Acute pancreatitis and COVID-19: an integrative review of the literature

SILVA, JULYANNE TEREZA CORDEIRO; FONSECA NETO, OLIVAL CIRILO LUCENA DA

doi:10.1590/0100-6991e-20233559-en

Acessibilidade / Reportar erro

Brasil

Revista do Colégio Brasileiro de Cirurgiões

Español English

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

Review Article • Rev. Col. Bras. Cir. 50 • 2023 • https://doi.org/10.1590/0100-6991e-20233559-en copy

Acute pancreatitis and COVID-19: an integrative review of the literature

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

The first cases of the COVID-19 disease were identified in late 2019 in China, but it didnt take long for it to become pandemic. At first, it was believed that it was restricted to respiratory symptoms only, until extrapulmonary manifestations were reported worldwide. Acute pancreatitis concomitant with the diagnosis of SARS-CoV-2 infection has been observed in some patients, in the absence of the most common etiologies described in the literature. It is postulated that the presence of the ECA-2 viral receptor in the pancreas is responsible for the direct cellular damage and that the hyperinflammatory state of COVID-19 favors the development of pancreatitis through an immune-mediated mechanism. This study aimed to analyze the correlation between acute pancreatitis and COVID-19 disease as a probable causality factor. An integrative literature review was carried out, including studies published between January 2020 and December 2022 that brought data on patients diagnosed with acute pancreatitis according to the revised Atlanta Classification with a confirmed diagnosis of COVID-19 in the same period. A total of thirty studies were reviewed. Demographic, clinical, laboratory and imaging aspects were analyzed and discussed. It is believed that SARS-CoV-2 was responsible for the development of acute pancreatitis in these patients, due to the absence of other precipitating risk factors, as well as the close temporal relationship between both. Attention should be given to gastrointestinal manifestations in patients affected by COVID-19.

