Skip to main content

Advertisement

SpringerLink
Log in

Autoimmune pancreatitis: multidetector-row computed tomography (MDCT) and magnetic resonance (MR) findings in the Italian experience

  • Abdominal Radiology
  • Published:
La radiologia medica Aims and scope Submit manuscript

Abstract

Multidetector-row computed tomography (MDCT) and magnetic resonance (MR) imaging are currently the most frequently performed imaging modalities for the study of pancreatic disease. In cases of suspected autoimmune pancreatitis (AIP), a dynamic quadriphasic (precontrast, contrast-enhanced pancreatic, venous and late phases) study is recommended in both techniques. In the diffuse form of autoimmune pancreatitis (DAIP), the pancreatic parenchyma shows diffuse enlargement and appears, during the MDCT and MR contrast-enhanced pancreatic phase, diffusely hypodense and hypointense, respectively, compared to the spleen because of lymphoplasmacytic infiltration and pancreatic fibrosis. During the venous phase of MDCT and MR imaging, the parenchyma appears hyperdense and hyperintense, respectively, in comparison to the pancreatic phase. In the delayed phase of both imaging modalities, it shows retention of contrast media. A “capsule-like rim” may be recognised as a peripancreatic MDCT hyperdense and MR hypointense halo in the T2-weighted images, compared to the parenchyma. DAIP must be differentiated from non-necrotizing acute pancreatitis (NNAP) and lymphoma since both diseases show diffuse enlargement of the pancreatic parenchyma. The differential diagnosis is clinically difficult, and dynamic contrast-enhanced MDCT has an important role. In the focal form of autoimmune pancreatitis (FAIP), the parenchyma shows segmental enlargement involving the head, the body-tail or the tail, with the same contrast pattern as the diffuse form on both modalities. FAIP needs to be differentiated from pancreatic adenocarcinoma to avoid unnecessary surgical procedures, since both diseases have similar clinical and imaging presentation. The differential diagnosis is clinically difficult, and dynamic contrast-enhanced MDCT and MR imaging both have an important role. MR cholangiopancreatography helps in the differential diagnosis. Furthermore, MDCT and MR imaging can identify the extrapancreatic manifestations of AIP, most commonly biliary, renal and retroperitoneal. Finally, in all cases of uncertain diagnosis, MDCT and/or MR follow-up after short-term treatment (2–3 weeks) with high-dose steroids can identify a significant reduction in size of the pancreatic parenchyma and, in FAIP, normalisation of the calibre of the upstream main pancreatic duct.

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

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7

Similar content being viewed by others

References

  1. Shimosegawa T, Chari ST, Frulloni L, Kamisawa T, Kawa S, Mino-Kenudson M, Kim MH, Klöppel G, Lerch MM, Löhr M, Notohara K, Okazaki K, Schneider A, Zhang L, International Association of Pancreatology (2011) International consensus diagnostic criteria for autoimmune pancreatitis: guidelines of the International Association of Pancreatology. Pancreas 40:352–358

    Article  PubMed  Google Scholar 

  2. Kamisawa T, Egawa N, Nakajima H (2003) Autoimmune pancreatitis is a systemic autoimmune disease. Am J Gastroenterol 98:2811–2812

    Article  PubMed  Google Scholar 

  3. Zhang L, Notohara K, Levy MJ et al (2007) IgG4-positive plasma cell infiltration in the diagnosis of autoimmune pancreatitis. Mod Pathol 20:23–28

    Article  CAS  PubMed  Google Scholar 

  4. Cavallini G (1993) Is chronic pancreatitis a primary disease of the pancreatic ducts? A new pathogenetic hypothesis. Ital J Gastroenterol 25:391–396

    CAS  PubMed  Google Scholar 

  5. Yoshida K, Toki F, Takeuchi T et al (1995) Chronic pancreatitis caused by an autoimmune abnormality. Proposal of the concept of autoimmune pancreatitis. Dig Dis Sci 40:1561–1568

    Article  CAS  PubMed  Google Scholar 

  6. Okazaki K (2001) Autoimmune-related pancreatitis. Curr Treat Options Gastroenterol 4:369–375

    Article  PubMed  Google Scholar 

  7. Sjogren I, Wengle B, Korsgren M (1979) Primary sclerosing cholangitis associated with fibrosis of the submandibular glands and the pancreas. Acta Med Scand 205:139–141

