A case-control emergency department-based analysis of acute pancreatitis in Covid-19: Results of the UMC-19-S6

The outcomes of COVID-19 and acute pancreatitis: a systematic review and meta-analysis

Background

Coronavirus disease 2019 (COVID-19) was first reported in China at the end of 2019. Several case studies have documented a probable association between infection with severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) and acute pancreatitis (AP). The objective of this study was to provide a complete analysis of existing literature that compares the clinical outcomes of AP in patients with COVID-19 and those without COVID-19. The intention was to further our understanding of the involvement of SARS-CoV-2 in the development of pancreatitis.

Methods

Between January 2019 and December 2022, we searched PubMed, Embase, Cochrane Library, Web of Science, and Scopus. Nine studies (3,160 patients) were included. In this meta-analysis, Stata 12.0. was utilized. The information provided in this study is presented following the MOOSE reporting checklist.

Results

Mortality [odds ratio (OR) =3.95, 95% confidence interval (CI): 2.87, 5.43, P<0.001], intensive care unit (ICU) administration (OR =3.74, 95% CI: 2.26, 6.20, P<0.001), mechanical ventilation (OR =4.84, 95% CI: 2.14, 10.96, P<0.001), severe pancreatitis (OR =2.71, 95% CI: 1.04, 7.04, P=0.042), etiology of idiopathic and unknown (OR =4.75, 95% CI: 1.80, 12.56, P=0.002), necrotizing pancreatitis (OR =1.88, 95% CI: 1.28, 2.76, P=0.001), and length of hospital stay [weighted mean difference (WMD) =5.10, 95% CI: 2.79, 7.41, P<0.001] were more significantly increased in AP cases with COVID-19 than those without it.

Conclusions

In conclusion, the findings of this study indicate a potential worsening of AP outcomes in patients affected by COVID-19.

Impact of COVID-19 in individuals with and without pre-existent digestive disorders with a particular focus on elderly patients

Coronavirus disease 2019 (COVID-19) has several extrapulmonary symptoms. Gastrointestinal (GI) symptoms are among the most frequent clinical manifestations of COVID-19, with severe consequences reported in elderly patients. Furthermore, the impact of COVID-19 on patients with pre-existing digestive diseases still needs to be fully elucidated, particularly in the older population. This review aimed to investigate the impact of COVID-19 on the GI tract, liver, and pancreas in individuals with and without previous digestive diseases, with a particular focus on the elderly, highlighting the distinctive characteristics observed in this population. Finally, the effectiveness and adverse events of the anti-COVID-19 vaccination in patients with digestive disorders and the peculiarities found in the elderly are discussed.

A Meta-analysis of the Severity of Acute Pancreatitis (AP) in COVID-19 Infection

Many studies have reported severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) affecting the gastrointestinal tract and causing gastritis, colitis, duodenitis and acute pancreatitis (AP). We conducted a meta-analysis to evaluate if SARS-CoV-2 infection (COVID-19 infection) affects the outcomes and severity of AP. We searched for articles in PubMed (MEDLINE), Cochrane Library, and clinicaltrials.gov databases and included studies comparing the outcomes of AP in patients with and without COVID-19. Our outcomes were the mean age of occurrence of AP, Charlson Comorbidity Index, incidence of idiopathic etiology of AP, severity of AP, incidence of necrotizing pancreatitis, need for intensive care unit (ICU) admission, and mortality between the two cohorts. We included five observational studies with a total population of 2,446 patients. Our results showed that in COVID-19 patients; AP had higher odds of having an idiopathic etiology (odds ratio, OR 3.14, 95% confidence interval, CI 1.36-7.27), be more severe (OR 3.26, 95% CI 1.47-7.49), had higher risk for pancreatic necrosis (OR 2.40, 95% CI 1.62-3.55), require ICU admission (OR 4.28, 95% CI 2.88-6.37) and had higher mortality (OR 5.75, 95% CI 3.62-9.14) than in patients without COVID-19 infection. Our study concluded that SARS-CoV-2 infection does increase the morbidity and mortality associated with AP and further large-scale multi-center studies are needed to confirm these results.