Keywords:
COVID-19; SARS-CoV-2; Pancreatitis

1^st Author	Age and Sex	Constitutional and/or respiratory symptoms	Gastrointestinal manifestations	Serum lipase and amylase	Image findings suggestive of acute pancreatitis	Outcome
Aloysius et al.¹⁸	36/F	Fever, cough, dyspnea	Epigastric abdominal pain and tenderness radiating to the back, nausea, vomiting, diarrhea	L: 627U/L A: 325U/L	No abnormalities	Recovered
Sharma et al.⁴¹	25/F	Fever, headache, chills, odynophagia	Excruciating epigastric abdominal pain and tenderness radiating to the back, vomiting	L: 11920,7U/L A: 1814,6U/L	Yes	Recovered
Almutairi et al.¹⁹	71/M	Fever, cough, dyspnea	Abdominal pain with epigastric tenderness radiating to the right upper quadrant	L: 1023U/L A: 544U/L	Yes	NR
Nizamic et al.²⁰	49/F	No respiratory symptoms	Abdominal pain, diarrhea, limited oral intake	L: 2864U/L A: NR	Yes	Recovered
AlHarmi et al.²¹	52/F	Fever, cough, dyspnea	Burning epigastric and right upper quadrant abdominal pain radiating to the back, worsened by oral ingestion, nausea, and vomiting	L: NR A: 47U/L	Yes	Recovered
1^st Author	Age and Sex	Constitutional and/or respiratory symptoms	Gastrointestinal manifestations	Serum lipase and amylase	Image findings suggestive of acute pancreatitis	Outcome
Tadkal et al.²²	42/M	Fever, headache	Abdominal pain	L: 119U/L A: 136U/L	Yes	Recovered
	71/M	Fever, cough, dyspnea	Abdominal pain and distention	L: 143U/L A: 93U/L	Yes	Recovered
	63/M	Fever, cough, dyspnea	Abdominal pain, nausea, and vomiting	L: 178U/L A: 139U/L	Yes	Recovered
	36/M	Fever, cough	Abdominal pain with tenderness in the umbilical region, vomiting	L: 185U/L A: 204U/L	Yes	Recovered
	28/M	Febre, tosse	Dor abdominal com sensibilidade em região umbilical, vômitos	L: 2851U/L A: 834U/L	Yes	Óbito
Arbati et al.²³	28/M	Fever, cough, dyspnea, myalgia	Severe epigastric abdominal pain radiating to the back, bloating, nausea, and vomiting	L: 758U/L A: 1273U/L	Yes	Recovered
Cheung et al.²⁴	38/M	Fever	Severe epigastric abdominal pain radiating to the back, nausea, and vomiting	L: 20320ukat/L A: U/L	Yes	Recovered
Ferreira et al.²⁵	35/M	Dyspnea	Sharp epigastric abdominal pain and tenderness radiating to the back, nausea, and vomiting	L: NR A: 1669U/L	Yes	Recovered
Simou et al.²⁶	67/ NR	Fever, dyspnea, myalgia, arthralgia	No characteristic gastrointestinal symptoms	L: 576U/L A: NR	Yes	Death
Hatch-Vallier et al.²⁷	39/F	Fever, cough, ageusia, anosmia	Epigastric abdominal pain and tenderness, nausea	L: 43U/L A: NR	Yes	Recovered
Kumaran et al.²⁸	67/F	No respiratory symptoms	Epigastric abdominal pain, nausea and vomiting, diarrhea	L: NR A: 1483U/L	Yes	Recovered
Jeelani et al.²⁹	24/M	Fever, cough, dyspnea	Epigastric abdominal pain and tenderness, nausea and vomiting, diarrhea	L: 2025U/L A: NR	Yes	Recovered
Eldaly et al.³⁰	44/M	No respiratory symptoms	Severe epigastric abdominal pain and tenderness radiating to the back, vomiting	L: 286U/L A: 773U/L	Yes	Recovered
Narang et al.³¹	20/F	Fever, cough, dyspnea, myalgia	Acute epigastric abdominal pain radiating to the back, nausea, and vomiting	L: 916U/L A: 396U/L	Yes	Recovered
Mitrovic et al.³²	33/M	No respiratory symptoms	Epigastric abdominal pain radiating to the back, nausea, and vomiting	L: 1082U/L A: 1426U/L	Yes	Óbito
Hadi et al.³³	47/F	Fever, headache, dyspnea	No characteristic gastrointestinal symptoms	L: NR A: 1500U/L	Yes	NR
1^st Author	Age and Sex	Constitutional and/or respiratory symptoms	Gastrointestinal manifestations	Serum lipase and amylase	Image findings suggestive of acute pancreatitis	Outcome
	68/F	fever, fatigue	Epigastric and periumbilical abdominal pain and tenderness, abdominal distention, vomiting, diarrhea	L: NR A: 934U/L	NR	NR
Brikman et al.³⁴	61/M	Fever, cough, dyspnea	Sudden onset diffuse abdominal pain and tenderness, anorexia	L: 203U/L A: 142U/L	Yes	Recovered
Fernandes et al.⁴²	36/F	Fever, dyspnea, headache	Upper abdominal pain	L: 640U/L A: 710U/L	Yes	Recovered
Karimzadeh et al.³⁵	65/F	Myalgia, chills; did not have respiratory symptoms on admission	Upper abdominal pain and tenderness, nausea	L: 283U/L A: 192U/L	No abnormalities	Recovered
Ghosh et al.³⁶	63/M	Fever, cough, dyspnea	No characteristic gastrointestinal symptoms	L: 412U/L A: 58U/L	Yes	Recovered
Ibrahim et al³⁷	33/M	Dyspnea	Abdominal pain with epigastric and right upper quadrant tenderness	L: >1200U/L A: 390U/L	Yes	Recovered
Bokhari et al.³⁸	32/M	Fever, cough, myalgia, chills, odynophagia	Severe epigastric abdominal pain radiating to the back, nausea and vomiting, diarrhea	L: 721U/L A: 672U/L	Yes	Recovered
Kurihara et al.³⁹	55/NR	Fever, cough	Description of abdominal pain not possible because of sedation	L: 263U/L A: 252U/L	Yes	Recovered
Abraham et al.⁴⁰	61/F	Fever, dyspnea	Periumbilical abdominal pain, vomiting	L: 904U/L A: NR	NR	Recovered
Schepis et al.⁸	67/F	Fever	Epigastric and mesogastric abdominal pain and tenderness, abdominal distention, vomiting	L: 900U/L* A: NR	Yes	NR

