Clinical management of autoimmune pancreatitis

Autoimmune pancreatitis (AIP) is a newly described entity with characteristic clinical, radiological, serological, and histological features, in which autoimmune mechanisms seem to be involved in pathogenesis. Many new clinical aspects of AIP have been clarified during 10 years, and AIP has become a distinct entity recognized worldwide. However, precise pathogenesis or pathophysiology remains unclear. As AIP responds dramatically to steroid therapy, accurate diagnosis of AIP is necessary to avoid unnecessary laparotomy or pancreatic resection. It is importance to misdiagnose pancreatic cancer as AIP as well as to misdiagnose AIP as pancreatic cancer. In the absence of a diagnostic serological marker for AIP, its diagnosis rests on identifying unique patterns of abnormalities. Japanese criteria are based on the minimum consensus features of AIP and aim to avoid misdiagnosis of malignancy. It contain 3 items: (1) enlargement of the pancreas and narrowing of the main pancreatic duct; (2) high serum gammaglobulin, IgG, or IgG4, or the presence of autoantibodies; (3) histological findings of lymphoplasmacytic infiltration and fibrosis in the pancreas. For diagnosing AIP, the presence of the imaging criterion is essential. Other clinical characteristics of AIP are elderly male preponderance, fluctuating obstructive jaundice without pain, occasional association with diabetes mellitus and extrapancreatic lesions, and favorite responsiveness to oral steroid therapy. Elevation of serum IgG4 levels and infiltration of abundant IgG4-positive plasma cells in various organs are rather specific in AIP patients. In an elderly male presenting obstructive jaundice and pancreatic mass, AIP should be considered as one of differential diagnoses.