The Pancreas in Coronavirus Disease 2019 Infection

An association between acute pancreatitis (AP) and coronavirus disease 2019 (COVID-19) has been proposed but the mechanisms of pancreatic injury of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and the implicative role on the development of AP are not yet fully understood. COVID-19 also imposed major challenges on pancreatic cancer management. We conducted an analysis on the mechanisms of pancreatic injury by SARS-CoV-2 and reviewed published case reports of AP attributed to COVID-19. We also examined the pandemic effect on pancreatic cancer diagnosis and management, including pancreatic surgery.

The burden of acute pancreatitis on COVID-19 in the United States

Background

Although SARS-CoV-2 primarily affects the respiratory system, gastrointestinal symptoms were also seen. Our study analyzed the prevalence and impact of acute pancreatitis (AP) on COVID-19 hospitalizations in the United States.

Methods

The 2020 National Inpatient Sample database was used to identify patients with COVID-19. The patients were stratified into 2 groups based on the presence of AP. AP as well as its impact on COVID-19 outcomes were evaluated. The primary outcome was in-hospital mortality. Secondary outcomes were intensive care unit (ICU) admissions, shock, acute kidney injury (AKI), sepsis, length of stay, and total hospitalization charges. Univariate and multivariate logistic/linear regression analyses were performed.

Results

The study population comprised 1,581,585 patients with COVID-19, from which 0.61% of people had AP. Patients with COVID-19 and AP had a higher incidence of sepsis, shock, ICU admissions, and AKI. On multivariate analysis, patients with AP had higher mortality (adjusted odds ratio [aOR] 1.19, 95% confidence interval [CI] 1.03-1.38; P=0.02). We also noted a higher risk of sepsis (aOR 1.22, 95%CI 1.01-1.48; P=0.04), shock (aOR 2.09, 95%CI 1.83-2.40; P<0.001), AKI (aOR 1.79, 95%CI 1.61-1.99; P<0.001), and ICU admissions (aOR 1.56, 95%CI 1.38-1.77; P<0.001). Patients with AP also had a longer length of stay (+2.03 days, 95%CI 1.45-2.60; P<0.001), and higher hospitalization charges ($44,088.41, 95%CI $33,198.41-54,978.41; P<0.001).

Conclusions

Our study revealed that the prevalence of AP in patients with COVID-19 was 0.61%. Although this was not strikingly high, the presence of AP is associated with worse outcomes and higher resource utilization.

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

Backgrounds. The novel coronavirus disease 2019 (COVID-19) has caused a global pandemic. Pancreatic injuries have been reported in COVID-19 patients. The present meta-analysis was conducted to compare the morbidity and outcomes of AP between COVID-19 positive and negative patients. Methods. Databases including Cochrane Library, PubMed, and EMBASE were systematically searched (until July 3rd 2022). Studies with English abstracts comparing the severity and outcomes of AP between COVID-19 positive and negative patients were included. Mean differences or odds ratios with a 95% confidence interval were employed for assess variables. Risk of publication bias was assessed with funnel plots. Results. Data from 7 studies with a total of 2816 AP patients were included. COVID-19 positive was associated with higher incidences of pancreatic necrosis (OR = 1.65; 95% CI: 1.13 to 2.42, $P$  = 0.01; $P$  = 0.82 for heterogeneity) and persistent organ failure (OR = 6.87; 95% CI: 2.37 to 19.98, $P$  = 0.0004; $P$  = 0.12 for heterogeneity), especially cardiovascular failure (OR = 2.92; 95% CI: 1.66 to 5.14, $P$  = 0.0002; $P$  = 0.58 for heterogeneity) and acute respiratory distress syndrome (ARDS) or acute lung injury (ALI) (OR = 3.03; 95% CI: 2.09 to 4.39, $P$  < 0.00001; $P$  = 0.20 for heterogeneity). COVID-19 infection induced a higher level of CRP (MD = 0.40; 95% CI: 0.16 to 0.64, $P$  = 0.001; $P$  < 0.00001 for heterogeneity) as well as coagulation disorders involving platelets, prothrombin time, activated partial thromboplastin time, and D-dimer (all $P$  < 0.05). During hospitalization, COVID-19 positive was associated with higher ICU admission rate (OR = 2.76; 95% CI: 1.98 to 3.85 $P$  < 0.00001; $P$  = 0.47 for heterogeneity). COVID-19 positive AP was associated with a higher mortality rate (OR = 3.70; 95% CI: 2.60 to 5.25, $P$  < 0.00001; $P$  = 0.12 for heterogeneity). Discussion. The number of included studies is limited and none is RCT, thus the risks of publication and selective bias could not be ignored. COVID-19 deteriorated the severity and clinical outcomes of AP, with a high incidence of morbidity and mortality.

