Outcomes of symptomatic gallstone disease in pregnant women: A retrospective study

Gallstone disease with advanced symptoms is one of the common abdominal emergencies during pregnancy and it is considered to be one of the most frequently reported non-obstetric surgical conditions in pregnant women. This study aimed to evaluate the outcomes of surgical cholecystectomy in pregnant women with symptoms of advanced gallstones. This is a retrospective analysis of 2814 pregnant women who attended various wards in government and private hospitals in the governorates of Diyala and Kirkuk in Iraq for more than 2 years, between February 2020 and June 2022. The hospital database was used to confirm the diagnosis of advanced gallstone symptoms in these pregnant women. The incidence of symptomatic gallstones in pregnant women, diagnosis and method of therapeutic management, cholecystectomy according to the pregnancy periods, and perinatal complications of patients according to therapeutic methods were determined. The results confirmed that out of 2814 pregnancies, only 126 (4%) had symptoms of gallstones. It was found that the majority of cases 67 (53%) were within the first trimester of pregnancy and the least 29 (23%) was observed in the second trimester. Acute cholecystitis was the generality 84 (67%) diagnosed in pregnant women with symptomatic gallbladder disease and only 9 (7%) of the patients had undergone prenatal cholecystectomy versus 117 (93%) who were managed conservatively. A total of 20 (16%) cases with undesirable complications were recorded, where 12 cases with low birth weight were noted, where 4 of them underwent surgery and 8 were treated conservatively. It was concluded that a large proportion of women suffer from symptoms of gallstones during pregnancy. Most cases can be managed conservatively, and intervention should be performed as often as needed.Copyright © 2023, Codon Publications. All rights reserved.

Research progress of ulinastatin in treatment of COVID-19.

Coronavirus disease 2019 (COVID-19) is still spreading worldwide. At present, no specific drug has been developed for the virus. Ulinastatin plays an important role in anti-inflammatory. Clinically, it is mainly used in acute pancreatitis, shock and disseminated intravascular coagulation. It also has the effects of antioxidant stress, anticoagulation and immune regulation, which may be of great significance to reduce the severity and mortality of COVID-19. Combined with the pharmacological effect of ulinastatin and its clinical application in the treatment of COVID-19 complications such as acute respiratory distress syndrome and sepsis lung injury, this paper discusses the feasibility of its application in COVID-19, so as to provide help for the clinical treatment and new drug research and development of this disease.Copyright © 2022 Tianjin Press of Chinese Herbal Medicines. All Rights Reserved.

Acute pancreatitis associated with diabetic ketoacidosis in a child with COVID-19 infection.

BACKGROUND: There is a mutual influence between COVID-19, diabetes ketoacidosis, and acute pancreatitis, with clinical manifestations overlapping each other, which can lead to misdiagnosis and delayed treatment that could aggravate the condition and affect the prognosis. COVID-19-induced diabetes ketoacidosis and acute pancreatitis are extremely rare, with only four case reports in adults and no cases yet reported in children. CASE PRESENTATION: We reported a case of acute pancreatitis associated with diabetic ketoacidosis in a 12-year-old female child post novel coronavirus infection. The patient presented with vomiting, abdominal pain, shortness of breath, and confusion. Laboratory findings showed elevated levels of inflammatory markers, hypertriglyceridemia, and high blood glucose. The patient was treated with fluid resuscitation, insulin, anti-infection treatments, somatostatin, omeprazole, low-molecular-weight heparin, and nutritional support. Blood purification was administered to remove inflammatory mediators. The patient's symptoms improved, and blood glucose levels stabilized after 20 days of admission. CONCLUSION: The case highlights the need for greater awareness and understanding of the interrelated and mutually promoting conditions of COVID-19, diabetes ketoacidosis, and acute pancreatitis among clinicians, to reduce misdiagnosis and missed diagnoses.

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.

Acute pancreatitis following SARS-CoV-2 infection: A case report.

