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Autoimmune Pancreatitis: Imaging Features¹

¹ From the Departments of Radiology (D.V.S., S.P.K., M.M.M., S.S., P.R.M., J.F.S.), Endoscopy (J.F.), Pathology (G.Y.L.), and Surgery (C.D.F., A.L.W.), Massachusetts General Hospital, White Bldg 270F, 55 Fruit St, Boston MA 02114. Received September 5, 2003; revision requested November 4; final revision received March 26, 2004; accepted April 15. Address correspondence to D.V.S. (e-mail: dsahani@partners.org).

View larger version (119K): [in a new window]   Figure 1a. Images obtained in 71-year-old man with diffuse form of autoimmune pancreatitis who had jaundice and abdominal pain at presentation. (a) Contrast-enhanced transverse CT scan shows diffuse enlargement of pancreas (white arrow), with sharp borders and minimal peripancreatic stranding. Associated dilated intra- and extrahepatic bile ducts (black arrow) are noted. (b) Transabdominal transverse US image shows diffuse enlargement with minimal decreased echotexture of pancreas (arrows). (c) Transverse CT scan obtained at the level of origin of inferior mesenteric artery shows circumferential thickening of aortic wall with periaortic soft tissue (arrow) consistent with retroperitoneal fibrosis. (d) Transverse CT scan obtained at the level of left renal vein shows two hypoattenuating renal lesions (arrows). (e) Transverse CT scan of chest shows multiple enlarged mediastinal (left arrow) and hilar (right arrow) nodes. (f) Frontal endoscopic retrograde cholangiopancreatographic image shows focal stricture (arrow) in distal common bile duct with diffuse narrowing of pancreatic duct. (g) Same type of image as in f obtained within a few weeks shows that patient developed multiple intrahepatic duct strictures (arrows). (h) Transverse CT scan obtained after steroid therapy shows normal-appearing pancreas (white arrows). Stent (black arrow) in common bile duct is also seen with residual intrahepatic ductal dilatation. (i) Transverse CT scan shows a decrease in periaortic soft tissue (arrow).

View larger version (85K): [in a new window]   Figure 1b. Images obtained in 71-year-old man with diffuse form of autoimmune pancreatitis who had jaundice and abdominal pain at presentation. (a) Contrast-enhanced transverse CT scan shows diffuse enlargement of pancreas (white arrow), with sharp borders and minimal peripancreatic stranding. Associated dilated intra- and extrahepatic bile ducts (black arrow) are noted. (b) Transabdominal transverse US image shows diffuse enlargement with minimal decreased echotexture of pancreas (arrows). (c) Transverse CT scan obtained at the level of origin of inferior mesenteric artery shows circumferential thickening of aortic wall with periaortic soft tissue (arrow) consistent with retroperitoneal fibrosis. (d) Transverse CT scan obtained at the level of left renal vein shows two hypoattenuating renal lesions (arrows). (e) Transverse CT scan of chest shows multiple enlarged mediastinal (left arrow) and hilar (right arrow) nodes. (f) Frontal endoscopic retrograde cholangiopancreatographic image shows focal stricture (arrow) in distal common bile duct with diffuse narrowing of pancreatic duct. (g) Same type of image as in f obtained within a few weeks shows that patient developed multiple intrahepatic duct strictures (arrows). (h) Transverse CT scan obtained after steroid therapy shows normal-appearing pancreas (white arrows). Stent (black arrow) in common bile duct is also seen with residual intrahepatic ductal dilatation. (i) Transverse CT scan shows a decrease in periaortic soft tissue (arrow).

View larger version (101K): [in a new window]   Figure 1c. Images obtained in 71-year-old man with diffuse form of autoimmune pancreatitis who had jaundice and abdominal pain at presentation. (a) Contrast-enhanced transverse CT scan shows diffuse enlargement of pancreas (white arrow), with sharp borders and minimal peripancreatic stranding. Associated dilated intra- and extrahepatic bile ducts (black arrow) are noted. (b) Transabdominal transverse US image shows diffuse enlargement with minimal decreased echotexture of pancreas (arrows). (c) Transverse CT scan obtained at the level of origin of inferior mesenteric artery shows circumferential thickening of aortic wall with periaortic soft tissue (arrow) consistent with retroperitoneal fibrosis. (d) Transverse CT scan obtained at the level of left renal vein shows two hypoattenuating renal lesions (arrows). (e) Transverse CT scan of chest shows multiple enlarged mediastinal (left arrow) and hilar (right arrow) nodes. (f) Frontal endoscopic retrograde cholangiopancreatographic image shows focal stricture (arrow) in distal common bile duct with diffuse narrowing of pancreatic duct. (g) Same type of image as in f obtained within a few weeks shows that patient developed multiple intrahepatic duct strictures (arrows). (h) Transverse CT scan obtained after steroid therapy shows normal-appearing pancreas (white arrows). Stent (black arrow) in common bile duct is also seen with residual intrahepatic ductal dilatation. (i) Transverse CT scan shows a decrease in periaortic soft tissue (arrow).