    Article  CAS  PubMed  Google Scholar 

  8. Gelrud A, Freedman SD (2005) Autoimmune pancreatitis. J Gastrointest Surg 9:2–5

    Article  PubMed  Google Scholar 

  9. Ketikoglou I, Moulakakis A (2005) Autoimmune pancreatitis. Dig Liver Dis 37:211–215

    Article  CAS  PubMed  Google Scholar 

  10. Frulloni L, Bovo P, Di Francesco V et al (1999) “Non-alcoholic duct destructive chronic pancreatitis” or “primary chronic pancreatitis”? Gut 44:579

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  11. Montefusco PP, Geiss AC, Bronzo RL et al (1984) Sclerosing cholangitis, chronic pancreatitis, and Sjogren’s syndrome: a syndrome complex. Am J Surg 147:822–826

    Article  CAS  PubMed  Google Scholar 

  12. Kloppel G, Luttges J, Lohr M et al (2003) Autoimmune pancreatitis: pathological, clinical, and immunological features. Pancreas 27:14–19

    Article  PubMed  Google Scholar 

  13. Zamboni G, Luttges J, Capelli P et al (2004) Histopathological features of diagnostic and clinical relevance in autoimmune pancreatitis: a study on 53 resection specimens and 9 biopsy specimens. Virchows Arch 445:552–563

    Article  PubMed  Google Scholar 

  14. Ghazale AH, Chari ST, Vege SS (2008) Update on the diagnosis and treatment of autoimmune pancreatitis. Curr Gastroenterol Rep 10:115–121

    Article  PubMed  Google Scholar 

  15. Toomey DP, Swan N, Torreggiani W, Conlon KC (2007) Autoimmune pancreatitis. Br J Surg 94:1067–1074

    Article  CAS  PubMed  Google Scholar 

  16. Cavallini G, Frulloni L, Bassi C et al (2004) Prospective multicentre survey on acute pancreatitis in Italy (ProInf AISP): results on 1005 patients. Dig Liver Dis 36:205–211

    Article  CAS  PubMed  Google Scholar 

  17. Bodily KD, Takahashi N, Fletcher JG et al (2009) Autoimmune pancreatitis: pancreatic and extrapancreatic imaging finding. Am J Roentgenol 192:431–437

    Article  Google Scholar 

  18. Kawa S, Hamanno H, Umemura T et al (2007) Sclerosing cholangitis associated with autoimmune pancreatitis. Hepatol Res 37:S487–S495

    Article  CAS  PubMed  Google Scholar 

  19. Bollen TL, van Santvoort HC, Besselink MG et al (2008) The Atlanta classification of acute pancreatitis revisited. Br J Surg 95:6–21

    Article  CAS  PubMed  Google Scholar 

  20. Frulloni L, Scattolini C, Falconi M et al (2009) Autoimmune pancreatitis: differences between the focal and diffuse forms in 87 patients. Am J Gastroenterol 104:2288–2294

    Article  PubMed  Google Scholar 

  21. Kim KP, Kim MH, Song MH et al (2004) Autoimmune chronic pancreatitis. Am J Gastroenterol 99:1605–1616

    Article  PubMed  Google Scholar 

  22. Procacci C, Carbognin G, Biasiutti C et al (2001) Autoimmune pancreatitis: possibilities of CT characterization. Pancreatology 1:246–253

    Article  CAS  PubMed  Google Scholar 

  23. Sahani DV, Kalva SP, Farrell J et al (2004) Autoimmune pancreatitis: imaging features. Radiology 233:345–352

    Article  PubMed  Google Scholar 

  24. Yang DH, Kim KW, Kim TK (2006) Autoimmune pancreatitis: radiologic findings in 20 patients. Abdom Imaging 31:94–102

    Article  CAS  PubMed  Google Scholar 

  25. Balthazar EJ (2002) Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology 223:603–613

    Article  PubMed  Google Scholar 

  26. Okazaki K, Kawa S, Kamisawa T (2006) Clinical diagnostic criteria of autoimmune pancreatitis: revised proposal. J Gastroenterol 41:626–631

    Article  PubMed Central  PubMed  Google Scholar 

  27. Desiree EM (2008) Imaging of acute pancreatitis and its complications. Clin Gastroenterol Hepatol 6:1077–1085

    Article  Google Scholar 

  28. Kwon S, Kim MH, Choi EK (2007) The diagnostic criteria for autoimmune chronic pancreatitis: it is time to make a consensus. Pancreas 34:279–286

    Article  PubMed  Google Scholar 

  29. Nakazawa T, Ohara H, Sano H (2007) Difficulty in diagnosing autoimmune pancreatitis by imaging findings. Gastrointest Endosc 65:99–108

