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Pancreatic head demonstrates atrophy of acini and extensive inter-and intra-lobular fibrosis, including focal storiform fibrosis. HE stain. ×20 magnification.
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Eosinophilic pancreatitis is a rare form of recurrent acute pancreatitis that demonstrates distinct histologic features, including diffuse, periductal, acinar, and septal inflammatory infiltrates comprised of a pure or predominant population of eosinophils, eosinophilic phlebitis and arteritis, and localized eosinophilic infiltrates with pseudocyst...
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... was relatively small, measur- ing 3.5 cm in greatest dimension, and did not contain any stones. Microscopic examination of the gallbladder exhibited nonspecific chronic inflammation with focal mild eosinophilia. The pancreatic head showed patchy atrophy of acini and extensive inter-and intra-lobular fibro- sis, including focal storiform fibrosis (Fig. 1). There was extensive eosinophilic infiltration in the septa, focally in the acini, and around veins and nerves (Fig. 2a, b). Significant apoptosis and karyorrhexis of eosinophils was noted. The pancreatic duct showed periductal mononu- clear cell infiltrate, focal denudation of epithelium, and mild neutrophilic inflammation in the ...
Citations
... EP is a rare disease that often takes the form of chronic pancreatitis but can also present as acute pancreatitis [4]. Furthermore, to our knowledge, there has only been one other case describing EP in the setting of ulcerative colitis [3]. ...
Eosinophilic pancreatitis (EP) is very rare and characterised by infiltration of eosinophils into the pancreatic parenchyma. A 40-year-old man was diagnosed with total-colitis-type ulcerative colitis at the age of 15 years. He was then diagnosed with steroid-dependent ulcerative colitis. He was given golimumab, which resulted in remission. Ten months after beginning golimumab, he was urgently hospitalised with a diagnosis of acute pancreatitis. Hence, endoscopic ultrasound-guided fine needle biopsy was performed to obtain a definitive diagnosis. Pathologically, abundant infiltration of eosinophils was observed in the edematous intralobular stroma of the pancreas. He was diagnosed with EP, and treated with corticosteroids.
... In the past several decades, the accumulation of eosinophils during different stages of pancreatitis (AP, RAP, and CP) has been noted and reported as eosinophilic pancreatitis (EP). In 1955, circulatory eosinophils were found in chronic relapsing pancreatitis patients [18], and several cases of EP are currently known [62][63][64][65][66]. The influx of eosinophils in the pancreas is also reported in other pancreatic diseases such as lymphoplasmacytic sclerosing pancreatitis, pancreatic allograft rejection, pancreatic pseudocyst, inflammatory myofibroblastic tumor, and histiocytosis X [7]. ...
... It is mostly reported in idiopathic group of patients that forms 20-25% of cases of AP [82,83]. A case of EP in a 44-year-old male patient was diagnosed after pancreatic resection for recurrent bouts of AP [66]. The patient's histological evaluations from the pancreatic head revealed reduced numbers of acinar cells and increased fibrosis with infiltration of eosinophils in fibrotic areas and eosinophilic phlebitis of small veins. ...
... The patient's histological evaluations from the pancreatic head revealed reduced numbers of acinar cells and increased fibrosis with infiltration of eosinophils in fibrotic areas and eosinophilic phlebitis of small veins. The patient had only minimal peripheral eosinophilia, no reported history of symptoms related to elevated eosinophilia or IgE, and only mild eosinophilic infiltrates in his gallbladder that improves with intravenous fluids and pain medication [66]. In another case report, a 35-year-old female was referred with symptoms of gastric outlet obstruction due to eosinophilic infiltration of the stomach and the duodenum. ...
Eosinophils comprise approximately 1–4% of total blood leukocytes that reside in the intestine, bone marrow, mammary gland, and adipose tissues to maintain innate immunity in healthy individuals. Eosinophils have four toxic granules known as major basic protein (MBP), eosinophil cationic protein (ECP), eosinophil peroxidase (EPO), and eosinophil-derived neurotoxin (EDN), and upon degranulation, these granules promote pathogenesis of inflammatory diseases like allergy, asthma, dermatitis, and gastrointestinal disorders. Additionally, the role of eosinophils is underscored in exocrine disorders including pancreatitis. Chronic pancreatitis (CP) is an inflammatory disorder that occurs due to the alcohol consumption, blockage of the pancreatic duct, and trypsinogen mutation. Eosinophil levels are detected in higher numbers in both CP and pancreatic cancer patients compared with healthy individuals. The mechanistic understanding of chronic inflammation–induced pancreatic malignancy has not yet been reached and requires further exploration. This review provides a comprehensive summary of the epidemiology, pathophysiology, evaluation, and management of eosinophil-associated pancreatic disorders and further summarizes current evidence regarding risk factors, pathophysiology, clinical features, diagnostic evaluation, treatment, and prognosis of eosinophilic pancreatitis (EP) and pancreatic cancer.
