ABSTRACT
Introduction: Acute pancreatitis affects a significant population globally. Usual etiologies are gallstones, alcohol, hypertriglyceridemia, medications;less frequent are trauma, hypercalcemia, infections, toxins, ischemia, anatomic anomalies, vasculitis, and idiopathic. Pancreatitis post coronary intervention is an uncommon cause with only 19 published cases in the last two decades. Being cognizant of this etiology is important given the increasing number of patients undergoing angiography. Case Description/Methods: An 81-year-old female with hypertension, diabetes, peripheral arterial disease, prior cholecystectomy underwent left lower extremity angioplasty at an outside center. Within a few hours, she started having severe epigastric pain radiating to her back, nausea, vomiting and loose bloody stool. She presented to the emergency department 24 hours after symptom onset. Epigastric tenderness was present on exam. Labs revealed leukocytosis (24,450/muL), elevated lipase (1410 U/L), elevated creatinine (1.3 mg/dL), lactate (3.1 mmol/L), calcium 9.4 mg/dL and triglycerides 161 mg/dL. Incidentally, found to be positive for COVID-19. Normal common bile duct diameter seen on sonogram. CT angiogram of the abdomen/pelvis showed acute pancreatitis, duodenal and central small bowel enteritis (Figure). She was not on any medications known to cause pancreatitis and denied alcohol use. Patient improved with analgesics and intravenous fluids. She had no recurrence of bloody stools and hemoglobin remained stable. On day 4, she was able to tolerate a regular diet, and leukocyte count and creatinine normalized. Patient did not have any COVID respiratory symptoms, and was discharged. Discussion(s): Given the temporal association to angioplasty and no other identifiable cause, acute pancreatitis was presumed to be due to the contrast used during angioplasty. Other possibilities included cholesterol embolism but no peripheral signs of cholesterol embolism were seen. Patient was an asymptomatic COVID-19 case. Although, there are case series of pancreatitis due to COVID, those were found in very sick symptomatic patients. On review of literature, cholesterol embolism was identified as a definite cause only on autopsy or laparotomy (Table). Other possible mechanisms are: high viscosity of the contrast media leading to ischemia and necrosis, contrast causing NF-kB activation followed by epithelial damage, and vasospasm. Pancreatitis after coronary angiography is rare, nonetheless, an important differential especially if there is a temporal relationship.
ABSTRACT
Background: SARS-Cov-2 infection (COVID-19) and associated gastrointestinal manifestations have been well documented during the pandemic. To date, several centers have reported isolated cases of COVID-19 and its effect on the pancreas. Here, we present a case series of 13 patients with acute pancreatitis (AP) due to COVID-19, which represents one of the larger case series to date. Methods: A retrospective review was performed from 3/1/2020 through 4/1/2020 at 4 NYC academic medical centers. Patients with a diagnosis of AP and COVID-19 were included. AP was diagnosed based on AGA criteria. COVID-19 infection was confirmed via nasopharyngeal viral PCR testing. All patients with a prior history of AP were excluded. Patients with apparent/suspected etiologies of AP (including gallstones, alcohol, hypertriglyceridemia, post ERCP, medication, and other viral etiologies) were excluded. 13 patients met our inclusion and exclusion criteria. Outcomes studied included mortality, ICU admission, length of stay, BISAP scores on admission and at 48 hours. Results: 7 of the 13 patients in this cohort were African American, 8 of 13 were men, and the median age was 51 years of age. The youngest patient was 18 years old and the oldest patient was 71 years old. Of the 13 patients, 5 patients died during their hospital course. Of those 5 who passed, 4 were African American, and all 5 were > 50 years of age. 6 of the 13 required ICU level of care. The mean length of stay for all patients was 23 days. On admission, 4 patients had BISAP scores > 3, at 48 hours 3 patients had BISAP scores > 3. Discussion: We report the characteristics of 13 patients with confirmed SARS-Cov-2 infection and AP without other common etiologies. We suspect that SARS-Cov-2 was a direct cause of AP in these patients. 5 patients died (38.5%) due to multiorgan failure from Acute Respiratory Distress Syndrome. Patients with COVID-19 and AP had a higher mortality rate than the overall mortality reported with COVID-19 during the same period. The mortality of patients in our series far exceeds the reported mortality in mild or moderate AP (less than 1%)1,2. Currently molecular theories suggest that viral attachment to ACE-2 receptors on pancreatic acinar cells leads to apoptosis, inhibition of nitric oxide production, and programmed cell death that ultimately leads to AP. Conclusion: This case series indicates a possible association between COVID-19 and AP and the increased mortality in this subset of patients. Further research is needed concerning the molecular mechanisms and clinical management of this entity. Larger studies are needed to confirm the worse outcomes with AP associated with COVID-19. Ref: 1. Russo MW et al. Digestive and liver diseases statistics, 2004. Gastroenterology. 2004;126:1448–53. 2. Triester SL et al. Prognostic factors in acute pancreatitis. J Clin Gastroenterol. 2002;34:167–76.