1^st Author	Goal	Methodology	Main results
Akarsu et al.⁴³	To investigate pancreatic damage caused by SARS-CoV-2 and the effects of developing acute pancreatitis on the progression of COVID-19.	Data from 316 patients admitted to the institution between March 25, 2020 and April 25, 2020 with a diagnosis of COVID-19 pneumonia were prospectively evaluated. Diagnosis of COVID-19 was via RT-PCR and CT findings. The diagnosis of pancreatitis was according to the revised Atlanta criteria. Patients were categorized into three levels of pneumonia severity (mild, severe, critical). Demographics, pancreatitis rate, biochemical, and radiological parameters of each group were analyzed. Patients were divided into two groups and the results were compared: COVID-19 patients with acute pancreatitis (Group P) and without acute pancreatitis (Group C).	Acute pancreatitis was detected in 12.6% of the 316 patients. The mean age for those with acute pancreatitis was 55. There was a positive correlation between advanced age and mortality (p=0.0003). Males constituted 59.1% of the patients. Sex did not make a significant difference in terms of mortality (p=0.3999) and development of pancreatitis (p=0.4192). Gastrointestinal symptoms such as abdominal pain, nausea, vomiting, and diarrhea were observed in 87.5% of patients who had pancreatitis. There were 50 patients (15.8%) in mild condition, 189 patients (59.8%) in severe condition and 77 patients (24.3%) in critical condition. There was no acute pancreatitis in mild patients; 7.9% of patients in severe condition and 32.5% of patients in critical condition had acute pancreatitis. There was a positive correlation between the severity of pneumonia and pancreatitis, and the rate of pancreatitis increased with pneumonia severity (p<0.0001). Hospitalization and mortality rates were higher in patients with COVID-19 accompanied by acute pancreatitis (p=0.0038 and p<0.0001, respectively).
Kumar et al.⁴⁵	To describe the epidemiology, clinical course, and outcome of patients hospitalized with COVID-19 and acute pancreatitis.	Retrospective analysis of the data record of all adult patients (>18 years old) who were admitted with a diagnosis of COVID-19 and acute pancreatitis (at the same encounter) from February 1 to June 30, 2020, at one of five Partners Hospitals Healthcare Network. COVID-19 disease was confirmed by RT-PCR. The diagnosis of acute pancreatitis was made according to the revised Atlanta Classification. Detailed data including demographics, symptoms, respiratory failure, shock, ICU transfer, mechanical ventilation, laboratory abnormalities, and imaging findings were recorded.	Of 985 patients screened, 17 were eligible for the study, nine (52.9%) were hospitalized primarily with ARDS associated with coronavirus disease, requiring intubation and mechanical ventilation. These patients developed acute pancreatitis after a median of 22.5 days (range 13 76) from the onset of COVID-19 symptoms. In contrast, eight patients had typical symptoms and were diagnosed with acute pancreatitis on admission. Of eight, three (37.5%) developed respiratory and constitutional symptoms of COVID-19, one (12.5%) before the diagnosis of acute pancreatitis, while two patients (25%) developed fever and cough after three days of hospitalization. Patients admitted primarily with severe COVID-19 were younger (mean age 57 vs. 63 years), female (55.6% vs. 25%), Hispanic ethnicity (55.6% vs. 25%), and obese (88.9% vs. 37.5%). Of the 17 patients, the median lipase peak among mechanically ventilated ones was higher (661 vs. 236U/L). One patient in each group did not have lipase elevation but had clinical courses and CT images characteristic of acute pancreatitis. In addition, levels of other markers used to monitor COVID-19 disease, including CRP, ferritin, lactate dehydrogenase, and D-dimer were higher among patients who subsequently developed acute pancreatitis. Although the triglyceride spike preceded the diagnosis of acute pancreatitis among these patients, triglyceride levels rapidly declined upon discontinuation of propofol and/or tube feeding. Among nine patients who subsequently developed acute pancreatitis, five (55.6%) experienced thromboembolic complications compared with one patient (12.5%) who presented with acute pancreatitis upon admission. Among patients who subsequently developed acute pancreatitis, three died of ARDS and multisystem organ failure, resulting in an in-hospital mortality rate of 33.3%. Patients hospitalized for acute pancreatitis had an in-hospital mortality rate of 12.5%.
