key: cord-0947366-8bqnpjic
authors: Stephens, J R; Wong, J L C; Broomhead, R; Stümpfle, R; Waheed, U; Patel, P; Brett, S J; Soni, S
title: Raised serum amylase in patients with COVID-19 may not be associated with pancreatitis
date: 2021-02-04
journal: Br J Surg
DOI: 10.1093/bjs/znaa168
sha: a3524363ce691a8488d12e1a8debc34d684c1b42
doc_id: 947366
cord_uid: 8bqnpjic

A high incidence of pancreatitis in COVID-19 has been reported. Although a high proportion of critically unwell patients with COVID-19 have raised serum amylase levels, this does not necessarily reflect acute pancreatitis or a clinically important pancreatic injury.

The authors therefore undertook a retrospective analysis of all patients with COVID-19 admitted to the ICUs at three London teaching hospitals between 14 March and 22 May 2020 in order to investigate the prevalence of either biochemical and/or radiological evidence of pancreatic injury. Peak and mean serum amylase concentrations were studied in relation to ICU mortality. An abnormally raised peak amylase concentration refers to a peak concentration greater than the upper limit of normal (ULN) (over 100 units/l).

Among 234 patients included in the study, the ICU mortality rate was 37.2 per cent (87 of 234) ( Table 1 ). In total, 158 of 234 patients (67.5 per cent ) had an abnormally raised peak amylase level during ICU admission, and in 52 (22.2 per cent) the peak value was more than three times greater than the ULN. Furthermore, 97 patients in this cohort (41.5 per cent) had a mean amylase concentration greater than the ULN. Sixty-one patients (26.1 per cent) met local clinical criteria for crosssectional imaging of the abdomen, after which four (1.7 per cent) met the revised Atlanta criteria (rAC) for acute pancreatitis. Of these four patients, two survived ICU admission and two did not. There was no statistically significant difference in mean and peak amylase concentrations between ICU survivors and non-survivors (P ¼ 0.890 and P ¼ 0.925 respectively) (Fig. 1) .

These results demonstrate that, although a significant proportion of critically unwell patients with COVID-19 disease had a raised serum amylase concentration, only a minority (1.7 per cent) had a confirmed diagnosis of acute pancreatitis as defined by the rAC. Furthermore, there was no statistical difference in amylase concentrations between patients who survived and those who died. Previous studies [1] [2] [3] [4] have suggested that patients with COVID-19 are at increased risk of pancreatic injury, defined as an increase in serum amylase concentration beyond the normal laboratory range. Yet, the reported increases in pancreatic biomarkers were only mild to moderately abnormal, and the data do not corroborate this theory of pancreatic injury. A raised serum amylase level may be multifactorial given that multiple organs can produce and/or secrete amylase, for example in generalized gut inflammation or impaired renal excretion. Therefore, in practice, acute pancreatitis is usually diagnosed by multimodal criteria and the rAC recommends correlating biochemical data (amylase level) with radiological imaging and clinical findings (such as typical abdominal pain).

The present results suggest that CT of the abdomen is not necessarily indicated in the context of a raised serum amylase level alone. It is proposed that a raised serum amylase value in patients with severe COVID-19 is most frequently not immediately attributable to acute pancreatitis or a clinically important pancreatic injury, but is more likely to be a non-specific manifestation of shock/critical illness. The authors hope this gives clinical teams reassurance when managing critically ill patients with COVID-19 who have an abnormally raised amylase level, and suggest that cross-sectional imaging should not be instigated 

Pancreatic injury patterns in patients with coronavirus disease 19 pneumonia

Highly ACE2 expression in pancreas may cause pancreas damage after SARS-CoV-2 infection

COVID-19 pandemic: perspectives on an unfolding crisis

Emerging phenotype of SARS-CoV2 associated pancreatitis

Coronavirus disease 2019 and the pancreas

COVID-19-related pancreatic injury

The authors thank the clinical teams at Imperial College NHS Trust for their unrelenting care of these patients, and the research nurses for assistance with data collection.Disclosure. The authors declare no conflict of interest.