... Eosinophilic pancreatitis (EP) is characterized by a purely eosinophilic systemic infiltrate [1]. It is associated with elevated immunoglobulin E (IgE) levels, hypereosinophilia, and eosinophilic infiltrates in other organs [2]. EP is a rare disorder, with only 16 case reports in 40 years. ...
... Eosinophil accumulation occurs in human pancreatitis more than with normal pancreatic tissue [4]. Typical presenting symptoms of EP include abdominal or mid-back pain and obstructive jaundice that mimic the presentation of pancreatic cancer [1,2,[5][6][7][8][9][10][11]. Distinguishing between EP and pancreatic cancer is crucial because the treatments and prognoses of the two diseases are Submitted: 14 April 2020; Revised: 24 September 2020; Accepted: 1 November 2020 V C The Author(s) 2020. ...
... Surgery is the cornerstone for decreasing perioperative morbidity and mortality [14], but it is unnecessary for EP patients. In all of the previously reported cases, eosinophilic infiltration of the pancreas was frequently noted after autopsy or pancreatic resection in patients with a suspected pancreatic tumor [1][2][3][5][6][7][8][9][10]. In general clinical work, pancreatic tissue is obtained by surgical resection or biopsy. ...
Eosinophilic pancreatitis (EP) is an extremely rare disease caused by purely eosinophilic infiltration of the pancreas. EP is prone to being misdiagnosed as pancreatic cancer, causing unnecessary economic and physical harm to the patient. We report three cases of EP that were cured by steroids without relapse from 2017 to now. The clinical data of the three patients, including clinical manifestations, serological manifestations, imaging (ultrasound, computed tomography, and MRI), pathological diagnosis and treatment, and telephone follow-up of all patients, were retrospectively analysed. In addition, a literature search was conducted on the Web of Science and PubMed databases using key terms related to EP, considering case reports with no restrictions on the date of publication or language. In conclusion, we analysed 19 cases and determined the diagnostic criteria for EP. The diagnostic algorithm for EP can be used to diagnose EP easily. We hope that our standards and algorithm can reduce the rate of misdiagnosis and contribute to clinical diagnosis and treatment. In addition, we expect to evaluate more EP cases to test our diagnostic criteria and design a systematic diagnostic flow chart.
... The first case of peripheral blood eosinophilia in a patient with chronic relapsing pancreatitis with pleural effusion was reported in 1955 [8]. Subsequently, several cases reports described eosinophils accumulation in pancreatitis patients and the diseases was termed eosinophilic pancreatitis (EP) [9][10][11][12][13]. Abraham et al. described two different histological patterns in patients with eosinophilic pancreatitis: 1) a diffuse periductal, acinar, and septal eosinophilic infiltrate with eosinophilic phlebitis and arteritis; and 2) localised intense eosinophilic infiltrates associated with pseudocyst formation [7]. ...
... Lab testing after 8 h indicates an eosinophil count of 8.5% (reference: 0-8%) and an absolute eosinophil count of 0.53 × 10 3 /µl (reference: 0.3-0.46 × 10 3 /µl). The patient has only minimal peripheral eosinophilia, no reported history of symptoms related to elevated eosinophilia or immunoglobulin (Ig) E, and only mild eosinophilic infiltrates in his gallbladder [13]. Therefore, EG may be considered in the differential diagnosis of unexplained acute pancreatitis, especially in a patient with duodenal oedema on imaging or peripheral eosinophilia. ...
... However, these steroidal approaches may have some adverse effects. Therefore, several non-steroid drugs can be used as a treatment option for EP, such as cromolyn, montelukast, hydroxyurea, azathioprine, and ketotifen [10,13]. Proper treatment of EP can restrict the progression of other associated disease conditions such as eosinophilic gastroenteritis and hypereosinophilic syndrome. ...
Several case reports show accumulation of eosinophils in pancreatitis patients and term the disease as "eosinophilic pancreatitis (EP)". EP usually presents with a pancreatic tumour and abdominal pain in obstructive jaundice, which is generally not diagnosed until the patient undergoes pancreatic resection. Histologically, EP reveals distinct patterns like diffused, periductal, acinar, and septal inflammatory infiltrates with eosinophils, eosinophilic phlebitis, and localised extreme eosinophilic infiltrates related with pseudocyst formation. EP patients also have elevated serum IgE levels with high eosinophil counts in the pancreas as well as in other organs such as the gastrointestinal tract, which is termed as eosinophilic gastroenteritis. Due to the lack of knowledge based on just a few case reports, it is considered that eosinophilic infiltration is quite rare in the pancreas; therefore, the significance of eosinophils in pancreatitis is not yet established. This review assesses the current understanding of eosinophilic pancreatitis and the important role of eosinophils in promoting pancreatic fibrosis including malignancy.
