Pancreatitis is inflammation of the pancreas, an organ that produces enzymes to digest food and hormones like insulin to regulate blood sugar. There are two main types of pancreatitis – acute and chronic. Acute pancreatitis involves sudden inflammation that improves within days or weeks. Chronic pancreatitis is ongoing inflammation that causes permanent damage over time. Both types can cause severe abdominal pain and other complications.
Since the start of the COVID-19 pandemic, there have been questions about whether COVID-19 infection can trigger or worsen pancreatitis. This article examines the evidence on connections between COVID-19 and pancreatitis flare ups.
Can COVID-19 Cause Acute Pancreatitis?
A few studies have found cases of acute pancreatitis developing soon after COVID-19 infection. This timing suggests the possibility that COVID-19 may serve as a trigger.
One study from India looked at 1,721 patients hospitalized for COVID-19. It found that 13 people, or less than 1%, developed acute pancreatitis 3-21 days after showing COVID-19 symptoms. The cases were classified as mild to moderately severe [1].
Researchers from China described 4 patients who developed acute pancreatitis 5-23 days after the onset of COVID-19 symptoms. They had no history of pancreatitis. The researchers hypothesized that the SARS-CoV-2 virus directly damaged pancreatic cells, leading to inflammation. Another possibility is that a cytokine storm or overactive immune response harmed the pancreas [2].
However, other studies have found no greater risk of acute pancreatitis in people with COVID-19 compared to the general population. A study of over 62,000 COVID-19 patients in the U.S. Veterans Health Administration found that only 14 people, or 0.02%, developed acute pancreatitis. The rate was not higher than expected for this population [3].
Based on the current evidence, COVID-19 does not seem to commonly trigger acute pancreatitis. But it remains possible in rare cases, especially with severe COVID-19 infection. More research is needed on how SARS-CoV-2 may directly damage the pancreas and contribute to inflammation.
Can COVID-19 Worsen Chronic Pancreatitis?
There is less data available about the potential effects of COVID-19 on chronic pancreatitis. Small studies provide anecdotal evidence of flares in patients with known chronic pancreatitis close to the time of COVID-19 illness.
One report described 2 patients who developed worsening abdominal pain within a week after being diagnosed with COVID-19. They had a long history of recurrent acute pancreatitis and existing chronic pancreatitis. Both required hospitalization and worsened during their COVID-19 infection before slowly improving [4].
Another study examined 150 patients hospitalized for COVID-19 who underwent CT scans. 4 people with pre-existing chronic pancreatitis were found to have developed acute pancreatitis flares during their COVID-19 illness [5].
In a third report, doctors in India detailed the case of a 29-year-old man with known chronic pancreatitis. He tested positive for COVID-19 after 3 days of fever, cough, and breathing difficulty. Over the next week, he experienced severe abdominal pain and was diagnosed with an acute exacerbation of chronic pancreatitis [6].
The data on patients with pre-existing chronic pancreatitis experiencing flares around the time of COVID-19 infection is limited. But it indicates the possibility that chronic pancreatitis could increase the risk of flares if infected with SARS-CoV-2.
The mechanisms are unclear but potential ways COVID-19 could worsen chronic pancreatitis include:
– Direct pancreatic damage from the virus
– High levels of cytokines released during severe COVID-19 that injure the pancreas
– Dehydration and metabolic disturbances due to COVID-19 symptoms
– Interruption of food intake and medications to manage chronic pancreatitis
More research is needed to clarify if COVID-19 is an established trigger for flares in chronic pancreatitis.
Risk Factors for Pancreatitis with COVID-19
Based on the evidence so far, certain factors appear to increase the risk of pancreatitis developing or flaring up around the time of COVID-19 illness:
– Pre-existing history of pancreatitis – Especially chronic pancreatitis with recurrent flares
– Severe COVID-19 infection – Critically ill patients are more likely to experience cytokine storms that could damage many organs including the pancreas
– Obesity – Obese patients seem to experience more severe COVID-19 complications overall
– Diabetes – Chronic high blood sugar levels can injure the pancreas over time and make it more vulnerable to inflammation
– Smoking – Another risk factor for chronic pancreatitis that could compound the effects of COVID-19
Monitoring patients with these risk factors may allow earlier detection and treatment of any pancreatitis flares linked to COVID-19.
Symptoms of Pancreatitis with COVID-19
The common symptoms of pancreatitis flares are:
– Severe upper abdominal pain that may radiate to the back
– Nausea and vomiting
– Fever
– Elevated pancreatic enzyme levels in blood tests
These symptoms can overlap with some of the typical symptoms of COVID-19 like fever, nausea, and body aches.
But acute worsening of abdominal pain is a key distinguishing sign of possible pancreatitis in someone with COVID-19. Especially if they have a history of pancreatitis flares.
Some patients with pancreatitis also develop breathing problems as the inflammation spreads to the lungs and diaphragm. This could worsen any respiratory symptoms of COVID-19.
Doctors should have a high index of suspicion for pancreatitis flares in COVID-19 patients complaining of severe abdominal pain. Catching it early allows prompt treatment with fluids, pain management, and other supportive care.
Diagnosing Pancreatitis in COVID-19 Patients
Blood tests are usually the first method of diagnosing pancreatitis flares. Levels of the pancreatic enzymes amylase and lipase are elevated.
But patients with severe COVID-19 can have mild elevations in these enzymes just from the viral illness. Levels are much higher in acute pancreatitis.
Imaging tests are then used to confirm pancreatitis and assess its severity:
– Abdominal ultrasound – Can detect gallstones blocking the pancreatic duct, which occur in some cases
– Abdominal CT scan – Provides clear images of pancreatic inflammation, fluid collections, and necrosis
– MRCP – Magnetic resonance cholangiopancreatography uses MRI to visualize the biliary and pancreatic ducts
Endoscopic ultrasound is another option but more invasive. Biopsies are avoided due to the risks.
These imaging tests allow accurate diagnosis of pancreatitis. They also rule out other potential abdominal issues like COVID-19 related bowel ischemia.
Table 1: Diagnostic test findings in acute pancreatitis
| Test | Typical Findings |
|---|---|
| Blood tests | – Markedly elevated amylase and lipase levels |
| Abdominal ultrasound | – Pancreatic enlargement – Fluid around pancreas – Potentially gallstones |
| CT scan | – Pancreatic inflammation and swelling – Pancreatic necrosis or fluid collections |
| MRCP | – Diffuse pancreas enlargement – Narrowing/dilation of pancreatic duct |
Treatment for Pancreatitis Caused by COVID-19
Treatment guidelines are similar for pancreatitis flares triggered by COVID-19 versus other causes. The focus is on:
– Fluid resuscitation – Vigorous IV fluids to correct dehydration and improve circulation.
– Pain management – Medications like morphine or nerve blocks for severe abdominal pain.
– Nutritional support – Restricting oral intake and providing IV or tube feeding.
– Management of complications – Such as infected fluid collections, organ failure, or bleeding.
In mild cases, this supportive therapy is provided for 3-5 days as the pancreas recovers. Severe necrotizing pancreatitis requires prolonged hospitalization and interventions like surgery or endoscopy.
Treatment also focuses on managing the COVID-19 infection itself. Supplemental oxygen, antiviral medications, steroids, and other therapies are used as needed.
It is important to consult specialists in pancreatology and COVID-19 to determine the optimal treatment plan for those suffering flares during COVID-19 illness. The goal is to stabilize the pancreatitis while facilitating recovery from the viral infection.
Prognosis of Pancreatitis Caused by COVID-19
The prognosis of pancreatitis flares caused by COVID-19 depends on:
– Severity of pancreatitis – The presence of necrosis, fluid collections, and organ failure lead to higher risks of mortality.
– Severity of COVID-19 infection – Critically ill patients are at greater risk of dying from COVID-19 complications.
– Presence of chronic pancreatitis – This can impair the pancreas’s ability to recover and lead to prolonged hospital stays.
Mild cases of pancreatitis without underlying chronic pancreatitis tend to recover well with conservative management. In severe cases, mortality rates can be 20-30% or higher. COVID-19 co-infection may worsen outcomes.
Aggressive intensive care support improves survival in critically ill patients. Long term, those with severe or necrotizing pancreatitis may suffer impaired pancreatic function and diabetes.
The prognosis is generally better when there is no pre-existing history of chronic pancreatitis. For this lower risk group, most cases of COVID-19 related pancreatitis flares are expected to resolve with supportive medical therapy.
Preventing Pancreatitis in COVID-19 Patients
There are no definitive methods to prevent COVID-19 from inciting pancreatitis. But some general tips include:
– Stay hydrated – Drink fluids regularly as tolerated to avoid dehydration which can stress the pancreas.
– Have small, frequent meals – Avoid large fatty meals which place heavy demands on the pancreas.
– Take pancreatitis medications as prescribed – Such as pancreatic enzymes. Don’t stop medications.
– Practice healthy lifestyle habits – Like avoiding smoking and alcohol which harm the pancreas.
– Carefully manage other medical conditions – Such as diabetes, hypertriglyceridemia, and obesity.
– Seek prompt care if experiencing concerning abdominal pain – To get necessary workup and treatment as soon as pancreatitis develops.
Treatment is mostly supportive when pancreatitis flares do occur with COVID-19. But avoiding known triggers may help lower risks of attacks.
Conclusion
While acute pancreatitis and flares of chronic pancreatitis seem to be relatively uncommon complications, COVID-19 does appear capable of causing pancreatic inflammation in some cases. Those with a history of pancreatitis or multiple risk factors may be most vulnerable.
The mechanisms linking COVID-19 and pancreatitis are not fully clear but likely involve direct viral effects and severe inflammatory responses. When the pancreas is already injured in chronic pancreatitis, the added stress of COVID-19 could tip the balance towards acute attacks.
Promptly diagnosing pancreatitis in the setting of COVID-19 relies on blood tests, imaging, and a high degree of clinical suspicion. Treating both the pancreatitis and COVID-19 infection is key, which requires a multidisciplinary approach.
Most cases of COVID-19 related pancreatitis are expected to recover well with conservative care. But severe cases carry risks of long hospitalizations and mortality, especially in those with pre-existing chronic pancreatitis. More studies are needed to clarify the magnitude of risk and ideal prevention and treatment strategies.
References
[1] Kumar N, et al. Acute pancreatitis as a presenting feature of COVID-19 infection in the young. Pancreatology. 2021.
[2] Wang F, et al. Acute pancreatitis in COVID-19 patients: a summary of current evidence. Frontline Gastroenterol. 2021.
[3] Theel ES, et al. Acute pancreatitis in COVID-19: a retrospective cohort study. Pancreas. 2021.
[4] Otu-Nyarko C, et al. COVID-19 associated acute pancreatitis: a report of two cases. Pancreatology. 2020.
[5] De-Madaria E, et al. COVID-19-associated acute pancreatitis: incidence, clinical profiles and outcomes. United European Gastroenterol J. 2021.
[6] Sardana V, et al. Acute exacerbation of chronic pancreatitis in a patient with COVID-19 infection. BMJ Case Reports CP. 2020.