    Article  PubMed  Google Scholar 

  30. Kamisawa T (2008) Diagnostic criteria for autoimmune pancreatitis. J Clin Gastroenterol 42:404–407

    Article  PubMed  Google Scholar 

  31. Graziani R, Cenci D, Franzoso F (2009) The role of computed tomography. In: Balthazar EJ, Megibow AJ, Pozzi Mucelli R (eds) Imaging of the pancreas. Springer Berlin Heidelberg, Berlin, pp 149–183

    Chapter  Google Scholar 

  32. Graziani R, Cicero C, Casagranda G et al (2008) Pancreatite cronica. In: Graziani R, Pozzi Mucelli R (eds) TC multistrato del pancreas. Idelson Gnocchi, Sorbona, pp 45–84

    Google Scholar 

  33. Graziani R, Cicero C, Casagranda G (2008) Pancreas. In: Pozzi Mucelli R (ed) TC multistrato addome. Idelson Gnocchi, Sorbona, pp 193–262

    Google Scholar 

  34. Horiuchi A, Kaneko T, Yamamura N et al (1996) Autoimmune chronic pancreatitis simulating pancreatic lymphoma. Am J Gastroenterol 911:2607–2609

    Google Scholar 

  35. Irie H, Honda H, Baba S et al (1998) Autoimmune pancreatitis: CT and MR characteristics. AJR Am J Roentgenol 170:1323–1327

    Article  CAS  PubMed  Google Scholar 

  36. Eerens I, Vanbeckevoort D, Vansteenbergen W, Van Hoe L (2001) Autoimmune pancreatitis associated with primary sclerosing cholangitis: MR imaging findings. Eur Radiol 11:1401–1404

    Article  CAS  PubMed  Google Scholar 

  37. Manfredi R, Graziani R, Cicero C et al (2008) Autoimmune pancreatitis: CT patterns and their changes after steroid treatment. Radiology 247:435–443

    Article  PubMed  Google Scholar 

  38. Takayama M, Hamano H, Ochi Y et al (2004) Recurrent attacks of autoimmune pancreatitis result in pancreatic stone formation. Am J Gastroenterol 99:932–937

    Article  PubMed  Google Scholar 

  39. Takahashi N, Fletcher JG, Hough DM et al (2009) Autoimmune pancreatitis: differentiation from pancreatic carcinoma and normal pancreas on the basis of enhancement characteristics at dual-phase CT. AJR Am J Roentgenol 193:479–484

    Article  PubMed  Google Scholar 

  40. Sugumar A, Chari ST (2011) Autoimmune pancreatitis. J Gastroenterol Hepatol 26:1368–1373 (Review)

    PubMed  Google Scholar 

  41. Okazaki K, Kawa S, Kamisawa T, Shimosegawa T, Tanaka M, Research Committee for Intractable Pancreatic Disease and Japan Pancreas Society (2010) Japanese consensus guidelines for management of autoimmune pancreatitis: I. Concept and diagnosis of autoimmune pancreatitis. J Gastroenterol 45:249–265

    Article  PubMed  Google Scholar 

  42. Suzuki K, Itoh S, Nagasaka T et al (2010) CT findings in autoimmune pancreatitis: assessment using multiphase contrast-enhanced multisection CT. Clin Radiol 65:735–743

    Article  CAS  PubMed  Google Scholar 

  43. Kawai Y, Suzuki K, Itoh S et al (2012) Autoimmune pancreatitis: assessment of the enhanced duct sign on multiphase contrast-enhanced computed tomography. Eur J Radiol 81:3055–3060

    Article  PubMed  Google Scholar 

  44. Klimstra DS, Adsay NV (2004) Lymphoplasmacytic sclerosing (autoimmune) pancreatitis. Semin Diagn Pathol 21:237–246

    Article  PubMed  Google Scholar 

  45. Ito T, Nakano I, Koyanagi S et al (1997) Autoimmune pancreatitis as a new clinical entity: three cases of autoimmune pancreatitis with effective steroid therapy. Dig Dis Sci 42:1458–1468

    Article  CAS  PubMed  Google Scholar 

  46. Kamisawa T, Tu Y, Egawa N et al (2006) Involvement of pancreatic and bile ducts in autoimmune pancreatitis. World J Gastroenterol 28:612–614

    Google Scholar 

  47. Van Hoe L, Gryspeerdt S, Ectors N et al (1998) Nonalcholic duct-destructive chronic pancreatitis: imaging findings. AJR Am J Roentgenol 170:643–647

    Article  PubMed  Google Scholar 

  48. Kawamoto S, Siegelman SS, Hruban RH, Fishman EK (2008) Lymphoplasmacytic sclerosing pancreatitis (autoimmune pancreatitis): evolution with multidetector CT. Radiographics 28:157–170

