Pancreatitis Associated with Viral Hepatitis: Systematic Review

Aetiology, clinical profile, management and outcome of acute pancreatitis at public hospitals in Addis Ababa, Ethiopia: a prospective observational study

Background

Acute pancreatitis (AP) is a rare gastrointestinal pathology that has recently become increasingly common owing to lifestyle changes. Its clinical presentation ranges from mild discomfort to organ failure and death. Previous studies in Ethiopia reported that AP is rare. However, lifestyle changes have recently increased. Therefore, this study aimed to assess the aetiology, clinical profile, management, and outcomes of AP.

Methods

This prospective observational study included 59 adults diagnosed with AP using the Revised Atlanta Classification between November 2021 and August 2022 at five public hospitals in Addis Ababa. The data were analyzed using SPSS 25. The mean ± standard deviation and adjusted odds ratio (AOR) at 95% CI were used.

Results

The mean age was 38.2 (SD±11.5 years), mostly aged 30-44, with 67% males and 89.8% patients presenting with new-onset AP. Abdominal pain and nausea were the most common presentations in 93.2% of patients. More than 52.5% of AP cases were caused by alcohol, followed by gallstones (28.8%), and gallstones (47.1%) underwent cholecystectomy during the index admission. One patient (1.7%) died. The length of hospital stay ranges from 1-47 days and increases with the severity of AP. Patients with recurrent AP had a 2.4 folds increase in complications compared to new-onset AP (AOR=2.4, 95% CI=1.38, 15.71).

Conclusion

Most AP cases were caused by alcohol consumption, followed by gallstones, smoking, and hypertriglyceridemia. One death in a 60-year-old male with an alcohol and smoking history was diagnosed and triaged as severe AP with persistent multiple organ failure; BISAP score 4, his Creatinine=2.55 mg/dl, haematocrit 72.6%; and left shift of WBC, was associated.

Recent advances in hepatitis A virus research and clinical practice guidelines for hepatitis A virus infection in Japan

In 2018, there was a hepatitis A outbreak in Japan, and hepatitis A virus (HAV) infection is considered a sexually transmitted disease. In general, patients with hepatitis A should be given attention, and this disease should be prevented more than ever. The Japan Agency for Medical Research and Development (AMED) Hepatitis A and E viruses (HAV and HEV) Study Group has worked on the project to create "Recent Advances in Hepatitis A Virus (HAV) Research and Clinical Practice Guidelines for HAV Infection in Japan". The group consists of expert hepatologists and virologists who gathered at virtual meeting on August 5, 2023. Data about the pathogenesis, infection routes, diagnosis, complications, several factors for the severities, vaccination, and current and future treatments for hepatitis A were discussed and debated for a draft version. The participants assessed the quality of cited studies. The finalized recommendations are presented in this review. The recent advances in HAV research and clinical practice for HAV infection in Japan, have been reviewed by the AMED HAV and HEV Study Group.

Occam’s razor or Hickam’s dictum-COVID-19 is not a textbook aetiology of acute pancreatitis: A modified Naranjo Score appraisal

BACKGROUND

Acute pancreatitis (AP) is a disease spectrum ranging from mild to severe disease. During the coronavirus disease 2019 (COVID-19) pandemic, numerous reports of AP have been published, with most authors concluding a causal relationship between COVID-19 and AP. Retrospective case reports or small case series are unable to accurately determine the cause-effect relationship between COVID-19 and AP.

AIM

To establish whether COVID-19 is a cause of AP using the modified Naranjo scoring system.

METHODS

A systematic review was conducted on PubMed, World of Science and Embase for articles reporting COVID-19 and AP from inception to August 2021. Exclusion criteria were cases of AP which were not reported to be due to COVID-19 infection, age < 18 years old, review articles and retrospective cohort studies. The original 10-item Naranjo scoring system (total score 13) was devised to approximate the likelihood of a clinical presentation to be secondary to an adverse drug reaction. We modified the original scoring system into a 8-item modified Naranjo scoring system (total score 9) to determine the cause-effect relationship between COVID-19 and AP. A cumulative score was decided for each case presented in the included articles. Interpretation of the modified Naranjo scoring system is as follows: ≤ 3: Doubtful, 4-6: Possible, ≥ 7: Probable cause.