The novel coronavirus 2019 (COVID-19) which is caused by severe acute respiratory syndrome coronavirus-2 was first reported from Wuhan, China in December 2019. Since then, it has caused global crisis and it still continues to be a Public Health Emergency of International Concern. Although it primarily involves respiratory system with symptoms ranging from mild to severe acute respiratory distress syndrome, extrapulmonary involvement including gastrointestinal manifestations is increasingly reported. There are few reported cases of acute pancreatitis following severe acute respiratory syndrome coronavirus-2 infection; however, little is known on true prevalence of acute pancreatitis or other extrapulmonary manifestations. More data and research on pathophysiology and organ-specific extrapulmonary manifestations would aid clinicians to monitor and recognise these wide spectra of manifestations so that organ-specific therapeutic strategies and management pathways could be developed. We report a case of acute pancreatitis in an otherwise asymptomatic severe acute respiratory syndrome coronavirus-2 infection. He developed acute upper abdominal pain on day 13th of severe acute respiratory syndrome coronavirus-2 infection detection. Diagnosis of acute pancreatitis was made after his serum amylase level was raised by more than five times the normal and the computed tomography abdomen showed oedematous pancreas. He was successfully managed and discharged after 12 days of diagnosis of acute pancreatitis. On follow-up after 1 year, there were no recurrent attacks of pancreatitis. Our case highlights that acute pancreatitis can occur even in asymptomatic and milder form of COVID-19 and the onset of such complications could be delayed. Abdominal pain in COVID-19 should be carefully assessed because prompt diagnosis and management of acute pancreatitis in COVID-19 patient is crucial in preventing multi-organ dysfunction leading to subsequent morbidity and mortality.

Acute Pancreatitis Following a Lower Extremity Angioplasty

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.

A Rare Case of Congenital Choledochal Cyst (CCC) Resulting in Recurrent Acute Pancreatitis in an Otherwise Healthy Young Woman

Introduction: Congenital choledochal cyst (CCC) is a rare cystic dilatation of intrahepatic or extrahepatic biliary ducts. We present a case of a type IVb choledochal cyst presenting as recurrent acute pancreatitis in a young healthy female with initial negative screenings. Case Description/Methods: An 18-year-old-female with a history of COVID-19 presented to the emergency department with one month of persistent abdominal pain, nausea, and vomiting. She was hospitalized once prior for similar symptoms and was diagnosed with acute pancreatitis. This admission, blood work showed elevated lipase, elevated liver enzymes, mild bilirubinemia with a normal lipid panel and urine was significant for infection. She received fluids, antiemetics and was started on prophylactic antibiotics for ascending cholangitis. A right upper quadrant ultrasound ruled out cholelithiasis or acute cholecystitis, but showed dilation of the common bile duct. MRCP confirmed dilation with bulbous termination in the periampullary region diagnosed as type IVb choledochal cyst. Discussion(s): CCCs are rare in Western countries with an incidence between 1 in 100,000 to 150,000. 80% of these cysts are diagnosed in patients under the age of 10. They are difficult to diagnose due to variable clinical presentations. A study of 214 CCC patients demonstrated the most common symptom was abdominal pain, followed by jaundice and fever. When cysts are found in adults, symptoms resemble atypical acute biliary tract disease. Surgical cyst removal may be needed for patients with significant risk factors such as older age and age of symptom onset, due to increased risk of malignant transformation. Longer periods of observation have been documented to be associated with an increased chance of developing late complications, such as anastomotic stricture, biliary calculi and recurrent cholangitis. Type IVb CCCs, as seen in this case, consist of multiple extrahepatic cysts and hepaticojejunostomy is the treatment. This patient's young age and recurrent acute pancreatitis combined with her lab and imaging findings strongly suggest the diagnosis of CCC. The anatomical location of the CCC impeded flow of pancreatic enzymes through the ampulla of vater, leading to recurrent pancreatitis in an otherwise healthy young female. CCC, although very rare, should be considered in the differential of acute pancreatitis when other causes such as gallstones and heavy alcohol consumption cannot be identified, as prompt diagnosis and surgical removal is imperative.

