Clinical Case Summary

Autoimmune pancreatitis is one of the less recognised associations and remains poorly understood. The overall reported prevalence of autoimmune pancreatitis in inflammatory bowel disease patients is 0.4% [1, 2] considering the only two studies in the literature specifically examining this issue, and that concern Asian populations. Autoimmune pancreatitis in the setting of inflammatory bowel disease is challenging to diagnose but a clinically important entity to recognize and treat. Here we report a case of a 43-year-old women followed for ulcerative colitis, presented with epigastric pain and dyspepsia symptoms associeted to steatorrhea and 12 kg weight loss in 2 months. Laboratory tests found fasting plasma glucose at 1.27 g/l. HbA1c was 8%, IgG4 Levels were normal and the fecal elastase level was low. Magnetic resonance imaging of abdomen revealed a swollen pancreas especially in the uncus. The Bilio-pancreatic endoscopic ultrasound showed heterogeneous hypoechoic lesion of the pancreas head. And the biopsy of the pancreas revealed signs compatible with autoimmune pancreatitis type 2. A final diagnosis of ulceratice colitis associated autoimmune pancreatitis type 2 was made and the patient was treated with corticosteroids, with impressive improvement during his follow-up. In the context of inflammatory bowel disease, autoimmune pancreatitis is a rare and challenging to identify condition. The creation of clear guidelines and diagnostic standards for autoimmune pancreatitis is anticipated to improve awareness of the condition and result in a rise in the number of confirmed cases during the ensuing years.

References

1. Park, S. H., Kim, D., Ye, B. D., Yang, S. K., Kim, J. H., Yang, D. H., ... & Kim, J. H. (2013). The characteristics of ulcerative colitis associated with autoimmune pancreatitis. Journal of clinical gastroenterology, 47(6), 520-525.
2. Ueki, T., Kawamoto, K., Otsuka, Y., Minoda, R., Maruo, T., Matsumura, K., ... & Iwashita, A. (2015). Prevalence and clinicopathological features of autoimmune pancreatitis in Japanese patients with inflammatory bowel disease. Pancreas, 44(3), 434-440.

Introduction

There has been a shift from percutaneous drainage towards endoscopic ultrasound (EUS)-guided drainage for management of post-operative pancreatic fluid collections (POPFC). However, available series have been limited by sample size and little is known about the factors that may influence clinical success.

Aims & Methods

Our aim was to evaluate the outcomes of EUS-guided drainage of POPFC following pancreatic surgery and identify predictors of clinical success.
We performed a retrospective review of patients who underwent EUS-guided drainage of POPFC between 2014 and August 2024 at three academic centers. Primary outcome was clinical success, defined as the complete radiological regression of the collection and resolution of symptoms without the need for additional drainage procedures.

Results

In total, 265 cases were included (mean age 64 [SD±13.9] years, 37% pylorus-resecting pancreatoduodenectomy). Early drainage (≤14 days) was performed in 52% of cases (n=138) and DPPS were used in 209 cases (79%).
Clinical success with a single EUS drainage procedure was achieved in 160 cases (60.4%). Step-up interventions were required in 67 patients (25.3%), 37 of which required endoscopic revision only. Technical success was achieved in 90% (n=238) and adverse events occurred in 43 cases (16%).
Stent type, drainage timing, splenectomy and drainage route did not seem to significantly influence clinical success. Multivariate analysis including stent type and surgical history, showed that distal pancreatectomy was an independent risk factor for clinical failure.

Conclusion

EUS-guided drainage of POPFC was effective in the majority of cases with a single procedure, although distal pancreatectomy was suggested as an independent risk factor for clinical failure. These results further support the use of EUS-guided drainage for the management of postoperative collections.

Disclosure

HH declares no competing interests. MB received trial support from Boston Scientific and holds consultancy agreements with Dekra, Ovesco and Prion Medical. GV received lecture fees from Boston Scientific and travel grants from Pentax Medical and Euromedical. RVW holds a consultancy agreement with Boston Scientific. Schalk van der Merwe holds the Cook chair in Interventional endoscopy, has consultancy agreements with Cook, Pentax and Olympus and co-chairs the Boston-Scientific Chair in Therapeutic Biliopancreatic Endoscopy.

