Response to “High‐Fat Diet, Hypertriglyceridemia, Hyperlipidemic Acute Pancreatitis: Don't Forget Novel Coronavirus–Induced Acute Pancreatitis”

Abstract

We wish to thank Dr Yu for his interest in our article. 1 We highly appreciate his input regarding different etiologies of acute pancreatitis and their implications for nutrition therapy. 2 In the early months of the pandemic, there was hardly any information published regarding coronavirus disease 2019 (COVID-19)-related pancreatitis. Since then, case reports and retrospective cohort studies have been published describing this association. With the angiotensinconverting enzyme 2 receptors expressed in the pancreas, entry of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) through these receptors, causing pancreatic inflammation, could indeed be plausible. Among the larger studies is a US-based retrospective cohort that revealed a point prevalence of 0.27% among 11,883 COVID-19 patients, with 69% considered as idiopathic. 3 Other literature reports have shown heterogeneous results because of the lack of standard diagnostic criteria. To date, there is still insufficient evidence to establish causality. More populationbased epidemiological studies addressing potential biases are needed. 4 However, although we recognize the potential of SARS-CoV-2 to cause acute pancreatitis, we would want to emphasize that it is important to rule out its more common etiologies first, such as gallstones, alcohol, and hypertriglyceridemia. Obtaining good history is crucial. Diagnostic workups should be done to further investigate and narrow down these etiologies.On a similar note, we agree with the authors that the association of COVID-19 with acute pancreatitis is important in the context of nutrition therapy. It has been proven that nutrition therapy for patients with acute pancreatitis is beneficial because of its immunologic effect, prevention of bacterial overgrowth, and decreased bacterial translocation and intestinal permeability. 5 As both COVID-19 infection and acute pancreatitis are considered highly catabolic disease processes, diagnosed patients are classified to have moderate to high nutrition risk, and hence, should be closely managed. The European Society for Clinical Nutrition and Metabolism (ESPEN) has crafted a guideline on the nutrition management of patients with acute pancreatitis. 6 Oral feeding should be offered as soon as clinically tolerated. Enteral feeding can be started for those with gastrointestinal intolerance and if nutrition targets are not met by oral diet alone. Parenteral nutrition should be reserved for patients who do not tolerate enteral nutrition or are unable to tolerate targeted nutrition requirements. In general, these practices have been proven to reduce overall disease severity and faster resolution of disease process, leading to shorter hospital length of stay and better clinical outcomes. 7 Although no study exists on the nutrition management of patients diagnosed with both acute pancreatitis and COVID-19, we recommend following prepandemic guidelines tempered by clinical judgment.

Effects of coronavirus disease 2019 on the digestive system and its nutritional implications

“…There was hardly any information regarding COVID-19-related pancreatitis in the early months of the pandemic except for a few case reports [37 ▪ ]. However, with the knowledge that ACE2 receptors are also expressed in the pancreas and endothelial damage can occur, SARS-CoV-2-induced pancreatitis is indeed plausible [38].…”

“…Since both acute pancreatitis and COVID-19 infection are considered highly catabolic diseases processes, patients are classified to have moderate to high nutrition risk, and hence, should be monitored and treated closely. There are no current guidelines on nutrition management of patients diagnosed with both acute pancreatitis and COVID-19 [37 ▪ ]. However, there are prepandemic guidelines that can be observed such as the recently published recommendations by the European Society for Clinical Nutrition and Metabolism (ESPEN).…”