Prognostic Value of Elevated Lipase in Pancreatitis versus Non Pancreatitis Hyperlipasemia (NPHL) due to Non-Malignant Causes

Introduction: While elevated lipase is typically used to diagnose acute pancreatitis, it has also been associated with other critical disease states including sepsis, COVID-19, bowel obstruction, and trauma. In this study we compared outcomes of patients with elevated lipase who had pancreatitis and NPHL. Method(s): Retrospective analysis was performed on all patients who presented to the Emergency Department between February 2016 and August 2020 with lipase >= 3x the upper limit of normal. Patient demographics and past medical history, including active cancer, were noted. Patient outcomes were followed through November 2021. If applicable, dates of death were also documented. Result(s): 414 total patients were included in this study. Upon initial evaluation, 305/414 (74%) were diagnosed with acute pancreatitis (AP) and 109/414 had NPHL. The age (54 617 vs. 58 618, p=0.0220), Sex (male 164/305 vs. 49/109, p=0.1194), and BMI (28.9 67.4 vs. 25.8 64.6, p=0.0066) were compared between the AP and NPHL groups. The serum lipase in the AP and NPHL group were respectively 1471 61070 vs. 605 6555 (p< 0.0001). The most common causes of NPHL were sepsis (10/109;9%) renal failure (7/109;6%), GI bleed (5/109;4%), and bowel obstruction (5/109;4%). The NPHL group had higher rate of malignancy (29/105;28%) compared to those with AP (35/305;11%, p< 0.0001). NPHL patients without malignancy had a higher mortality rate (63/80;80%) compared to those without malignancy in the AP group (17/270;6.3%, p< 0.0001). The most common malignancy in patients with AP was breast (6/35;17%, vs. 3/29;10%, p=0.4943). In NPHL, the most common malignancies were pancreatic (4/29;14%, vs. 3/35;9%, p=0.6920) and bowel malignancies (4/29;14%, vs. 4/35, 11% p51.0000). Conclusion(s): Patients with NPHL without malignancy have higher mortality than those with pancreatitis despite lower serum lipase levels. A limitation of our study is the difference between age and BMI of AP versus NPHL patients. Whether this impacts the prognostic relevance of NPHL on survival need to be explored in future studies.

Nirmatrelvir/ritonavir - A New Culprit of Acute Pancreatitis

Introduction: Nirmatrelvir/ritonavir is a new medication approved for the treatment of COVID-19 infection. It prevents viral replication by inhibiting the SARS-CoV-2 main protease. While mild adverse effects were described, including dysgeusia, diarrhea, hypertension and myalgia1, there were no reported cases of pancreatitis. Case Description/Methods: An 81-year-old female with a past medical history of hypertension and COPD presented to the hospital complaining of abdominal pain and nausea for one day. She had no history of alcohol, tobacco or marijuana use, recent travel, or trauma. Her medications included lisinopril and prednisone, and she had completed a 5-day course of nirmatrelvir/ritonavir for the treatment of COVID-19 infection 2 days prior to presentation. On abdominal exam, she had left upper and lower quadrant tenderness. Blood tests revealed an amylase of 1333 U/L, lipase of 3779 U/L, triglycerides of 297 mg/dL and calcium of 8.7 mg/dL. CT scan revealed an indurated pancreatic body and tail with peripancreatic fluid along the paracolic gutter. Ultrasound of the abdomen and MRCP did not reveal any acute findings. IgG subclasses 1-4 were normal. Discussion(s): According to the revised Atlanta criteria, the patient had clinical findings consistent with acute pancreatitis. Common causes such as gallstone, alcohol, autoimmune and hypertriglyceridemiainduced pancreatitis were ruled out. There were no masses or structural abnormalities on imaging that might have explained her diagnosis. There have been at least 2 reported cases of lisinopril and prednisone induced pancreatitis, however according to Badalov et al.2 both of these medications are class III drugs that lack any rechallenge in the literature. Moreover, the patient had been taking these medications for many years, making them an unlikely cause of the presenting diagnosis. There are no reports of nirmatrelvir/ritonavir associated pancreatitis or known pharmacologic interaction with her home medications, and a meta-analysis conducted by Babajide et al. revealed no association between acute pancreatitis and COVID-19 infection (3). Given the negative findings stated above and the recent initiation of a new medication, nirmatrelvir/ritonavir was the likely cause of acute pancreatitis.

