COVID-19, Necrotizing Pancreatitis, and Abdominal Compartment Syndrome: A Perfect Cytokine Storm?

Abstract

Coronavirus disease 2019 (COVID-19) induces a dysregulated immune response, leading to a drastic elevation of proinflammatory cytokines. This cytokine storm has the potential to aggravate any prior ongoing inflammation. Moreover, acute pancreatitis can cause local necrosis, thereby causing extensive abdominal inflammation. This condition increases the risk of abdominal compartment syndrome (ACS) and its deleterious consequences. We report the case of a 37-year-old male with a past medical history of chronic pancreatitis and alcohol use disorder who presented to the emergency department complaining of abdominal pain. Physical examination revealed a tender abdomen. Initial workup showed elevated amylase and lipase, a positive COVID-19 polymerase chain reaction (PCR) test, and elevated inflammatory markers. The patient denied any respiratory symptoms. Initial abdominal CT scan revealed mild pancreatic inflammation. The patient was admitted to the respiratory ICU and managed with fluid resuscitation and pain control. However, the patient had increasing oxygen requirements, leukocytosis, and worsening kidney function. A trans-bladder measurement of intra-abdominal pressure revealed severe ACS. Broad-spectrum antibiotics were started; however, after 72 hours of treatment, the patient had a cardiopulmonary arrest. He returned to spontaneous circulation after advanced cardiovascular life support (ACLS) protocol and intubation. A repeat CT scan of the abdomen showed necrotizing pancreatitis with a largevolume hemoperitoneum. Urgent pancreatic necrosectomy was performed with drainage of the hemoperitoneum. The patient was transferred to a long-term acute care facility for extended antibiotic therapy where he eventually recovered. This case illustrates the catastrophic consequences of necrotizing pancreatitis complicated by sepsis and ACS in a COVID-19-positive patient.

COVID-19 Infection Deteriorates the Clinical Condition and Outcomes of Acute Pancreatitis: A Meta-Analysis

“…It is supposed that the pancreas injury may be due to the direct cytopathic effect mediated by COVID-19. Moreover, this pancreas injury may be caused by the exaggerated immune response with subsequent cytokine storm and endothelial damage triggered by COVID-19 in the clinical condition such as the Systemic Inflammatory Response Syndrome (SIRS) [7]. In the present meta-analysis, COVID-19 patients with AP were associated with a higher risk of pancreatic necrosis and SAP.…”

“…is is due to the ndings that the pancreas is the potential target organ of COVID-19, with acinar and islet cells containing ACE2 receptors [4,5]. COVID-19 infection may contribute to AP or aggravated in ammatory response, which causes the increased risk of organ failure and complications [6,7]. AP is a common emergency disease, and about 20-30% patients develop into severe acute pancreatitis (SAP) [8].…”

Intraabdominal hypertension and Abdominal Compartment Syndrome in patients with COVID-19: an integrative review

“… Title Age Comorbidity IAP monitoring Volume resuscitation MV Decompressive Laparotomy for Veno-Venous Extracorporeal Membrane Oxygenation Failure due to Intra-Abdominal Hypertension in Critically Ill COVID-19 Patient 2 53 NR No NR Yes Spontaneous liver rupture following SARS-CoV-2 infection in late pregnancy: A case report 9 32 No No Yes No Chryseobacterium Indologenes Sepsis and Acute Renal Failure Secondary to Abdominal Compartment Syndrome in a Confirmed COVID-19 Patient 10 70 Hypertension and obesity No Yes Yes COVID-19, Necrotizing Pancreatitis, and Abdominal Compartment Syndrome: A Perfect Cytokine Storm? 11 37 Chronic pancreatitis and alcohol use disorder No Yes Yes Title Age Comorbidity IAP monitoring Volume resuscitation MV Severe Intraabdominal Hypertension in Critically Ill COVID-19 Patients With Acute Kidney Injury 12 69* …”

“… Title ECMO ARF Decompressive Laparotomy Death Decompressive Laparotomy for Veno -Venous Extracorporeal Membrane Oxygenation Failure due to Intra-Abdominal Hypertension in Critically Ill COVID-19 Patient 2 Yes NR Yes Yes Spontaneous liver rupture following SARS-CoV-2 infection in late pregnancy: A case report 10 No No No No Chryseobacterium Indologenes Sepsis and Acute Renal Failure Secondary to Abdominal Compartment Syndrome in a Confirmed COVID-19 Patient 11 No Yes No Yes COVID-19, Necrotizing Pancreatitis, and Abdominal Compartment Syndrome: A Perfect Cytokine Storm? 12 No Yes No No Severe Intraabdominal Hypertension in Critically Ill COVID-19 Patients With Acute Kidney Injury 13 NR Yes NR 77.2%* NR: not reported; *Percentage referring to the sample of patients in the study who had COVID-19 and ACS. …”

Impact of COVID-19 on the Gastrointestinal Tract: A Clinical Review

“…The pancreatic involvement of COVID-19 ranges from an asymptomatic mild elevation of serum amylase and/or lipase levels to acute pancreatitis and some with further progression to necrotic pancreatitis [94][95].…”