PMC3362181_01
a Initial contrast-enhanced T1-weighted image showing swelling of the processus uncinatus (white arrow) and conspicuous cholestasis (black arrows). b Likewise, initial ERCP revealed a significant stenosis of the distal DHC induced by pancreatic head swelling (white arrow) and bihilar strictures of the main hepatic bile ducts (black arrows).
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F1
Differentiation between a chronic process of inflammation or a malignant process was not possible with certainty (fig. 1a). Consecutive endoscopic retrograde cholangiopancreatography (ERCP) showed a stenosis of the distal ductus hepaticus communis (DHC) caused by pancreatic head swelling and also a bihilar stenosis of the main hepatic bile ducts (fig. 1b).
a Following 3 months of immunosuppressive therapy, coronal contrast-enhanced T1-weighted image displayed normal pancreas morphology without malignancy and regressive cholestasis with thin DHC (white arrow). b Follow-up ERCP demonstrated a completely regressive development of the diverse stenoses of the DHC and the main right and left bile ducts.
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F2
ERCP revealed a significant regression of the stenosis of the DHC and the main right and left bile ducts (fig. 2b). A malignant tumor of the pancreas was no longer detectable (fig. 2a).
a Total bilirubin continuously decreased from 5.5 to 0.4 mg/dl during immunosuppressive therapy. b gamma-GT significantly decreased from 359 to 107 U/l during immunosuppressive therapy. Likewise, AP continuously decreased from 294 to 48 U/l during immunosuppressive therapy. c IgG4 continuously decreased from 2,350 to 1,110 mg/l during immunosuppressive therapy. d Finally, CA 19-9 continuously decreased to normal values from 532 to 9 U/ml during immunosuppressive therapy.
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F3
Total serum bilirubin (0.2 mg/dl), gamma-GT (107 U/l), AP (48 U/l), IgG4 (1,110 mg/l), and finally CA 19-9 (9 U/ml) were within normal ranges (fig. 3).