Pancreatitis Secondary to Paxlovid-Induced Tacrolimus Toxicity

Introduction: Pancreatitis is a very common gastrointestinal disease that results in hospital admission. Early detection and treatment leads to better outcomes. This is the first reported case of pancreatitis secondary to elevated tacrolimus in a patient with prior renal transplantation after receiving Paxlovid for a COVID-19 infection. Case Description/Methods: A 57-year-old male with past medical history of 4 renal transplants secondary to posterior urethral valves who presented to the emergency room with acute onset epigastric pain for 24 hours. He was on tacrolimus 5 mg every 48 hours monotherapy for his immunosuppression. 10 days prior to his presentation he had developed chills and anxiety. He tested positive for COVID-19 at that time on a home rapid test. His symptoms had not significantly improved and given his immunosuppressed state he was given Paxlovid (Nirmatrelvir/ritonavir). He took 2 days of Paxlovid, however after his second day of treatment he developed severe epigastric pain requiring him to go to the emergency room. On admission his labs were notable for a lipase of 150 U/L (ULN 63 U/L). He underwent a CT scan was notable for an enlarged pancreatic head and neck with peripancreatic fat stranding (Figure). He also had a right upper quadrant ultrasound without any cholelithiasis and only trace sludge noted. His creatinine was noted to be 1.81 mg/dl which was above his baseline of 1.2 mg/dl. His tacrolimus trough level resulted at a level 45.6 ng/ml and later peaked at 82.2 ng/ml. His liver enzymes were normal. He was treated as acute pancreatitis with hydration and his tacrolimus was held with overall clinical improvement. Discussion(s): Tacrolimus is one of the most common medications used in solid organ transplantation. It is a calcineurin inhibitor that inhibits both T-lymphocyte signal transduction and IL-2 transcription. It is metabolized by the protein CYP3A and levels are monitored closely. Paxlovid is currently prescribed as an antiviral therapy for COVID-19 infection. The ritonavir compound in Paxlovid is potent inhibitor of CYP3A. Currently the guidelines do not recommend Paxlvoid as a therapeutic in patients taking tacrolimus as there is concern about increased drug levels. There have been several case reports of pancreatitis in setting of tacrolimus. This case report helps to demonstrate the need for close monitoring of therapeutics levels, especially in medications with high risk of drug to drug interaction to help prevent serious side effects such as tacrolimus induced pancreatitis.