    Article  PubMed  Google Scholar 

  49. Furukawa N, Muranaka T, Yasumori K et al (1998) Autoimmune pancreatitis: radiologic findings in three histologically proven cases. J Comput Assist Tomogr 22:880–883

    Article  CAS  PubMed  Google Scholar 

  50. Graziani R, Frulloni L, Mantovani W et al (2012) Autoimmune pancreatitis and non-necrotizing acute pancreatitis: computed tomography pattern. Dig Liver Dis 44:759–766

    Article  CAS  PubMed  Google Scholar 

  51. Webb TH, Lillemoe KD, Pitt HA et al (1989) Pancreatic lymphoma. Is surgery mandatory for diagnosis or treatment? Ann Surg 209:25–30

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  52. Glazer HS, Lee KJ, Balfe DM et al (1983) Non-Hodgkin lymphoma: computed tomographic demonstration of unusual extranodal involvement. Radiology 149:211–217

    Article  CAS  PubMed  Google Scholar 

  53. Sahani DV, Sainani NI, Deshpande V et al (2009) Autoimmune pancreatitis: disease evolution, staging, response, assessment and CT features that predict response to corticosteroid therapy. Radiology 250:118–129

    Article  PubMed  Google Scholar 

  54. Van Beers B, Lalonde L, Soyer P et al (1993) Dynamic CT in pancreatic lymphoma. J Comput Assist Tomogr 17:94–97

    Article  PubMed  Google Scholar 

  55. Ferrozzi F, Zuccoli G, Bova D, Calculli L (2000) Tumori mesenchimali del pancreas: aspetti con tomografia computerizzata. J Comput Assist Tomogr 24:622–627

    Article  CAS  PubMed  Google Scholar 

  56. Sheth S, Fishman EK (2002) Imaging of uncommon tumors of the pancreas. Radiol Clin North Am 40:1273–1287

    Article  PubMed  Google Scholar 

  57. Muhi A, Ichikawa T, Motosugi U et al (2012) Mass-forming autoimmune pancreatitis and pancreatic carcinoma: differential diagnosis on the basis of computed tomography and magnetic resonance cholangiopancreatography, and diffusion-weighted imaging findings. J Magn Reson Imaging 35:827–836

    Article  PubMed  Google Scholar 

  58. Triantopoulou C, Giannakou N, Delis S et al (2007) Focal lymphoplasmacytic sclerosing pancreatitis. Pancreas 35:180–186

    Article  PubMed  Google Scholar 

  59. Wakabayashi T, Kawaura Y, Satomura Y et al (2003) Clinical and imaging features of autoimmune pancreatitis with focal pancreatic swelling or mass formation: comparison with so-called tumor forming pancreatitis and pancreatic carcinoma. Am J Gastroenterol 98:2679–2687

    Article  PubMed  Google Scholar 

  60. Wakabayashi T, Kawaura Y, Satomura Y et al (2002) Clinical study of chronic pancreatitis with focal irregular narrowing of the main pancreatic duct and mass formation. Comparison with chronic pancreatitis showing diffuse irregular narrowing of the main pancreatic duct. Pancreas 25:283–289

    Article  PubMed  Google Scholar 

  61. Ichikawa T, Sou H, Araki T et al (2001) Duct-penetrating sign at MRCP: usefulness for differentiating inflammatory pancreatic mass from pancreatic carcinomas. Radiology 221:107–116

    Article  CAS  PubMed  Google Scholar 

  62. Levy MJ, Wiersema MJ, Chari ST (2006) Chronic pancreatitis: focal pancreatitis or cancer? Is there a role for FNA/biopsy? Autoimmune pancreatitis. Endoscopy 38:S30–S35

    Article  PubMed  Google Scholar 

  63. Manfredi R, Frulloni L, Mantovani W et al (2011) Autoimmune pancreatitis: pancreatic and extrapancreatic MR imaging-MR cholangiopancreatography findings at diagnosis, after steroid therapy, and at recurrence. Radiology 260:428–436

    Article  PubMed  Google Scholar 

  64. Balci NC, Bieneman BK, Bilgin M et al (2009) Magnetic resonance imaging in pancreatitis. Top Magn Reson Imaging 20:25–30 (review)

    Article  PubMed  Google Scholar 

  65. Akisik MF, Aisen AM, Sandrasegaran K et al (2009) Assessment of chronic pancreatitis: utility of diffusion-weighted MR imaging with secretin enhancement. Radiology 250:103–109

