SARS-CoV-2-Induced Pancreatitis is a Rare but Real Entity
Authors: Sumant Inamdar, Arvind J. Trindade
Journal: Clinical Gastroenterology and Hepatology (2021)

We read with great interest the letter by Ramsey et al1Ramsey M.L. et al.Clin Gastroenterol Hepatol. 2021; 19: 1982-1987Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar in which they present original data on hyperlipasemia in 1992 patients with coronavirus disease 2019 (COVID-19) from 36 medical centers. Of 400 patients with hyperlipasemia, they found only 2 patients who presented with pancreatitis of which both had a biliary etiology. They found an additional 6 that were diagnosed with pancreatitis during the hospital stay and were attributed to COVID-19. They conclude that most COVID-19 patients with hyperlipasemia are likely from critical illness and not pancreatitis; and that the cause of pancreatitis needs investigation when present. Although the results of the study are interesting, we find 2 methodologic flaws that make this report hard to draw conclusions from. First, when studying the prevalence of a disease (pancreatitis) that we know is infrequent, it would be ideal to report on 1 large population. In this study, several small populations are combined to form the dataset (around 55 patients a center). Statistically this is not ideal to evaluate the prevalence of an uncommon disease. Second, a study evaluating the causative role of pancreatitis in COVID-19 should have a control group with patients without COVID-19. Two recent studies report on this topic. A large single health system retrospective study examined 48,012 hospitalized patients in New York, of which 11,883 were COVID positive.2Inamdar S. et al.Gastroenterology. 2020; 159: 2226-2228Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar Of the total population, 189 met criteria for pancreatitis (a strict criteria of 3/3 Atlanta classification was required) on admission of which 32 were COVID-19 positive. Among patients with COVID-19, the most common etiology was idiopathic at 69%, compared with 21% in patients who were COVID-19 negative (P < .0001). These data implicate SARS-CoV-2 in a possible causative role and shows COVID-19 can present as pancreatitis. Another study from 1 large health system in Minnesota found similar results when comparing patients with pancreatitis with and without COVID-19. Patients with COVID-19 and pancreatitis had an idiopathic etiology in 57% of cases compared with 2% on patients without COVID-19.3Dirweesh A. et al.Gastroenterology. 2020; 159: 1972-1974Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar We do agree with Ramsey et al1Ramsey M.L. et al.Clin Gastroenterol Hepatol. 2021; 19: 1982-1987Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar in that patients with a serum lipase less than 3 times the upper limit of normal and who do not meet Atlanta criteria have lipase elevations likely from critical illness. We examined this cohort in our large health system and also found this association.4Benias P. et al.medrxiv. 2021; https://doi.org/10.1101/2021.04.13.21252871Crossref Scopus (0) Google Scholar Not surprisingly, patients with pancreatitis had better outcomes than those with critical illness. We believe there are 3 groups of patients with COVID-19 who could have elevated lipase: (1) critically ill patients in whom lipase is <3 upper limit of normal; (2) critically ill patients in whom lipase is >3 upper limit of normal, but do not meet criteria for pancreatitis (as per Atlanta criteria); and (3) patients with pancreatitis who meet Atlanta criteria (with known etiology of pancreatitis and also idiopathic pancreatitis that might be caused by COVID-19 infection). In conclusion, pancreatitis caused by SARS-CoV-2 is a real but rare entity; in fact COVID-19 can present as pancreatitis. Sufficient evidence exists to implicate SARS-CoV-2 in a causative role. Patients should meet the Atlanta classification for pancreatitis. Hyperlipasemia in COVID-19 not meeting the definition of pancreatitis is likely from critical illness. Serum Lipase Elevations in COVID-19 Patients Reflect Critical Illness and not Acute PancreatitisClinical Gastroenterology and HepatologyVol. 19Issue 9PreviewWe read with interest the article "ACE2 Expression in Pancreas May Cause Pancreatic Damage After SARS-CoV-2 Infection" by Liu et al.1 The authors noted abnormalities of serum amylase and lipase values among nearly 20% of hospitalized patients with COVID-19 and concluded that these enzyme abnormalities represent pancreatic injury and might even lead to chronic pancreatitis. However, many conditions may cause elevations in serum lipase, and these should not be attributed to pancreatic injury in the absence of acute pancreatitis (AP). Full-Text PDF