Pancreatic disease in the autoimmune rheumatic disorders

La enfermedad biliopancreática aguda comprende la pancreatitis aguda de cualquier causa, el cólico biliar, la colecistitis aguda, la colangitis y la coledocolitiasis. Se trata de patologías frecuentes con una morbimortalidad elevada en casos graves, por lo que será importante la clasificación de gravedad desde el servicio de urgencias (SU) para un mejor manejo. En su mayor parte, estas entidades nosológicas están causadas por cálculos biliares que son cada vez más frecuentes (5%-15% de la población occidental) en una población con un porcentaje de obesidad y sobrepeso crecientes. Son más frecuentes a partir de los 65 años y en mujeres. A pesar de lo frecuentes que son, las litiasis biliares solamente producen síntomas en el 15%-20% de los pacientes. En su mayor parte, estas patologías cursan con dolor abdominal, generalmente en el hemiabdomen superior, por lo que es importante saber diferenciar unas de otras, para iniciar el tratamiento necesario lo más precozmente posible y mejorar el pronóstico. La historia clínica y la exploración física, la analítica con perfil hepático y pancreático y la ecografía abdominal o la tomografía computarizada abdominal serán necesarias para el diagnóstico diferencial de la mayoría de estos pacientes. De inicio, estos pacientes precisarán en prácticamente todos los casos una dieta absoluta, sueroterapia, analgesia y, solamente en algunos casos, antibioterapia empírica. Aquí resumiremos los aspectos más importantes de cada patología, centrándonos sobre todo en el enfoque en el SU.

Acute biliopancreatic disease encompasses acute pancreatitis due to any cause, biliary colic, acute cholecystitis, cholangitis, and choledocholithiasis. They are common diseases with high morbidity and mortality in severe cases. For this reason, the severity classification in the emergency department (ED) is important for better management. In large part, these nosological diseases are caused by gall stones, which are becoming more and more common (5% – 15% of the Western population) in a population with a growing percentage of obesity and overweight. They are more common in individuals over 65 years of age and in women. Despite how common they are, gall stones only cause symptoms in 15% – 20% of patients. In large part, these diseases progress with abdominal pain, generally in the upper half of the abdomen. Therefore, it is important to know how to differentiate one from another in order to start the necessary treatment as early as possible to improve the prognosis. The medical record, a physical examination, a blood test with a liver and pancreatic panel, and an abdominal ultrasound or abdominal computed tomography scan will be necessary for the differential diagnosis of most patients. Initially, in practically all cases, these patients will need a liquid diet; fluid therapy; analgesics; and, only in some cases, empiric antibiotic therapy. The most important aspects of each disease will be summarized herein, focusing especially on the approach in the ED.

We report a case of autoimmune pancreatitis without obvious evidence of autoimmunological participation, which responded well to steroid treatment and provided histologic and radiographic evidence for this improvement. A 68-year-old woman presented abdominal fullness, diffuse pancreatic swelling on abdominal computed tomography and ultrasonography, and diffuse narrowing of the main pancreatic duct on endoscopic retrograde pancreatography. Transgastric aspiration needle biopsy of the body of the pancreas performed under endoscopic ultrasonography showed severe atrophy of acinar cells, infiltration of T lymphocytes. She was diagnosed as having autoimmune pancreatitis without obvious evidence of autoimmunological participation. Administration of 30 mg/day of predonisolone was started. Computed tomography showed marked improvement of the diffuse swelling of the pancreas, and endoscopic retrograde pancreatograpy showed amelioration of the narrowing of the main pancreatic duct after the start of treatment. Pancreatic tissue obtained by needle biopsy after the start of treatment with predonisolone revealed marked histologic improvement, including amelioration of the fibrosis, and infiltration of inflammatory lymphocytes, and a substantial increase in the number of pancreatic acinar cells. The present report is the first to demonstrate histologic recovery of autoimmune pancreatitis after steroid therapy.