Clinical Case Summary

A 38 year old female with jaundice, multiple limb bruises and a left breast haematoma on a background of decompensated alcohol related cirrhosis, presented to our hospital’s emergency department in December 2024 with spontaneous oropharyngeal bleeding. There was no history of any oropharyngeal infections, trauma, tongue bite or alcohol withdrawal seizure. She lost a litre of blood in a four-five hour period following her presentation in the emergency department. Initial interventions by ENT surgery team and Maxillofacial surgery teams proved unsuccessful in achieving definitive haemostasis in the glossal bed. This resulted in airway compromise which was managed by intubation by the anaesthetics team. Following input from the interventional radiology team, patient underwent angiograms of the right and left external carotid and common carotid arteries and a vascular blush was identified. She underwent successful embolization of the right sided facio-lingual and left sided lingual vessels and haemostasis was achieved.
Patient remained intubated in ITU and received management for ongoing coagulopathy and hepatic encephalopathy. Following step down to the Gastroenterology ward, extensive dietitian, physiotherapy, speech and language therapy input was required. She achieved baseline status after one month of extensive medical management and her cognitive function improved. She was eventually discharged to a rehabilitation assessment bed.
Spontaneous lingual artery haemorrhage is a rare manifestation of coagulopathy secondary to cirrhosis with other cases in literature stemming mainly from a co-existing asymptomatic pseudoaneurysm. This case illustrates an atypical presentation of decompensated liver cirrhosis with an acute spontaneous lingual artery haemorrhage requiring embolization of bilateral facio-lingual vessels. It emphasizes the need for early joined up multidisciplinary care and intervention to achieve haemostasis and a successful outcome in these patients.

Disclosure

The authors declare no conflict of interest

Introduction

Atrophic gastritis (AG) is a well-established precursor of gastric cancer, and its most frequent aetiological agent is Helicobacter pylori (H. pylori). Accurate risk stratification is essential to optimise endoscopic surveillance and resource allocation. The Operative Link on Gastritis Assessment (OLGA) system offers a histological staging tool to quantify the severity of gastric atrophy and associated cancer risk. Despite high H. pylori endemicity in Colombia, local data on the prevalence of advanced OLGA stages remains scarce. This study aimed to elucidate the distribution of OLGA stages and their correlation with age and H. pylori status in a large dyspeptic cohort.

Aims & Methods

We conducted a cross-sectional, observational study of adult patients undergoing upper gastrointestinal endoscopy for dyspepsia between January 2019 and December 2023 at a high-volume reference centre in Bogotá, Colombia. All cases followed the updated Sydney biopsy protocol, with five mapped gastric samples analysed by experienced gastrointestinal pathologists. The OLGA system was applied to stage gastric atrophy (0–IV). H. pylori detection was based on histology using Giemsa and H&E stains. Demographic variables, H. pylori status, OLGA stage, and histological features were recorded. Data were processed using SPSS v26, and statistical significance was set at p<0.05.

Results

Out of 6,746 patients (mean age: 59 years; 73.4% female), 99% exhibited low-risk OLGA stages (0–II). Only 3 patients (0.04%) presented with advanced OLGA stages (III–IV). A positive correlation was noted between increasing age and the frequency of gastric atrophy, although this did not correspond to an increase in advanced stages. H. pylori infection was confirmed in 82% of the cohort, showing an upward trend over the study period. Interestingly, no cases of H. pylori infection were observed among patients with OLGA III–IV. The majority of infections were restricted to the antrum. Gastric dysplasia and cancer were rare events, both observed in <1% of patients. The association between H. pylori and gastric cancer did not reach statistical significance (OR 0.49; 95% CI 0.23–1.04; p=0.07).

Conclusion

Despite the high prevalence of H. pylori, the frequency of advanced OLGA stages remains remarkably low in Colombian dyspeptic patients. These findings reinforce the utility of the OLGA system, coupled with Sydney protocol biopsies, as a valuable approach to risk stratification. Only 1% of patients would benefit from endoscopic surveillance under international guidelines, suggesting that widespread follow-up may be unnecessary and potentially wasteful.

References

1. Rugge M, Genta RM, Dixon MF. OLGA staging for gastritis: a tutorial. Dig Liver Dis. 2008 Oct;40(10):650–8. doi:10.1016/j.dld.2008.02.029.
2. El-Zimaity HM, Graham DY. Evaluation of gastric mucosal atrophy in clinical practice: OLGA is OK, but incomplete and in need of standardization. Am J Gastroenterol. 2011 Feb;106(2):469–70. doi:10.1038/ajg.2010.417.
3. Correa P. Human gastric carcinogenesis: a multistep and multifactorial process—First American Cancer Society Award Lecture on Cancer Epidemiology and Prevention. Cancer Res. 1992 Dec 1;52(24):6735–40.
4. Herrera-Goossens A, Bravo LE, Correa P. Helicobacter pylori infection and histopathological findings in a population at high risk for gastric cancer in Colombia. Am J Gastroenterol. 2005 Nov;100(11):2314–20. doi:10.1111/j.1572-0241.2005.00226.x.