Spontaneous Gastro-pancreatic Fistula: A Rare Complication of Acute Pancreatitis

Introduction: Although Gastrointestinal fistula is a well-recognized complication of acute pancreatitis, it has been rarely reported. Here we present a rare case of spontaneous gastro-pancreatic fistula following acute pancreatitis. Case Description/Methods: 42 y/o female with PMH of SLE with a recent prolonged hospitalization for acute drug-induced pancreatitis with pseudocyst came to ED with fever, abdominal pain, nausea, and vomiting. She was tachycardic, had leukocytosis, and was positive for COVID-19. CT Scan A/P showed multiple infected peripancreatic collections with communication of the left upper quadrant collection with the gastric lumen (Figure). The patient was hospitalized, Kept NPO, and started on fluids and antibiotics. IR evaluated and put 2 pigtail catheters for drainage of peripancreatic collections. The tip of the pigtail catheter in the left peripancreatic/retroperitoneal collection was in the gastric lumen. The surgery team recommended continuing with conservative treatment with parenteral nutrition, and IV antibiotics as the patient were nontoxic with no signs of free perforation, and pancreatitis would more likely erode a staple or suture line and would put the patient at further risk of free perforation if repair attempted. IR was successful in pulling the drain out of the gastric lumen on the second attempt to allow gastric perforation to heal. Antibiotics were upgraded as per the culture and sensitivity results of the drain fluid. Repeated multiple bedside leak tests and CT scans with oral contrast continue to be positive for patent gastro-pancreatic fistula. Pigtails catheter continues to drain significant necrotic collection. The patient continues to be hospitalized and is being managed conservatively with Parenteral nutrition, and IV antibiotics. Discussion(s): Fistula of the GI tract following acute pancreatitis can be caused by multiple reasons. Necrosis of the bowel may occur concomitantly with the pancreatic or peripancreatic tissue. Furthermore, enzyme-rich fluid and necrosis can lead to vascular thrombosis, which compromises the blood supply of the segmental GI tract, eventually leading to bowel necrosis. GI fistulas are more common in patients with necrotizing pancreatitis with infected pancreatic necrosis. Despite pharmacologic suppression of pancreatic exocrine secretion and advances in endoscopic and percutaneous therapeutic techniques, pancreatic fistula continues to be a source of morbidity and mortality following pancreatitis and requires multidisciplinary treatment.

Covid-19 Infection Presenting as Acute Pancreatitis

Purpose of study Introduction COVID-19 emerged at the end of 2019 as an epidemic of respiratory disease in Wuhan, China that later spread globally and was declared as pandemic. The common clinical manifestations of COVID-19 infection include fever, cough, myalgias, headache, sore throat, anosmia, nasal congestion, fatigue and chest pain. The most serious complications include bilateral multifocal pneumonia and acute respiratory distress syndrome. Acute pancreatitis is rarely reported in association with COVID-19 infection. We report a case of acute pancreatitis secondary to COVID-19 infection. Case Report: A 69-year-old man with past medical history of hyperlipidemia and seizure disorder presented with two days of epigastric pain radiating to back. The patient reported fever, malaise and dry cough for the last 3 days. Home medication included atorvastatin and carbamazepine for 10 and 15 years respectively. The patient denied smoking and alcohol use. COVID- 19 PCR was positive. Labs showed WBC of 3800/muL, hgb 11.8 g/dL, calcium 8.4 mg/dL , lipase 426 U/L, D-Dimer 179 ng/ml DDU, High sensitivity C-reactive protein 27.5 mg/L (normal <5 mg/L) ALT 26 U/L, AST 31 U/L, alkaline phosphatase 103 U/L and total bilirubin 0.3 mg/dL. Ultrasound of the right upper quadrant and CT abdomen showed normal pancreas, common bile duct and gallbladder with no evidence of gallstones. Triglyceride level was 70 mg/dL (<149 mg/dL) on the lipid panel. The patient was diagnosed with acute pancreatitis and received treatment with IV fluids and pain medication. The symptoms improved gradually and the patient was discharged home with resumption of home medications. Methods used Case Report Summary of results The common differentials for acute pancreatitis include alcohol use, gallstones, hypertriglyceridemia, viral infections like mumps and measles, hypercalcemia and medication-related, etc. Normal AST, ALT, alkaline phosphatase and total bilirubin along with absence of gallstones and normal common bile duct ruled out alcoholic and biliary pancreatitis. Normal calcium level and triglyceride level rule out hypercalcemia and hypertriglyceridemia as the cause of pancreatitis. Carbamazepine has rarely been reported to cause acute pancreatitis typically soon after the initiating the therapy or with increase in the dose. The use of carbamazepine for more than 15 years without any recent dose change makes this unlikely as the cause of pancreatitis. The onset of acute pancreatitis during the timeline of COVID-19 constitutional symptoms and absence of other risk factors suggests that COVID-19 infection is responsible for acute pancreatitis in our patient. Conclusions We report a case of acute pancreatitis secondary to COVID-19 infection. Further studies are warranted to better understand the etiology and the pathophysiology of acute pancreatitis secondary to COVID-19 infection.