RESULTS

The initial search resulted in 909 articles, with 740 articles after removal of duplicates. A total of 67 articles were included in the final analysis, with 76 patients which had AP reported to be due to COVID-19. The mean age was 47.8 (range 18-94) years. Majority of patients (73.3%) had ≤ 7 d between onset of COVID-19 infection and diagnosis of AP. There were only 45 (59.2%) patients who had adequate investigations to rule out common aetiologies (gallstones, choledocholithiasis, alcohol, hypertriglyceridemia, hypercalcemia and trauma) of AP. Immunoglobulin G4 testing was conducted in 9 (13.5%) patients to rule out autoimmune AP. Only 5 (6.6%) patients underwent endoscopic ultrasound and/or magnetic resonance cholangiopancreatogram to rule out occult microlithiasis, pancreatic malignancy and pancreas divisum. None of the patients had other recently diagnosed viral infections apart from COVID-19 infection, or underwent genetic testing to rule out hereditary AP. There were 32 (42.1%), 39 (51.3%) and 5 (6.6%) patients with doubtful, possible, and probable cause-effect relationship respectively between COVID-19 and AP.

CONCLUSION

Current evidence is weak to establish a strong link between COVID-19 and AP. Investigations should be performed to rule out other causes of AP before establishing COVID-19 as an aetiology.

PECULIARITIES OF THE FUNCTIONAL STATE OF THE LIVER IN PATIENTS WITH CHRONIC HEPATITIS C IN THE PRESENCE OF CHRONIC PANCREATITIS

OBJECTIVE

The aim: To study the features of the functional state of the liver in patients with chronic hepatitis C (CHC) in the presence of CP, depending on the enzymatic activity of the pancreas.

PATIENTS AND METHODS

Materials and methods: 72 patients were under observation: 52 with CHC and CP with exocrine secretory insufficiency (EI) of the pancreas and 20 - with CHC and CP without EI. In all patients, the degree of liver fibrosis, levels of aminotransferases, total bilirubin, gamma-glutamyltransferase, albumin, stool coproscopy and pancreatic fecal elastase-1 (FE-1) were determined.

RESULTS

Results: It was revealed that in patients with CHC combined with CP+EI of the pancreas, higher activity of the necroinflammatory process and deeper stages of liver fibrosis is more often noted than in patients with preserved exocrine function of the pancreas. A statistically significant association was established between the degree of liver fibrosis and the presence of EI of the pancreas (p=0.03), namely, in patients with CHC and CP with EI of the pancreas, the degree of fibrosis F2-4 was 2.8 times more frequent. Also, higher levels of aminotransferases and lower levels of albumin were noted in this group of patients than in patients with CHC and CP with preserved exocrine function of the pancreatic gland.

CONCLUSION

Conclusions: In patients with CHC combined with CP+EI of the pancreas, higher levels of fibrosis and necroinflammatory activity of the liver are more often detected, as well as a tendency to lower albumin levels, than in patients with CHC and CP without EI.

