key: cord-0883914-l0cgx7r6
authors: Inamdar, Sumant; Trindade, Arvind J.
title: SARS-CoV-2 Induced Pancreatitis is a Rare but Real Entity
date: 2021-05-14
journal: Clin Gastroenterol Hepatol
DOI: 10.1016/j.cgh.2021.05.020
sha: e75305d87c23c4fbb67703512591cde8220492cf
doc_id: 883914
cord_uid: l0cgx7r6

nan

We read with great interest the letter by Ramsey et al 1 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 the majority of COVID-19 patients with hyperlipasemia are likely from critical illness and not pancreatitis; and that the etiology of pancreatitis needs investigation when present.

Although the results of the study are interesting, we find two methodological 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 one 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 2 . Of the total population, 189 met criteria for pancreatitis (a strict criteria of 3/3 Atlanta classification was required) on admission of which thirty-two were COVID-19 positive. Among patients with COVID-19, the most common etiology was idiopathic at 69%, compared to 21% in patients who were COVID-19 negative (P < .0001). This data implicates SARS-CoV-2 in a possible causative role and shows COVID-19 can present as pancreatitis. Another study from one 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 to 2% on patients without COVID-19 3 .

We do agree with Ramsey et al in that patients with a serum lipase less than three 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 4 . Not surprisingly, patients with pancreatitis had better outcomes than those with critical illness.

We believe there are three groups of patients with COVID-19 who could have elevated lipase 1) critically ill patients in whom lipase is <3ULN 2) critically ill patients in whom lipase is >3ULN, 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 which might be due to 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