Acute Pancreatitis as a Rare and Unusual Manifestation of COVID-19 in a Child with Acute Lymphoblastic Leukemia

Introduction: The coronavirus disease 2019 (COVID-19) mainly causes pulmonary disease. However, extrapulmonary manifesta-tions, which affect the gastrointestinal tract and hepatobiliary system, have been reported. Case Presentation: Here we reported a 4-year-old boy with acute lymphoblastic leukemia and abdominal pain who had acute necrotic pancreatitis secondary to COVID-19. Conclusion(s): According to the COVID-19 epidemic, if drug-induced pancreatitis is ruled out, viral causes, especially COVID-19, should be considered.Copyright © 2023, Author(s).

New Onset Diabetes and Acute Pancreatitis- A Sequela of Long COVID?

Introduction: The association between worse COVID-19 outcomes and diabetes has been well-established in the literature. However, with more cases of new-onset diabetes and pancreatitis being reported with or after COVID-19 infection, it poses the question if there is a causal relationship between them. Case Description: 31 y/o female with COVID-19 infection 4-6 weeks ago with moderate symptoms (not requiring hospital admission or monoclonal ab), presented to ED with bandlike epigastric pain radiating to back, which is worsened with food, associated with nausea, vomiting, polyuria, and fatigue. Workup showed lipase 232, AST 180, ALT 256. Blood glucose was 281 and HbA1c was 12. CT A/P showed post cholecystectomy status, normal pancreas with mesenteric adenitis. MRCP showed hepatic steatosis with trace fluid around the pancreas s/o inflammation, and no evidence of choledocholithiasis or biliary dilatation. She denied alcohol use and autoimmune workup for pancreatitis was unremarkable. Islet cell antibodies were negative. The patient improved with fluid resuscitation and was discharged home on insulin with plans to transition to oral agents outpatient. Discussion(s): Long COVID is defined as a range of conditions or symptoms in patients recovering from COVID-19, lasting beyond 4 weeks after infection. A retrospective cohort study showed increased new-onset diabetes incidence in patients after COVID-19. This was redemonstrated in a systematic review and meta-analysis that showed a 14.4% increased proportion of new diagnoses of diabetes in patients hospitalized with COVID-19. Possible pathophysiology that have been attributed to this include undiagnosed pre-existing diabetes, hyperglycemia secondary to acute illness and stress from increased inflammatory markers during the cytokine storm, the effect of viral infections on the pancreas, and concurrent steroid use in patients with severe respiratory disease. The binding of SARS-CoV-2 to ACE2 receptors is thought to the other mechanism by which COVID can cause pancreatitis and hyperglycemia. Study showed increased lipase and amylase levels in patients with COVID and the increase in serum levels was proportional to the severity of the disease. Patients who died due to COVID-19 were also found to have degeneration of the islet cells. While, several studies have showed new onset diabetes and pancreatitis during an active COVID infections, we need larger cohort studies to comment on its true association or causation, especially in patients with long COVID symptoms. As more cases of new onset diabetes and pancreatitis with COVID-19 are being reported, there may be a need for more frequent blood sugar monitoring during the recovery phase of COVID-19.Copyright © 2023

Impact of the COVID-19 pandemic on acute pancreatitis in the Czech Republic: pilot data from the PANACOTA (pancreatitis acuta in COVID time analysis) study

