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DOI: 10.1055/s-0045-1805788
Obstructive jaundice secondary to immune-mediated acute pancreatitis: an infrequent presentation
Authors
As a consequence of incessant use of immune checkpoint inhibitors (ICIs), an increased incidence of immune-mediated side effects have been reported.
A 65 year old woman with a stage IV lung adenocarcinoma PDL-1+that progressed after Cisplatin-Pemetrexed initiated Pembrolizumab (anti PD-1). Two months later, she presented with cholestatic syndrome. Analytically, we observed hypertransaminasemia with mixed pattern (ALT 1139 U/l, AST 877 U/l, GGT 1974 U/l, ALP 1164 U/l), a total bilirubin of 8.6 mg/dl and an elevation in lipase exceeding three times the upper limit of normal.
Image studies showed dilated bile ducts conditioned by an edematous acute pancreatitis (AP). Choledocholithiasis and other etiologies were ruled out. The appearance of the pancreatic parenchyma by endoscopic ultrasound brought the differential diagnosis with autoimmune pancreatitis. Seric IgG4 was normal. Pembrolizumab was discontinued with persistence of cholestasis. We initiated methylprednisolone 1 mg/kg with subsequent analytic and image normalization. At discharge, a descending corticosteroid regimen was prescribed [1] [2] [3] [4] [5] [6].
Efficacy of ICIs is based on the amplification of immune T response against tumoral cells, which can lead to immune-mediated adverse events. Pancreatic toxicity is infrequent. Specifically, immune-mediated acute pancreatitis has been associated more frequently with CTLA-4 (4% vs 1% with PD-1), with a variable latency time. In severe and moderate cases, suspension of immunotherapy and initiation of intravenous corticoids 0.5-1 mg/kg/day (even at double dose) is recommended with gradual tapering in 4-6 weeks, since recurrence is not unusual.
Publication History
Article published online:
27 March 2025
© 2025. European Society of Gastrointestinal Endoscopy. All rights reserved.
Georg Thieme Verlag KG
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References
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