View larger version (102K): [in a new window]   Figure 1d. Images obtained in 71-year-old man with diffuse form of autoimmune pancreatitis who had jaundice and abdominal pain at presentation. (a) Contrast-enhanced transverse CT scan shows diffuse enlargement of pancreas (white arrow), with sharp borders and minimal peripancreatic stranding. Associated dilated intra- and extrahepatic bile ducts (black arrow) are noted. (b) Transabdominal transverse US image shows diffuse enlargement with minimal decreased echotexture of pancreas (arrows). (c) Transverse CT scan obtained at the level of origin of inferior mesenteric artery shows circumferential thickening of aortic wall with periaortic soft tissue (arrow) consistent with retroperitoneal fibrosis. (d) Transverse CT scan obtained at the level of left renal vein shows two hypoattenuating renal lesions (arrows). (e) Transverse CT scan of chest shows multiple enlarged mediastinal (left arrow) and hilar (right arrow) nodes. (f) Frontal endoscopic retrograde cholangiopancreatographic image shows focal stricture (arrow) in distal common bile duct with diffuse narrowing of pancreatic duct. (g) Same type of image as in f obtained within a few weeks shows that patient developed multiple intrahepatic duct strictures (arrows). (h) Transverse CT scan obtained after steroid therapy shows normal-appearing pancreas (white arrows). Stent (black arrow) in common bile duct is also seen with residual intrahepatic ductal dilatation. (i) Transverse CT scan shows a decrease in periaortic soft tissue (arrow).

View larger version (80K): [in a new window]   Figure 1e. Images obtained in 71-year-old man with diffuse form of autoimmune pancreatitis who had jaundice and abdominal pain at presentation. (a) Contrast-enhanced transverse CT scan shows diffuse enlargement of pancreas (white arrow), with sharp borders and minimal peripancreatic stranding. Associated dilated intra- and extrahepatic bile ducts (black arrow) are noted. (b) Transabdominal transverse US image shows diffuse enlargement with minimal decreased echotexture of pancreas (arrows). (c) Transverse CT scan obtained at the level of origin of inferior mesenteric artery shows circumferential thickening of aortic wall with periaortic soft tissue (arrow) consistent with retroperitoneal fibrosis. (d) Transverse CT scan obtained at the level of left renal vein shows two hypoattenuating renal lesions (arrows). (e) Transverse CT scan of chest shows multiple enlarged mediastinal (left arrow) and hilar (right arrow) nodes. (f) Frontal endoscopic retrograde cholangiopancreatographic image shows focal stricture (arrow) in distal common bile duct with diffuse narrowing of pancreatic duct. (g) Same type of image as in f obtained within a few weeks shows that patient developed multiple intrahepatic duct strictures (arrows). (h) Transverse CT scan obtained after steroid therapy shows normal-appearing pancreas (white arrows). Stent (black arrow) in common bile duct is also seen with residual intrahepatic ductal dilatation. (i) Transverse CT scan shows a decrease in periaortic soft tissue (arrow).

View larger version (96K): [in a new window]   Figure 1f. Images obtained in 71-year-old man with diffuse form of autoimmune pancreatitis who had jaundice and abdominal pain at presentation. (a) Contrast-enhanced transverse CT scan shows diffuse enlargement of pancreas (white arrow), with sharp borders and minimal peripancreatic stranding. Associated dilated intra- and extrahepatic bile ducts (black arrow) are noted. (b) Transabdominal transverse US image shows diffuse enlargement with minimal decreased echotexture of pancreas (arrows). (c) Transverse CT scan obtained at the level of origin of inferior mesenteric artery shows circumferential thickening of aortic wall with periaortic soft tissue (arrow) consistent with retroperitoneal fibrosis. (d) Transverse CT scan obtained at the level of left renal vein shows two hypoattenuating renal lesions (arrows). (e) Transverse CT scan of chest shows multiple enlarged mediastinal (left arrow) and hilar (right arrow) nodes. (f) Frontal endoscopic retrograde cholangiopancreatographic image shows focal stricture (arrow) in distal common bile duct with diffuse narrowing of pancreatic duct. (g) Same type of image as in f obtained within a few weeks shows that patient developed multiple intrahepatic duct strictures (arrows). (h) Transverse CT scan obtained after steroid therapy shows normal-appearing pancreas (white arrows). Stent (black arrow) in common bile duct is also seen with residual intrahepatic ductal dilatation. (i) Transverse CT scan shows a decrease in periaortic soft tissue (arrow).