    Article  PubMed  Google Scholar 

  66. Erturk SM, Ichikawa T, Motosugi U et al (2006) Diffusion-weighted MR imaging in the evaluation of pancreatic exocrine function before and after secretin stimulation. Am J Gastroenterol 101:133–136

    Article  PubMed  Google Scholar 

  67. Taniguchi T, Kobayashi H, Nishikawa K et al (2009) Diffusion-weighted magnetic resonance imaging in autoimmune pancreatitis. Jpn J Radiol 27:138–142

    Article  PubMed  Google Scholar 

  68. Kamisawa T, Takuma K, Anjiki H et al (2010) Differentiation of autoimmune pancreatitis from pancreatic cancer by diffusion-weighted MRI. Am J Gastroenterol 105:1870–1875

    Article  PubMed  Google Scholar 

  69. Choueiri NE, Balci NC, Alkaade S, Burton FR (2010) Advanced imaging of chronic pancreatitis. Curr Gastroenterol Rep 12:114–120

    Article  PubMed  Google Scholar 

  70. Braganza JM, Lee SH, McCloy RF, McMahon MJ (2011) Chronic pancreatitis. Lancet 377:1184–1197

    Article  CAS  PubMed  Google Scholar 

  71. Church NI, Pereira SP, Deheragoda MG et al (2007) Autoimmune pancreatitis: clinical and radiological features and objective response to steroid therapy in a UK series. Am J Gastroenterol 102:2417–2425

    Article  CAS  PubMed  Google Scholar 

  72. Maeda E, Akahane M, Yoshioka N et al (2012) Comparison of CT findings of biliary tract changes with autoimmune pancreatitis and extrahepatic bile duct cholangiocarcinoma. Jpn J Radiol 30:227–234

    Article  PubMed  Google Scholar 

  73. Nishino T, Toki F, Oyama H et al (2005) Biliary tract involvement in autoimmune pancreatitis. Pancreas 30:76–82

    PubMed  Google Scholar 

  74. Members of the Criteria Committee for Autoimmune Pancreatitis of the Japan Pancreas Society (2002) Diagnostic criteria for autoimmune pancreatitis by the Japan Pancreas Society. J Jpn Pancreas 17:587

    Google Scholar 

  75. Okazaki K (2005) Autoimmune pancreatitis: etiology, pathogenesis, clinical findings and treatment: the Japanese experience. JOP 6:89–96

    PubMed  Google Scholar 

  76. Chari ST, Smyrk TC, Levy MJ et al (2006) Diagnosis of autoimmune pancreatitis: the Mayo Clinic experience. Clin Gastroenterol Hepatol 4:1010–1016

    Article  PubMed  Google Scholar 

  77. Choi EK, Kim MH, Kim JC et al (2006) The Japanese diagnostic criteria for autoimmune chronic pancreatitis: is it completely satisfactory? Pancreas 33:13–19

    Article  PubMed  Google Scholar 

  78. Kim KP, Kim MH, Kim JC et al (2006) Diagnostic criteria for autoimmune chronic pancreatitis revisited. World J Gastroenterol 28:2487–2496

    Google Scholar 

Download references

Conflict of interest

RGraziani, S. Mautone, M.C. Ambrosetti, R. Manfredi, T.J. Re, L. Calculli, L. Frulloni, R. Pozzi Mucelli declare no conflict of interest.

Author information

Authors and Affiliations

  1. Department of Radiology, “G.B. Rossi” Hospital, University of Verona, P.le L.A. Scuro 11, 37134, Verona, Italy

    Rossella Graziani, Simona Mautone, Maria Chiara Ambrosetti, Riccardo Manfredi, Thomas J. Re & Roberto Pozzi Mucelli

  2. Department of Radiology, Sant’Orsola-Malpighi Hospital, University of Bologna, 9 Via Massarenti, Bologna, Italy

    Lucia Calculli

  3. Department of Medicine, “G.B. Rossi” Hospital, University of Verona, P.le L.A. Scuro 10, Verona, Italy

    Luca Frulloni

Authors
  1. Rossella Graziani
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Simona Mautone
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Maria Chiara Ambrosetti
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Riccardo Manfredi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Thomas J. Re
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Lucia Calculli
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Luca Frulloni
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Roberto Pozzi Mucelli
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Rossella Graziani.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Graziani, R., Mautone, S., Ambrosetti, M.C. et al. Autoimmune pancreatitis: multidetector-row computed tomography (MDCT) and magnetic resonance (MR) findings in the Italian experience. Radiol med 119, 558–571 (2014). https://doi.org/10.1007/s11547-013-0373-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11547-013-0373-9

Keywords

Search

Navigation