Hyperlipidemia, COVID-19 and acute pancreatitis: A tale of three entities

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused the ongoing pandemic of coronavirus disease 2019 (COVID-19), which presented as not only respiratory symptoms, but various digestive manifestations including pancreatic injury and acute pancreatitis (AP). The underlying mechanism is still unclear. Hypertriglyceridemia has become one of the leading causes of AP in recent years and hyperlipidemia is highly reported in COVID-19 cases. The current narrative review aimed to explore the associations between AP, COVID-19 and hyperlipidemia. Substantial cases of COVID-19 patients complicated with AP were reported, while the incidence of AP in the COVID-19 population was relatively low. Hyperlipidemia was common in COVID-19 patients with a pooled incidence of 32.98%. Hyperlipidemia could be a mediating factor in the pathogenesis of AP in COVID-19 patients. Further studies are warranted to clarify the relationship among AP, lipid metabolism disorders and COVID-19.

Review on acute pancreatitis attributed to COVID-19 infection

The coronavirus disease 2019 (COVID-19) is known to cause gastrointestinal symptoms. Recent studies have revealed COVID-19-attributed acute pancreatitis (AP). However, clinical characteristics of COVID-19-attributed AP remain unclear. We performed a narrative review to elucidate relation between COVID-19 and AP using the PubMed database. Some basic and pathological reports revealed expression of angiotensin-converting enzyme 2 and transmembrane protease serine 2, key proteins that aid in the entry of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) into the pancreas. The experimental and pathological evaluation suggested that SARS-CoV-2 infects human endocrine and exocrine pancreas cells, and thus, SARS-CoV-2 may have a direct involvement in pancreatic disorders. Additionally, systemic inflammation, especially in children, may cause AP. Levels of immune mediators associated with AP, including interleukin (IL)-1β, IL-10, interferon-γ, monocyte chemotactic protein 1, and tumor necrosis factor-α are higher in the plasma of patients with COVID-19, that suggests an indirect involvement of the pancreas. In real-world settings, some clinical features of AP complicate COVID-19, such as a high complication rate of pancreatic necrosis, severe AP, and high mortality. However, clinical features of COVID-19-attributed AP remain uncertain due to insufficient research on etiologies of AP. Therefore, high-quality clinical studies and case reports that specify methods for differential diagnoses of other etiologies of AP are needed.

Acute pancreatitis and COVID-19: a new target for infection?

This review aimed to investigate whether SARS-CoV-2 is capable of infecting the gland and causing acute pancreatitis, and the peculiarities in the management of these cases. The research was conducted through PubMed^® database, and 62 articles were systematically selected for analysis. Differences were found in the literature; however, there are important warnings, such as the presence of hyperlipasemia, clinical and imaging findings suggestive of acute pancreatitis in the presence and even in the absence of respiratory symptoms. Attention should be paid to clinical and imaging findings during this virus infection, since it is possible to identify these two diseases early. Therefore, it is possible to detect and isolate these patients more quickly, providing the correct care and decreasing the morbidity and mortality of two potentially severe diseases.

Pancreatic Injury in Patients with SARS-Cov-2 (COVID-19) Infection: A Retrospective Analysis of CT Findings

Objective

To determine the association between COVID-19 infection and peripancreatic changes on CT as a sign of acute pancreatic injury.

Methods

Retrospective analysis of CT examinations in patients with confirmed COVID-19 infection yielded 103 instances. An age- and gender-matched cohort of patients without COVID-19 was found. CT examinations were evaluated for peripancreatic stranding or edema, fluid collection, or necrosis, without any other explanation. Depicted pulmonary parenchyma was evaluated for possible COVID-19-related changes. Clinical and laboratory data were retrieved from the clinical database.

