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Autoimmune pancreatitis (AIP) is an uncommon disease that represents a diagnostic challenge unless it is considered as a cause of acute pancreatitis, pancreatic exocrine insufficiency and a pancreatic mass. This entity is under diagnosed and successful medical therapy is available. In this paper, we will describe a case of a 59 year-old, Hispanic woman diagnosed with autoimmune pancreatitis, a disease previously believed to affect typically older men. We will review the definition, types, clinical manifestations, radiological features, serology, histopathological findings, treatment strategies and diagnostic criteria of autoimmune pancreatitis.

Autoimmune pancreatitis (AIP) is an uncommon disease that represents a diagnostic challenge unless it is considered as a cause of acute pancreatitis, pancreatic exocrine insufficiency and a pancreatic mass. This entity is under diagnosed and successful medical therapy is available. In this paper, we will describe a case of a 59 year-old, Hispanic woman diagnosed with autoimmune pancreatitis, a disease previously believed to affect typically older men. We will review the definition, types, clinical manifestations, radiological features, serology, histopathological findings, treatment strategies and diagnostic criteria of autoimmune pancreatitis La pancreatitis autoinmune (PAI) es una enfermedad rara que se presenta como un reto diagnóstico a menos que sea considerada como causa de pancreatitis aguda, insuficiencia pancreática exocrina y masa pancreática. Es una enfermedad sub diagnosticada y existe una terapia médica satisfactoria. En este trabajo, describiremos un caso de una mujer hispana de 59 años diagnosticada de pancreatitis autoinmune, una enfermedad que se creía previamente que afectaba típicamente a hombres de avanzada edad. Revisaremos la definición, los tipos, las manifestaciones clínicas, hallazgos radiológicos, serología, hallazgos histopatológicos, estrategias de tratamiento y criterios diagnósticos de la pancreatitis autoinmune

A previously healthy 52-year old woman presented to the hospital with a 6-month history of progressive dyspnea. Associated symptoms included a persistent dry cough that started 2 months prior admission and an unintentional weight loss of 20 pounds over the course of her illness. On lung examination revealed fine bilateral end-inspiratory crackles in both lower and upper lobes. Radiographic studies showed evidence of interstitial lung disease. The patient underwent bronchoscopy were transbronchial biopsies were taken and showed fibrosis of bronchial walls and lung parenchyma with prominent non-necrotizing granulomata that contained abundant polarizing crystalline material. Once the pathologic findings were known, the patient was re-interviewed. She reported that for the last 20-years, she used baby talcum powder regularly at least twice a day, usually after bathing for personal hygiene. In addition, she habitually applied it to her bed sheets nightly. She was started on prednisone at a dose of 0.5 mg/kg/day, which was gradually tapered and then maintained on a dose of 5 mg daily. Her symptoms rapidly improved over weeks to the point whereshe no longer required home oxygen therapy.

Celiac Disease (CD) is an immune reaction to gluten containing foods such as rye, wheat and barley. This condition affects individuals with a genetic predisposition; it targets the small bowel and may cause symptoms including diarrhea, malabsorption, weight loss, abdominal pain and bloating. The diagnosis is made by serologic testing of celiac-specific antibodies and confirmed by histology. Certain endoscopic characteristics, such as scalloping, reduction in the number of folds, mosaic-pattern mucosa or nodular mucosa, are suggestive of CD and can be visualized under white light endoscopy. Due to its low sensitivity, endoscopy alone is not recommended to diagnose CD; however, enhanced visual identification of suspected mucosal abnormalities through the use of new technologies, such as narrow band imaging with magnification (NBI-ME), could assist in targeting biopsies and thereby increasing the sensitivity of endoscopy. This is a case series of seven patients with serologic and histologic diagnoses of CD who underwent upper endoscopies with NBI-ME imaging technology as part of their CD evaluation. By employing this imaging technology, we could identify patchy atrophy sites in a mosaic pattern, with flattened villi and alteration of the central capillaries of the duodenal mucosa. We refer to this epithelial pattern as “Leopard Skin Sign”. Since epithelial lesions are easily seen using NBI-ME, we found it beneficial for identifying and targeting biopsy sites. Larger prospective studies are warranted to confirm our findings. La enfermedad celiaca (EC) es una reacción inmune a los alimentos que contienen gluten como el centeno, el trigo y la cebada. Esta condición afecta a las personas con predisposición genética, comprometiendo al intestino delgado causando síntomas como diarrea, mala absorción, pérdida de peso, dolor abdominal y meteorismo. El diagnóstico se hace con estudios serológicos de anticuerpos específicos celiacos y es confirmado por histología. Algunas características endoscópicas tales como “scalloping”, reducción en el número de pliegues, patrón mucoso tipo mosaico o mucosa nodular, son sugestivos de EC y se pueden observar con endoscopía de luz blanca. Debido a su baja sensibilidad la endoscopía por sí sola no se recomienda para diagnosticar EC, sin embargo, una visualización cuidadosa de las anormalidades mucosas sospechosas a través de nuevas tecnologías como “Narrow Band Imagining” con magnificación (NBI-ME) puede ayudar a dirigir las biopsias y así incrementar la sensibilidad de la endoscopía. Esta es una serie de siete casos con diagnóstico serológico e histológico de EC a quienes se les realizó una endoscopía digestiva alta con NBI-ME. En ellos se pudo identificar sitios de atrofia parcelar en un patrón de mosaico, con vellosidades aplanadas y alteración de los capilares de la mucosa duodenal. Nos referimos a esta alteración como el “Signo de la Piel de Leopardo”. Como las lesiones epiteliales se ven fácilmente usando NBI-ME, lo encontramos beneficioso para identificar y dirigir los sitios donde tomar las biopsias. Estudios prospectivos más grandes deben realizarse para confirmar nuestros hallazgos.