Introduction: The COVID-19 pandemic had a significant impact on healthcare. Acute pancreatitis (AP) is a clinically serious disease that almost always requires hospitalisation and treatment that cannot be delayed or planned. International studies have highlighted the potential negative impact of COVID-19 infection on the onset and severity of the disease. The aim of this study is to analyse the impact of the COVID-19 pandemic on the epidemiology, treatment and prognosis of acute pancreatitis at the population level. Method(s): Comparison of parameters of hospitalizations for acute pancreatitis, care provided and treatment outcomes during the pandemic (2020 + 2021) with previous years (2010-2019) using data from the National Registry of Covered Health Services. Presentation of pilot data. Result(s): Hospitalizations for AP increased slightly from 2010 to 2015 to about 7000/year with a relatively stationary number in 2016- 2021. Hospitalizations for AP in each month of 2020 and 2021 did not correlate with the number of COVID-19 positive patients and showed a similar trend (with peaks in summer and at the end of the year) as in the years prior to the pandemic. Concurrently with AP, 2.3% and 3.7% of patients had COVID-19 infection in 2020 and 2021, respectively. AP mortality in the pre-pandemic and pandemic years was virtually the same at 3.9%. There was no difference in length of hospital or ICU stay. There was a downward trend in the number of ERCPs and surgical interventions performed. Conclusion(s): According to pilot population data, the COVID-19 pandemic did not have an impact on the incidence or prognosis of acute pancreatitis in the Czech Republic. Changes in trends in interventions performed correlate with recent expert recommendations and are unlikely to be related to the reduction in care due to the pandemic.

Retrospective Evaluation of the Frequency of Acute Pancreatitis in Adult Hospitalized Patients with COVID-19 Infection

Introduction: Data on the relationship between Coronavirus disease-2019 (COVID-19) and acute pancreatitis are limited. This study aimed to investigate the possible role of COVID-19 in the etiology of acute pancreatitis in a tertiary-care educational university hospital by retrospectively evaluating the incidence of acute pancreatitis in adult hospitalized patients with COVID-19. Materials and Methods: Severe acute respiratory syndrome-Coronavirus-2 (SARS-CoV-2) polymerase chain reaction (PCR)-positive adult inpatients from March 15, 2020, to February 1, 2021, constituted the study group in our hospital. This cohort was analyzed for acute pancreatitis criteria, including acute abdominal pain, increased amylase and/or lipase more than three times the normal value, and radiological finding supporting the disease. Patients who met at least two of the acute pancreatitis diagnostic criteria were determined, and those who met the criteria during or after SARS-CoV-2 PCR positivity detection were included in the study. These patients were further analyzed for COVID-19-related data and pancreatitis severity status. Results: Our hospital had 1227 inpatients with COVID-19 diagnosis in one year. A total of four cases met the inclusion criteria. Acute pancreatitis rates were detected at 0.3% and 1.07% for all cohorts (n=1227) and the pancreatic enzyme-tested group (n=372), respectively. Of these four patients, two (50%) were females (50%) and the mean age was 70.7 (range: 64-79) years. There was no correlation between COVID-19 pneumonia and pancreatitis severity scores, including Ranson, Acute Physiologic Assessment and Chronic Health Evaluation 2, and modified computed tomography severity scores. Conclusion: COVID-19 is a rare risk factor for acute pancreatitis and did not affect the pancreatitis severity or mortality in our cohort.

Radiologic and Endoscopic Treatment for a Disconnected Pancreatic Duct Syndrome Associated to Percutaneous Pancreatic Fistula: Achieving the "Internalization of the Fistula"

Background and aim: A 40-year-old male was referred to our institute for the management of a percutaneous pancreatic fistula after acute pancreatitis due to SARS-COV2 infection. He developed a peripancreatic collection(PPC) which was percutaneously drained due to infection. After the resolution of PPC, a percutaneous leakage of the main pancreatic duct (MPD) was observed, so he underwent Endoscopic Retrograde ColangioPancreatography(ERCP) with biliary plus pancreatic sphincterotomy and placement of both pancreatic and biliary stent without resolution of the leak. Material(s) and Method(s): Then he was referred to our institution, where initial management included ERCP with placement of two trans-papillary pancreatic stents and the removal of percutaneous catheter, but the fistula kept to drain. Result(s): A multidisciplinary-board decided to perform a rendezvous with interventional radiology to facilitate an endoscopic ultrasound(EUS) trans-gastric drainage of the pancreatic area draining in the percutaneous fistula. Conclusion(s): The procedure included an initial ERCP with replacement of the two pancreatic stents while the radiologist places percutaneously a guidewire through the fistula to the pancreatic point of leakage into MPD. After that, EUS identified the point in which the percutaneous guidewire was getting into the MPD and a trans-gastric EUS-guided insertion of a guidewire achieved the MPD through a 19-Gauge needle. The latter guidewire crossed the percutaneous fistula and came out. At that point, a dilation up to 10 mm was performed to create a trans-gastric pancreatic fistula. The next step was to insert percutaneously a double pigtail(10 Fr) releasing the distal side into the stomach and the proximal side into the main pancreatic duct in order to stabilize the neo-fistula. Another trans-gastric plastic stent was endoscopically placed through the pancreato-gastric neo-fistula. At the end, injection of contrast dye through the percutaneous fistula showed a complete drainage into stomach. In conclusion, the procedure achieved the complete exclusion and resolution of the pancreatic-cutaneous fistula.Copyright © 2023. Editrice Gastroenterologica Italiana S.r.l.

