Mounting data support acute pancreatitis as one possible GI manifestation of COVID-19, according to investigators.
While previous case reports suggested that infection with SARS-CoV2 may lead to pancreatitis, this retrospective analysis, which is the largest to date, is the first to offer substantial evidence for this claim, reported lead author Sumant Inamdar, MBBS, of the University of Arkansas, Little Rock, and colleagues.
“It has become increasingly clear that COVID-19 has systemic effects that also includes the gastrointestinal and pancreaticobiliary systems,” the investigators wrote in Gastroenterology. “As islet cells of the pancreas contain ACE2 receptor proteins, SARS-CoV2 can bind to these receptors and cause pancreatic injury.”
For the present analysis, Dr. Inamdar and colleagues reviewed charts from 48,012 patients who were hospitalized in New York between March and June of this year. While pancreatitis is usually diagnosed based on two out of three criteria, disease classification in the study required all three: characteristic upper abdominal pain upon admission, lipase greater than three times the upper limit of normal, and evidence of pancreatitis on cross-sectional imaging.
“[B]y including all three criteria for pancreatitis in our definition, we may be underestimating the rate of pancreatitis,” the investigators wrote. “However, we felt including diagnostic lipase levels and imaging was important for the accuracy of the diagnosis.”
Primary outcomes included mechanical ventilation, length of stay, development of pancreatic necrosis, and mortality. Outcomes were compared between patients with and without COVID-19.
Out of 48,012 hospitalized patients, 11,883 (24.75%) tested positive for SARS-CoV2. Across the entire population, 189 patients had pancreatitis (0.39%), and of these, 32 (17%) also had COVID-19. This translates to a point prevalence for pancreatitis of 0.27% for patients hospitalized with COVID-19.
Among patients with pancreatitis who did not have COVID-19, the most common etiologies for pancreatitis were gallstones (34%) and alcohol (37%), compared with just 16% and 6% of SARS-CoV2-positive cases of pancreatitis, respectively. Idiopathic pancreatitis was significantly more common among patients with COVID-19 than those without (69% vs 21%; P less than .0001).
Black or Hispanic patients with pancreatitis were 4-5 times more likely to have COVID-19 than patients with pancreatitis who were white. Across all races/ethnicities, patients with pancreatitis and COVID-19 more often required mechanical ventilation (odds ratio [OR], 5.65) and longer hospital stays (OR, 3.22), compared with those who had pancreatitis alone. While rates of mortality and pancreatic necrosis showed similar trends, associations with COVID-19 were not statistically significant.
“These findings support the notion that pancreatitis should be included in the list of GI manifestations of COVID-19,” the investigators wrote.
When caring for patients with COVID-19, Dr. Inamdar and colleagues recommended that clinicians pay close attention to any history of abdominal pain, and consider testing serum lipase levels.
“Further large studies are needed to confirm our findings,” they concluded.
Gyanprakash Avinash Ketwaroo, MD, of Baylor College of Medicine in Houston, agreed that more work is needed; in the meantime, he suggested that evidence is now strong enough for clinicians to take notice.
Dr. Gyanprakash Ketwaroo
“Overall, this study adds further weight to COVID-19 acute pancreatitis,” he said. “Larger studies, and convincing pathophysiologic data, will be needed to confirm COVID-19 as a cause of acute pancreatitis. However, there appears to be enough circumstantial evidence to consider a COVID-19 diagnosis in patients presenting with acute pancreatitis.”
He noted that the new clinical evidence also stands on a solid theoretical foundation.
“Viruses, especially mumps and measles, have long been known to cause acute pancreatitis,” he said. “Additionally, the ACE2 receptor is present on pancreatic beta-cells and may mediate COVID-19 induced pancreatitis.”
Along with larger observational studies, Dr. Ketwaroo suggested that a number of interventional questions remain unanswered.
“While most acute pancreatitis is treated with supportive care, could proven therapies for COVID-19, such as steroids, also mitigate COVID-19 acute pancreatitis?” he asked. “Is COVID-19 a cofactor for acute pancreatitis caused by alcohol or endoscopic retrograde cholangiopancreatography? We await further information from an active area of research.”
The investigators disclosed relationships with Boston Scientific, Olympus, Fujifilm, and others.
SOURCE: Inamdar S et al. Gastroenterology. 2020 Aug 26. doi: 10.1053/j.gastro.2020.08.044.