Insufficient etiological workup of COVID-19-associated acute pancreatitis: A systematic review

Abstract

BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, mostly causing respiratory symptoms, is also known to affect the gastrointestinal tract. Several case reports hypothesize that SARS-CoV-2 could be an etiological factor in acute pancreatitis (AP). AIM To assess all the available evidence in the literature relating to coronavirus disease 2019 (COVID-19) and AP. METHODS We performed a systematic review of the available literature on the topic. The systematic search was conducted on 15 May 2020 on MEDLINE, EMBASE, CENTRAL, Web of Science and Scopus with a search key using the terms “amylase,” “lipase,” “pancr*,” “COVID-19” and synonyms. Due to the low quality and poor comparability of the studies, a meta-analysis was not performed. RESULTS Six case reports and two retrospective cohorts were included, containing data on eleven COVID-19 patients with AP. Five patients had AP according to the Atlanta classification. Other publications did not provide sufficient information on the diagnostic criteria. Most cases were considered SARS-CoV-2-induced, while several established etiological factors were not investigated. We were able to identify other possible causes in most of them. CONCLUSION We strongly highlight the need for adherence to the guidelines during a diagnostic and etiological workup, which could alter therapy.

Association between acute pancreatitis and COVID-19 infection: What do we know?

“…In our opinion, in these patients, another cause of AP (analgesics or antibiotics) cannot be ruled out. We agree with the opinion of Juhász et al [ 52 ] that there is a risk of bias in reviewed case reports, particularly in patients for whom AP appeared a longer time after treatment of COVID-19.…”

“…We should add that according to some authors, the etiological association between AP and COVID-19 is controversial. Juhász et al [ 52 ] questioned the role of COVID-19 in AP etiology. In the authors’ systematic review registered with PROSPERO as “Pancreas involvement in COVID-19: A systematic review”, six case reports and two retrospective cohort studies were analyzed.…”

“…The authors strongly advised all clinicians to perform proper etiological analysis before a diagnosis of COVID-19-related AP. In the authors’ opinion, the potential mechanisms of pancreatic injury in COVID-19 should be investigated by basic research studies using animal models in order to assess a possible etiological association between SARS-CoV-2 and AP[ 52 ].…”

Coronavirus Disease-19-associated Acute Pancreatitis: Report of Three Cases and Review of Case Reports

“…Although there are many case reports [2], [3], [4], [5], [7], [8], [9], [10, [11], [12], [13], [14], [15], [16], [17], [18], [19], [20] and one study [21], describing patients with COVID-19-associated acute pancreatitis with no obvious etiology, it is unclear whether these acute pancreatitis events were coincidental or were causally related to COVID-19, and the relationship between COVID-19 and acute pancreatitis remains a subject of debate, as the cause-and-effect relationship has not yet been directly investigated [23], [24].…”

“…One theory postulated that SARS-CoV-2 enters epithelia through the ACE2 receptor, which is expressed in both the exocrine glands and islet cells of the pancreas. A direct cytopathic effect of SARS-CoV-2 immune reaction mediated by its local replication can induce acute pancreatitis and organ failure [14], [24]. Some authors suggest that microvascular injury and thrombosis that have been described as a consequence of COVID-19 could also cause pancreatic damage [24], [26].…”