... There were total 40 reports of EP appearing from the following countries: USA [7,8,14,15,18,25,28,78,100], Turkey [3,17], China [16,22], Korea [13,21], France [9,11,77,101], India [6,27], Japan [20,24,106], Denmark [18], UK [5], Brazil [29], Italy [26], and Tunisia [76]. ...
Abstract
Background: Among the rarest causes of acute pancreatitis, in addition to the drugs (DIAP), there are eosinophilic pancreatitis (EP) and autoimmune pancreatitis (AIP).
Methods: We surveyed on PUBMED the descriptions of clinical cases of eosinophilic pancreatitis appeared from 1990 to June 2019 and those related to new drugs responsible for acute pancreatitis.
Results: We found forty reports on eosinophilic pancreatitis associated or not with hypereosinophilia and gastro-intestinal manifestations. There are several reports on drugs implicated in acute pancreatitis.
Conclusions: Here we discuss the importance of hypereosinophilia in EP and IgG–4 increase in Type 1 AIP. Differential diagnosis with pancreatic neoplasms and therapy schedules are also discussed as well.
... Lately, patients with inflammatory infiltrate involving the pancreatic tissue, composed mainly of eosinophils have been classified as a rare form of chronic pancreatitis [23] or recurrent acute pancreatitis [24], eosinophilic pancreatitis (EP). ...
... Despite the fact that CT scans showed duodenal wall thickening only in 2/20 patients[31] [35] and upper endoscopy revealed duodenitis in one patient [28] and papilitis in three [26] In addition, cholecystectomy was performed in 2 patients [24][29], gastrojejunostomy and tube cholecystotomy in one due to duodenal obstruction [28], and multiple pancreatic duct stents were placed for pancreatic duct leak in another one [24], while en block distal pancreatectomy and splenectomy followed by Cromoglycate administration [30] [36]. ...
... Despite the fact that CT scans showed duodenal wall thickening only in 2/20 patients[31] [35] and upper endoscopy revealed duodenitis in one patient [28] and papilitis in three [26] In addition, cholecystectomy was performed in 2 patients [24][29], gastrojejunostomy and tube cholecystotomy in one due to duodenal obstruction [28], and multiple pancreatic duct stents were placed for pancreatic duct leak in another one [24], while en block distal pancreatectomy and splenectomy followed by Cromoglycate administration [30] [36]. ...
Background: Over the past years, eosinophil infiltration involving the gastrointestinal tract and pancreas leading to eosinophilic pancreatitis, eosinophilic gastroenteritis and hypereosinophilic syndrome, has been reported in the literature.
We aimed to analyze and compare the features involving patients with eosinophilic pancreatitis and pancreatitis associated with eosinophilic gastroenteritis and to determine ifthere is a connection between the two disorders or if they in fact meet the diagnostic criteria for hypereosinophilic syndrome.
Material and methods: The following search was performed in March 2019 on PubMed (MEDLINE) database using the medical terms “pancreatitis”, “eosinophilic pancreatitis”, “eosinophilic gastroenteritis” and “hypereosinophilic syndrome”.
Results: The search revealed 119 publications from 1970 onwards. A total of 83 papers were excluded, and the remaining 36 publications, consisting in case reports and case series, were analyzed. From 45 patients, 20 subjects with eosinophilic gastroenteritis developed pancreatitis, 20/45 had eosinophilic pancreatitis, and 5/45 Hypereosinophilic syndrome involving the pancreas. There was no significant difference regarding clinical, laboratory and imaging features between the three groups, despite the multiple theories that explain the association of pancreatic and gastrointestinal eosinophilic infiltration. Although there was a strong resemblance between the three groups, histological evidence of eosinophilic gastrointestinal infiltration guided the treatment towards a less invasive way, while subjects with eosinophilic pancreatitis underwent pancreatic surgery to exclude potentially malignant lesions.
Conclusion: Although there are various theories that explain pancreatitis development in patients with eosinophilic gastroenteritis, hypereosinophilia diagnostic work-up should be taken into account in all patients with high number of blood eosinophils, even in those with eosinophilic pancreatitis in order to establish the diagnosis using a minimally invasive approach and to apply an adequate treatment.
... It is a very rare form with only few cases reported in literature. 11,12 In the second instance, which is a more common form, peripheral eosinophilia is not associated with eosinophilic infiltration of pancreas. ...
