, Tsuruta K, Okamoto A, Tabata I, Fujita N. Lymphoplasmacytic sclerosing pancreatitis with cholangitis: a variant of primary sclerosing cholangitis extensively involving pancreas. Hum Pathol. 1991;22:387–95.

    Article  PubMed  CAS  Google Scholar 

  67. Kloppel G. Chronic pancreatitis, pseudotumors and other tumor-like lesions. Mod Pathol. 2007;20 Suppl 1:S113–31.

    Article  PubMed  Google Scholar 

  68. Kamisawa T, Takuma K, Tabata T, Inaba Y, Egawa N, Tsuruta K, Hishima T, Sasaki T, Itoi T. Serum IgG4-negative autoimmune pancreatitis. J Gastroenterol. 2010;46:108–16.

    Article  PubMed  Google Scholar 

  69. Naitoh I, Nakazawa T, Ohara H, Ando T, Hayashi K, Okumura F, Miyabe K, Yoshida M, Sano H, Takada H, Kanematsu T, Joh T. Comparative evaluation of the Japanese diagnostic criteria for autoimmune pancreatitis. Pancreas. 2010;39:1173–9.

    Article  PubMed  Google Scholar 

  70. Kloppel G, Detlefsen S, Chari ST, Longnecker DS, Zamboni G. Autoimmune pancreatitis: the clinicopathological characteristics of the subtype with granulocytic epithelial lesions. J Gastroenterol. 2010;45: 787–93.

    Article  PubMed  Google Scholar 

  71. Deshpande V, Gupta R, Sainani N, Sahani DV, Virk R, Ferrone C, Khosroshahi A, Stone JH, Lauwers GY. Subclassification of autoimmune pancreatitis: a histologic classification with clinical significance. Am J Surg Pathol. 2010;35:26–35.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA

    Michael J. Levy M.D.

  2. Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA

    William R. Brugge

Authors
  1. Michael J. Levy M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. William R. Brugge
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Michael J. Levy M.D. .

Editor information

Editors and Affiliations

  1. and Hepatology, Mayo Clinic Division of Gastroenterology, Rochester, Minnesota, USA

    Michael J. Levy

  2. and Hepatology, Mayo Clinic Division of Gastroenterology, Rochester, Minnesota, USA

    Suresh T. Chari

Rights and permissions

Reprints and permissions

Copyright information

© 2013 Springer Science+Business Media New York

About this chapter

Cite this chapter

Levy, M.J., Brugge, W.R. (2013). EUS Features. In: Levy, M., Chari, S. (eds) Autoimmune (IgG4-related) Pancreatitis and Cholangitis. Springer, New York, NY. https://doi.org/10.1007/978-1-4419-6430-4_6

Download citation

  • DOI: https://doi.org/10.1007/978-1-4419-6430-4_6

  • Published:

  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-1-4419-6429-8

  • Online ISBN: 978-1-4419-6430-4

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation