Insights into Acute Pancreatitis Associated COVID-19: Literature Review

Abstract

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) primarily affects the lungs, causing respiratory symptoms. However, the infection clearly affects all organ systems including the gastrointestinal system. Acute pancreatitis associated with coronavirus disease 2019 (COVID-19) has been widely reported Recent studies have discussed pancreatic compromise incidentally in asymptomatic patients, or in a form of clinical symptoms such as abdominal pain, nausea, or vomiting, which is further reflected in some cases with abnormal serum lipase and amylase levels It was suggested that upregulation of angiotensin-converting enzyme II cell receptors or inflammatory cytokines play a major role in predisposing pancreatic injury in SARS-CoV-2 positive patients To date, there is insufficient data to establish the causality of acute pancreatitis in SARS-CoV-2 infected cases. In this paper, we organize recent studies conducted to observe the frequency of acute pancreatitis associated with COVID-19 cases while highlighting present hypotheses, predisposing factors, and their effect on the outcome, and point to gaps in our knowledge.

Drug-Induced Acute Pancreatitis in Hospitalized COVID-19 Patients

“…A variety of different drugs have been administered to COVID-19 patients, but some of them belong to the list of 525 drugs that have been reported by the WHO as suspected causative agents of AP [ 15 ]. These drugs are summarized in Table 1 and include antiviral agents such as lopinavir/ritonavir, remdesivir and interferons; anti-inflammatory drugs such as dexamethasone, glucocorticosteroids and non-steroidal anti-inflammatory drugs (NSAIDs); antibiotics such as azithromycin, ciprofloxacin and doxycycline; monoclonal antibodies such as tocilizumab; antipyretics such as acetaminophen; anesthetic agents such as propofol; and antihypertensive agents such as enalapril and lisinopril [ 3 , 25 , 26 ].…”

“…Despite the fact that NSAIDs constitute one of the most commonly used drug categories, there is a risk of gastrointestinal complications, as well as cardiovascular and renal adverse effects with their chronic use [ 33 ]. Furthermore, due to their mode of operation [ 15 , 33 ], NSAIDs have been used on hospitalized patients during SARS-CoV-2 infections in order to relieve pain (especially headache) and fever, as is shown in Figure 5 .…”

“…A threat of developing AP has been reported in relation to the administration of NSAIDs to COVID-19-positive patients [ 15 , 34 ]. In several reported cases of AP in patients with a SARS-CoV-2 infection, the consumption of NSAIDs was considered to be the main cause of the elevation of pancreatic enzymes, rather than the viral effects [ 35 ] ( Figure 5 ).…”

“…Interestingly, apart from the direct viral damage in pancreatic cells and the thrombogenic state of COVID-19, the development of AP in COVID-19 patients may be related to the drugs they received during their hospitalization [ 1 ]. Drug-induced acute pancreatitis (DIAP) is not a common condition, representing less than 5% of all cases of AP, while at the same time, over 525 different drugs have been reported by World Health Organization (WHO) as suspected causative agents [ 15 , 16 ]. A great number of these drugs have been administered to COVID-19 patients and have led to direct or indirect pancreatic damage, mainly through the development of hypertriglyceridemia (HGT) [ 15 , 17 ], as is presented in Figure 1 .…”

“…Drug-induced acute pancreatitis (DIAP) is not a common condition, representing less than 5% of all cases of AP, while at the same time, over 525 different drugs have been reported by World Health Organization (WHO) as suspected causative agents [ 15 , 16 ]. A great number of these drugs have been administered to COVID-19 patients and have led to direct or indirect pancreatic damage, mainly through the development of hypertriglyceridemia (HGT) [ 15 , 17 ], as is presented in Figure 1 . Pathogenesis of DIAP involves certain mechanisms, such as direct toxic effects, accumulation of toxic metabolites or intermediates, immune response and hypersensitivity reaction [ 18 ].…”