Acute Pancreatitis in Early Postpartum Woman with Confirmed Covid-19: A Rare Case Report

Background: The Coronavirus disease 2019 (COVID-19) pandemic is a significant challenge for public health and clinical medicine. COVID-19 mainly impairs the respiratory tract. However, gastrointestinal manifestations of COVID-19 are increasingly being recognized. Although acute viral pancreatitis has been described in other viral infections, pancreatic involvement in SARS-CoV-2 disease is still poorly defined. We reported a case of acute maternal pancreatitis in an early postpartum period woman with confirmed COVID-19. Case Presentation: A 31-year-old woman in term pregnancy had a caesarean section due to acute respiratory distress syndrome (ARDS) caused by COVID-19 pneumonia. One day after surgery, her stomach appeared bloated, bowel sounds were weak, and her abdominal circumference increased. Ultrasound examination did not reveal any suspicion of bleeding or hematoma. Her abdominal contrast-enhanced computerized tomography (CT) scan showed small bowel obstruction and oedematous pancreas. Amylase levels increased to 382 units/litre and lipase levels to 724 units/litre. C-reactive protein and procalcitonin were also increased. The diagnosis of sepsis was made, and she received broad-spectrum antibiotics and treatment for the COVID-19 infection. Recovery was characterized by a gradual resolution of abdominal and pulmonary signs and symptoms. A decline of amylase and lipase was observed by the tenth day. On the 13th day, she was extubated and gradually recovered from respiratory symptoms, with a negative result for COVID-19 RT-PCR. Based on this case, we consider that pregnancy and COVID-19 support each other as the cause of acute pancreatitis. Conclusion(s): Early diagnosis and severity classification are essential steps for successful management because late recognition and treatment may allow a greater prevalence of associated complications.Copyright © 2022, Philippine College of Physicians. All rights reserved.

Drug-Induced Acute Pancreatitis in Hospitalized COVID-19 Patients.

Coronavirus disease-19 (COVID-19), caused by SARS-CoV-2, is a systemic disease that affects not only the respiratory system, but also other systems, including gastrointestinal. A great number of different drugs have been used on hospitalized patients for the management of COVID-19, and acute pancreatitis (AP) has been reported as a complication or side effect of these drugs. The development of drug-induced acute pancreatitis (DIAP) follows a complex of pathophysiological mechanisms, and particular risk factors play a key role. Diagnosis of DIAP depends on specific criteria, and based on these, a drug may be characterized as having a definite, probable or possible connection with AP. The aim of this review is to present the medications that are used for COVID-19 management and are associated with AP in hospitalized patients. The list of these drugs mainly includes corticosteroids, glucocorticoids, non-steroidal anti-inflammatory drugs (NSAIDs), antiviral agents, antibiotics, monoclonal antibodies, estrogens and anesthetic agents. Moreover, the prevention of the development of DIAP is vital, especially for critically ill patients who may receive multiple drugs. DIAP management is mainly non-invasive and the first step concerns the exception of the suspicious drug from patients therapy.