... 13 EP is usually associated with eosinophilic gastroenteritis or hyper-eosinophilic syndrome. 11 It is difficult to distinguish from pancreatic cancer and autoimmune pancreatitis (AIP) by clinical or radiological findings. 12 patients may be more of a secondary phenomenon due to serous membrane response due to stimulation of serosa by pancreatic fluid causing inflammatory response. ...
Background: Eosinophilia in peripheral blood has been observed in few patients with chronic pancreatitis (CP) but the clinical significance and the causes are not well understood. The aim was to analyse the features of CP in patients with and without eosinophilia and compare both groups and assess its significance.Methods: All patients diagnosed to have CP during period June 2009 to July 2012 were included in the study. Patients were divided into two groups based on eosinophil count in peripheral blood. Those with eosinophil count >0.6x109/L (6%) were considered as having eosinophilia. Author had analyzed and compared the clinical features of CP in patients with and without eosinophilia.Results: There were 28 (24.56%) patients with eosinophilia among 114 CP patients. Mean age at presentation was similar in two groups. The male to female ratio was significantly higher in patients with eosinophilia (p=0.03). Patients with eosinophilia had higher incidence of pancreas enlargement (78.57% vs. 37.2%, p=0.007). Mean intraductal pressures (20.42 vs. 22.52; p=0.05) and average pancreatic ductal diameter (7.85 vs. 8.90; p=0.03) were lower in patients with eosinophilia. The incidence of complications was significantly more in patients with eosinophilia (85.71% vs. 20.93%; p=<0.001). There was no infiltration of eosinophils in all the pancreatic tissue samples analysed in both groups.Conclusions: Association of eosinophilia with CP is a relatively common entity. It is associated with significantly increased incidence of disease related inflammatory complications, but the exact mechanism is not clear. Whether eosinophilia is a cause or effect of complication is not clear.
... EP is usually not diagnosed until the patient undergoes percutaneous biopsy or pancreatic resection. 49,50 Groove Pancreatitis ...
There is a broad range of inflammatory, pseudotumoral and benign lesions that may masquerade as pancreatic malignancies, often representing a challenge to the radiologist. Unawareness of these entities can lead to inadequate differential diagnoses or misdiagnosis, with important prognostic and therapeutic consequences. The purpose of this article is to revisit a spectrum of lesions, varying from common to exceedingly rare non-malignant, that may mimic malignant pancreatic neoplasms on imaging, identifying relevant features that may contribute to reaching the correct diagnosis. Representative cases include focal fatty replacement, intrapancreatic accessory spleen, pancreatic lobulation, lipoma, autoimmune pancreatitis, focal pancreatitis, eosinophilic pancreatitis, groove pancreatitis, hemangioma, intrapancreatic aneurysm, tuberculosis and Castleman′s disease.
... Eosinophils promote tissue fibrosis by secreting pro-fibrotic TGF-b1 and other cytokines [9]. Several cases reports have been cited in the literature indicating the accumulation of eosinophils in pancreatitis patients and termed this condition as "Eosinophilic Pancreatitis (EP)" [10][11][12][13][14] but detailed mechanistic analysis of eosinophilic pancreatitis is ignored and not well explored. ...
http://www.alliedacademies.org/articles/eosinophilic-pancreatitis-need-an-attention.pdf
A 70-year-old man presented with unprovoked weight loss and intermittent left upper quadrant tenderness for one-and-a-half month. Computed tomography revealed irregular cystic lesions in the pancreatic tail. Endoscopic ultrasonography (EUS) revealed pancreatic tail enlargement and giant, thick-walled cysts surrounding the pancreatic tail with no connection with the pancreatic duct. Endoscopic ultrasonography-guided fine-needle aspiration was performed on the enlarged pancreatic parenchyma and thickened cyst wall. Both biopsies showed hyper eosinophilia and few plasma cells. Endoscopic retrograde pancreatography revealed an irregular narrowing of the main pancreatic duct. Pancreatic juice cytology revealed substantial eosinophilia. Blood sampling showed an elevated eosinophil count and immunoglobulin G4 (IgG4) and immunoglobulin E (IgE) levels at the initial examination. We considered the patient to have eosinophilic pancreatitis (EP) with autoimmune pancreatitis, or alternately, EP with IgG4-related retroperitoneal fibrosis (RPF). Upon prednisolone administration, the abdominal pain improved, the peripheral blood eosinophil count decreased to zero, IgG4 and IgE levels decreased, pancreatic enlargement improved, and the cystic lesions disappeared. The condition did not recur within the following 3 years. Both EP and EP with IgG4-related RPF are rare etiologies of pancreatitis, and this case is very instructive.