Results

Peripancreatic fat stranding (n = 8) or fluid collection (n = 2) without any other cause was found in 10 (10%) patients. Abdominal complaints were reported in 4 (40%) patients. Elevated serum amylase or lipase levels were documented in 5 (50%) patients who also satisfied the diagnostic criteria for acute pancreatitis. From the study sample of 103 patients with COVID-19, pulmonary parenchyma was depicted in 102 (99%), and from these, 57 (55%) had an evidence of pulmonary changes compatible with COVID-19 pneumonia. This proportion was not significantly different between patients with and without peripancreatic changes (p = 0.35). In the matched cohort, we found peripancreatic changes in 2 (2%, p = 0.033) patients. Patients with pancreatic injury and elevated amylase levels were more likely to require orotracheal intubation (35% vs. 12%, p = 0.021).

Conclusions

We showed that the prevalence of peripancreatic stranding or fluid collection is higher in patients diagnosed with COVID-19 infection compared to an age- and gender-matched cohort. Patients with pancreatic injury and elevated amylase levels are more likely to require orotracheal intubation. Our findings corroborate the link between COVID-19 infection and pancreatic injury from the perspective of imaging.

A case-control analysis of stroke in COVID-19 patients: Results of unusual manifestations of COVID-19-study 11

OBJECTIVE

We investigated the incidence, predictor variables, clinical characteristics, and stroke outcomes in patients with COVID-19 seen in emergency departments (EDs) before hospitalization.

METHODS

We retrospectively reviewed all COVID-19 patients diagnosed with stroke during the COVID-19 outbreak in 62 Spanish EDs. We formed two control groups: COVID-19 patients without stroke (control A) and non-COVID-19 patients with stroke (control B). We compared disease characteristics and four outcomes between cases and controls.

RESULTS

We identified 147 strokes in 74,814 patients with COVID-19 seen in EDs (1.96‰, 95% confidence interval [CI] = 1.66‰ to 2.31‰), being lower than in non-COVID-19 patients (6,541/1,388,879, 4.71‰, 95% CI = 4.60‰ to 4.83‰; odds ratio [OR] = 0.42, 95% CI = 0.35 to 0.49). The estimated that standardized incidences of stroke per 100,000 individuals per year were 124 and 133 for COVID-19 and non-COVID-19 individuals, respectively (OR = 0.93 for COVID patients, 95% CI = 0.87 to 0.99). Baseline characteristics associated with a higher risk of stroke in COVID-19 patients were hypertension, diabetes mellitus, and previous cerebrovascular and coronary diseases. Clinically, these patients more frequently presented with confusion, decreased consciousness, and syncope and higher D-dimer concentrations and leukocyte count at ED arrival. After adjustment for age and sex, the case group had higher hospitalization and intensive care unit (ICU) admission rates (but not mortality) than COVID-19 controls without stroke (OR = 3.41, 95% CI = 1.27 to 9.16; and OR = 3.79, 95% CI = 1.69 to 8.50, respectively) and longer hospitalization and greater in-hospital mortality than stroke controls without COVID-19 (OR = 1.55, 95% CI = 1.24 to 1.94; and OR = 1.77, 95% CI = 1.37 to 2.30, respectively).

CONCLUSIONS

The incidence of stroke in COVID-19 patients presenting to EDs was lower than that in the non-COVID-19 reference sample. COVID-19 patients with stroke had greater need for hospitalization and ICU admission than those without stroke and longer hospitalization and greater in-hospital mortality than non-COVID-19 patients with stroke.

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

The disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also called coronavirus disease 2019 (COVID-19), first originated in Wuhan, China, displaying atypical pneumonia-like respiratory symptoms in affected patients. SARS-CoV-2 primarily attacks the respiratory system, and the most common symptoms include cough, shortness of breath, and fever. However, its impact on the digestive system has been shown, and various clinical gastrointestinal manifestations of this disease have been recognized. Some reports have shown acute pancreatitis (AP) as the initial symptom in patients with COVID-19. AP may be a consequence of direct pancreatic damage by the virus because pancreatic acinar cells contain angiotensin-converting enzyme 2 receptor proteins, and SARS-CoV-2 can bind to these receptors, causing pancreatic injury. Moreover, AP may be a secondary indicator of cytokine storms and altered inflammatory responses. Our review of the literature shows that SARS-CoV-2 appears to be a new etiological infectious factor related to AP. In this manuscript, a comprehensive review of case reports and case series of patients with AP and COVID-19 is presented. All reports on COVID-19-associated AP are summarized. All cases are thoroughly analyzed and discussed in-depth.