Acute Pancreatitis in Patients After Liver Transplantation

BACKGROUND Acute pancreatitis (AP) is a relatively rare but serious complication that can occur after organ transplantation. MATERIAL AND METHODS The aim of this study was to evaluate the incidence, potential risk factors, and course of AP in patients following liver transplantation at a single large-volume transplant center. RESULTS Out of a total of 1850 transplanted patients, 49 (2.8%) were diagnosed with AP. Of this group, 37 (75.5%) had a mild form of AP and 12 (24.5%) had a severe form of AP. The mortality rate was 10% overall and 42% in the group of patients with severe AP. An early form of AP (<30 days from transplantation) occurred in 13 patients (26.5%), most of whom presented with severe AP (10 patients, 76.9%); 4 patients died (40%). A late form of AP was diagnosed in 36 patients (73.5%), most of whom had mild AP (34 patients, 94.4%); 1 of 2 patients with severe AP died. The most common AP etiologies were post-ERCP (38.8%), idiopathic (34.7%), and postoperative (18.4%). Chronic HBV infection was a risk factor for development of AP (P=0.01). CONCLUSIONS AP in liver transplant recipients was more frequent and more severe than in the general population. This unfavorable course was associated with the occurrence of AP in the early post-transplant period. Liver transplantation due to complications of HBV infection was a risk factor for the development of AP.

Two rare pancreatic parenchymal hemorrhagic lesions associated with acute pancreatitis in acute liver failure: a case report and literature review

Acute pancreatitis is an uncommon occurrence in acute liver failure. Furthermore, such cases are rarely complicated by parenchymal hemorrhages. Herein, we report the case of a 69-year-old male patient with multiple pancreatic parenchymal hemorrhages concomitant with acute liver failure. The patient underwent conservative treatment for acute liver failure caused by hepatitis B virus infection. Plain computed tomography on the 30th day revealed two high-density mass lesions in the pancreatic body and tail, which were suspected to be multiple pancreatic parenchymal hemorrhages. Despite restarting gabexate mesylate, the patient died of multiple organ failure on the 49th day. The clinical information of the present case and our literature review of 61 similar cases in 43 case reports identified via a systematic keyword search of the PubMed database, which described acute pancreatitis concomitant with acute hepatitis and acute liver failure, will aid physicians in the diagnosis and treatment of this rare condition.

Risk Factors for Pancreatic Cancer: Emerging Role of Viral Hepatitis

Pancreatic cancer is one of the most aggressive malignant neoplastic diseases. The incidence and mortality rates of this disease vary depending on geographical area, which might be explained by the different exposure to risk factors. To improve the prognosis of patients with pancreatic cancer, different approaches are needed for an earlier diagnosis. Identification of risk factors and implementation of screening strategies are essential for a better prognosis. Currently, the risk factors for pancreatic cancer fall into two broad categories, namely extrinsic and intrinsic factors. Extrinsic factors include alcohol consumption, smoking, a diet rich in saturated fats, and viral infections such as chronic infection with hepatitis B and C viruses. The pathophysiological mechanisms explaining how these hepatotropic viruses contribute to the development of pancreatic cancer are not fully elucidated. The common origin of hepatocytes and pancreatic cells in the multipotent endodermal cells, the common origin of the blood vessels and biliary ducts of the pancreas and the liver, or chronic inflammatory changes may be involved in this interaction. A careful monitoring of patients with viral liver infections may contribute to the early diagnosis of pancreatic cancer and improve the prognosis of these patients.

Hepatitis E, what is the real issue?

Hepatitis E virus (HEV) infection is a worldwide disease and the primary cause of acute viral hepatitis with an estimated 3.3 million symptomatic cases every year and 44,000 related deaths. It is a waterborne infection in the developing countries. In these countries, HEV genotypes 1 and 2 cause large outbreaks and affect young subjects resulting in significant mortality in pregnant women and patients with cirrhosis. In developed countries, HEV genotypes 3 and 4 are responsible for autochthonous, sporadic hepatitis and transmission is zoonotic. Parenteral transmission by the transfusion of blood products has been identified as a potential new mode of transmission. HEV can also cause neurological disorders and chronic infections in immunocompromised patients. The progression of acute hepatitis E is usually asymptomatic and resolves spontaneously. Diagnosis is based on both anti-HEV IgM antibodies in serum and viral RNA detection in blood or stools by PCR in immunocompetent patients, while only PCR is validated in immunocompromised individuals. Ribavirin is the only validated treatment in chronic infection. A vaccine has been developed in China.