Tanto la pancreatitis aguda como crónica causan diferentes complicaciones que antes del advenimiento de la terapéutica endoscópica tenían que ser tratadas con cirugía convencional. El avance de la endoscopía intervencionista nos ha permitido acceder al páncreas y tratar estas complicaciones efectivamente y con menor morbilidad para nuestros pacientes. Aproximadamente el 90% de las pancreatitis aguda son edematosas, tienen una resolución clínica temprana y sin complicaciones. Los pacientes que son admitidos con pancreatitis necrotizante están predispuestos a tener diferentes tipos de complicaciones tanto locales como sistémicas particularmente si hay falla orgánica. Por otro lado la pancreatitis crónica es un proceso inflamatorio crónico del páncreas en donde se ha establecido la fibrosis de la glándula con posible disfunción exocrina y/o endocrina. El objetivo principal de la terapéutica endoscópica en la pancreatitis crónica es aliviar la obstrucción y disminuir la presión del conducto pancreático con la intención de aliviar el dolor abdominal. En esta revisión vamos a hablar acerca de las indicaciones y técnica endoscópica para tratar las diferentes complicaciones de la pancreatitis como, drenaje de pseudoquistes, necrosectomía pancreática, manejo del síndrome de conducto desconectado y terapia endoscópica en pancreatitis crónica. Acute and chronic pancreatitis may lead to complications that prior the recent advancement of therapeutic endoscopy had to be treated with conventional surgery. The current techniques in interventional endoscopy allow us to access the pancreas and treat some of the complications in a minimally invasive way leading to less morbidity in our patients. Approximately 90% of acute pancreatitis episodes are edematous with early resolution of clinical symptoms and rarely leading to major complications. Patients with necrotizing pancreatitis are susceptible to local and systemic complications particularly in the setting of organ failure. On the other hand chronic pancreatitis is as a chronic inflammatory process that leads to fibrosis of the gland and in occasions to exocrine and/or endocrine insufficiency. The main objective of therapeutic endoscopy in chronic pancreatitis is to relief the obstruction and decreases the pressure in the pancreatic duct with the intention to alleviate abdominal pain. In this review we will address the indications and endoscopic techniques to treat the different complications of pancreatitis such as pseudo cyst drainage, walled off necrosis debridement, disconnected duct syndrome and different options for endoscopic therapy in chronic pancreatitis.

Propylthiouracil- (PTU-) induced hepatotoxicity is rare but potentially lethal with a spectrum of liver injury ranging from asymptomatic elevation of transaminases to fulminant hepatic failure and death. We describe two cases of acute hepatic failure due to PTU that required liver transplantation. Differences in the clinical presentation, histological characteristics, and posttransplant management are described as well as alternative therapeutic options. Frequent monitoring for PTU-induced hepatic dysfunction is strongly advised because timely discontinuation of this drug and implementation of noninvasive therapeutic interventions may prevent progression to liver failure or even death.