Bulthuis et al.⁴⁴	To investigate the incidence, severity, and clinical impact of acute pancreatitis in patients with COVID-19.	Cross-sectional study of a prospective, observational cohort of all COVID-19 patients admitted to two Dutch teaching hospitals between March 4, 2020 and May 26, 2020. COVID-19 was defined as a positive result on high-report sequencing yield or via RT-PCR and/or characteristic chest CT findings. Acute pancreatitis was defined according to the revised Atlanta Classification. The primary outcome was acute pancreatitis potentially related to COVID-19 infection. A potential relationship with COVID-19 was defined as the absence of a clear etiology of acute pancreatitis. Secondary outcomes included the development of pancreatic necrosis, organ failure, and the clinical impact of acute pancreatitis.	Among 433 patients with COVID-19, five (1.2%) had potentially related acute pancreatitis according to the revised Atlanta Classification. The median age of these five patients was 60 years (47 71). Four patients (80%) were male. These five patients were suffering from severe COVID-19 infection. All suffered organ failure due to COVID-19: three (60%) suffered from respiratory failure, two (40%) renal, and three (60%) cardiovascular. Four patients were admitted to the ICU for an average of 14 days (12 14). All patients with acute pancreatitis underwent contrast-enhanced abdominal CT. The median length of stay was 21 days (20 35). No additional interventions related to acute pancreatitis were performed. Three patients (60%) died.
Gubatan et al.⁴⁶	To report the point prevalence, risk factors, and outcomes of hospitalized patients with COVID-19 presenting with acute pancreatitis and compare the pancreatitis outcomes in patients without COVID-19.	Retrospective, observational cohort study of patients aged 18 years and older admitted to 12 hospitals within the Northwell Health System from March 1, 2020 to June 1, 2020, in New York City. Patients were identified as having acute pancreatitis if they fulfilled all three criteria of the revised Atlanta Classification. Those with acute pancreatitis and COVID 19 were compared to a group of patients with acute pancreatitis but without COVID 19. Patients’ charts were manually reviewed not only to confirm the diagnosis of pancreatitis, but also to determine its etiology. The primary outcomes of mortality, length of stay, need for mechanical ventilation, and development of pancreatic necrosis was compared between the two groups.	During the study period, 48,012 patients were hospitalized and of them 11,883 (24.75%) were positive for COVID-19 at admission. A total of 189 had a diagnosis of pancreatitis (point prevalence 0.39%) and 32 of the 189 (17%) were positive for COVID 19, yielding a point prevalence of 0.27% for pancreatitis among hospitalized patients with COVID 19. There was a higher proportion of Black and Hispanic patients with pancreatitis in the COVID positive group compared with the COVID negative group. Among the group of negative COVID-19 patients, gallstone and alcohol etiologies were the most common, with 34% and 37%, respectively, similar to the general population. However, among patients with COVID-19, these etiologies accounted for only 16% and 6% of cases, respectively. Instead, idiopathic pancreatitis was the most common etiology in this group - 69%, compared with 21% in patients who were COVID negative (p<0.0001). Patients with pancreatitis who were also COVID positive were more likely to require mechanical ventilation and had longer hospital stays compared with patients with pancreatitis without COVID 19 (OR 5.65, p=0.01 and OR 3.22, p=0.009, respectively).

Colégio Brasileiro de Cirurgiões Rua Visconde de Silva, 52 - 3º andar, 22271- 090 Rio de Janeiro - RJ, Tel.: +55 21 2138-0659, Fax: (55 21) 2286-2595 - Rio de Janeiro - RJ - Brazil
E-mail: revista@cbc.org.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] Mailing address: Julyanne Tereza Cordeiro Silva E-mail: julyannecordeiro@gmail.com