View larger version (109K): [in a new window]   Figure 1g. Images obtained in 71-year-old man with diffuse form of autoimmune pancreatitis who had jaundice and abdominal pain at presentation. (a) Contrast-enhanced transverse CT scan shows diffuse enlargement of pancreas (white arrow), with sharp borders and minimal peripancreatic stranding. Associated dilated intra- and extrahepatic bile ducts (black arrow) are noted. (b) Transabdominal transverse US image shows diffuse enlargement with minimal decreased echotexture of pancreas (arrows). (c) Transverse CT scan obtained at the level of origin of inferior mesenteric artery shows circumferential thickening of aortic wall with periaortic soft tissue (arrow) consistent with retroperitoneal fibrosis. (d) Transverse CT scan obtained at the level of left renal vein shows two hypoattenuating renal lesions (arrows). (e) Transverse CT scan of chest shows multiple enlarged mediastinal (left arrow) and hilar (right arrow) nodes. (f) Frontal endoscopic retrograde cholangiopancreatographic image shows focal stricture (arrow) in distal common bile duct with diffuse narrowing of pancreatic duct. (g) Same type of image as in f obtained within a few weeks shows that patient developed multiple intrahepatic duct strictures (arrows). (h) Transverse CT scan obtained after steroid therapy shows normal-appearing pancreas (white arrows). Stent (black arrow) in common bile duct is also seen with residual intrahepatic ductal dilatation. (i) Transverse CT scan shows a decrease in periaortic soft tissue (arrow).

View larger version (103K): [in a new window]   Figure 1h. Images obtained in 71-year-old man with diffuse form of autoimmune pancreatitis who had jaundice and abdominal pain at presentation. (a) Contrast-enhanced transverse CT scan shows diffuse enlargement of pancreas (white arrow), with sharp borders and minimal peripancreatic stranding. Associated dilated intra- and extrahepatic bile ducts (black arrow) are noted. (b) Transabdominal transverse US image shows diffuse enlargement with minimal decreased echotexture of pancreas (arrows). (c) Transverse CT scan obtained at the level of origin of inferior mesenteric artery shows circumferential thickening of aortic wall with periaortic soft tissue (arrow) consistent with retroperitoneal fibrosis. (d) Transverse CT scan obtained at the level of left renal vein shows two hypoattenuating renal lesions (arrows). (e) Transverse CT scan of chest shows multiple enlarged mediastinal (left arrow) and hilar (right arrow) nodes. (f) Frontal endoscopic retrograde cholangiopancreatographic image shows focal stricture (arrow) in distal common bile duct with diffuse narrowing of pancreatic duct. (g) Same type of image as in f obtained within a few weeks shows that patient developed multiple intrahepatic duct strictures (arrows). (h) Transverse CT scan obtained after steroid therapy shows normal-appearing pancreas (white arrows). Stent (black arrow) in common bile duct is also seen with residual intrahepatic ductal dilatation. (i) Transverse CT scan shows a decrease in periaortic soft tissue (arrow).

View larger version (106K): [in a new window]   Figure 1i. Images obtained in 71-year-old man with diffuse form of autoimmune pancreatitis who had jaundice and abdominal pain at presentation. (a) Contrast-enhanced transverse CT scan shows diffuse enlargement of pancreas (white arrow), with sharp borders and minimal peripancreatic stranding. Associated dilated intra- and extrahepatic bile ducts (black arrow) are noted. (b) Transabdominal transverse US image shows diffuse enlargement with minimal decreased echotexture of pancreas (arrows). (c) Transverse CT scan obtained at the level of origin of inferior mesenteric artery shows circumferential thickening of aortic wall with periaortic soft tissue (arrow) consistent with retroperitoneal fibrosis. (d) Transverse CT scan obtained at the level of left renal vein shows two hypoattenuating renal lesions (arrows). (e) Transverse CT scan of chest shows multiple enlarged mediastinal (left arrow) and hilar (right arrow) nodes. (f) Frontal endoscopic retrograde cholangiopancreatographic image shows focal stricture (arrow) in distal common bile duct with diffuse narrowing of pancreatic duct. (g) Same type of image as in f obtained within a few weeks shows that patient developed multiple intrahepatic duct strictures (arrows). (h) Transverse CT scan obtained after steroid therapy shows normal-appearing pancreas (white arrows). Stent (black arrow) in common bile duct is also seen with residual intrahepatic ductal dilatation. (i) Transverse CT scan shows a decrease in periaortic soft tissue (arrow).

View larger version (152K): [in a new window]   Figure 2a. Transverse images obtained in 80-year-old man with focal form of autoimmune pancreatitis who had abdominal pain and jaundice at presentation. (a) CT scan shows isoattenuating enlargement (arrow) of head and uncinate process of pancreas. (b) Endoscopic US image shows focal hypoechoic mass in the head and uncinate process of pancreas.

View larger version (144K): [in a new window]   Figure 2b. Transverse images obtained in 80-year-old man with focal form of autoimmune pancreatitis who had abdominal pain and jaundice at presentation. (a) CT scan shows isoattenuating enlargement (arrow) of head and uncinate process of pancreas. (b) Endoscopic US image shows focal hypoechoic mass in the head and uncinate process of pancreas.

View larger version (160K): [in a new window]   Figure 3. Frontal endoscopic retrograde cholangiopancreatographic image obtained in 58-year-old man with autoimmune pancreatitis who had jaundice at presentation. Image shows stricture (double arrows) in distal common bile duct and proximal pancreatic duct (single arrow).