key: cord-1040362-6ckxyd0l
authors: Inamdar, Sumant; Benias, Petros C.; Liu, Yan; Sejpal, Divyesh V.; Satapathy, Sanjaya K.; Trindade, Arvind J.
title: Prevalence, risk factors, and outcomes of hospitalized patients with COVID-19 presenting as acute pancreatitis
date: 2020-08-26
journal: Gastroenterology
DOI: 10.1053/j.gastro.2020.08.044
sha: 56911fe73a7f945899f2ca12ead80b440ebcd9b2
doc_id: 1040362
cord_uid: 6ckxyd0l

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The novel corona virus disease (COVID-19) has caused a global pandemic. Although most patients present with respiratory symptoms, gastrointestinal (GI) symptoms have also been reported in up to 25% of patients 1 . Some case reports have shown acute pancreatitis as the initial presentation in patients with COVID-19 [2] [3] [4] . As islet cells of the pancreas contain ACE2 receptor proteins, SARS-CoV2 can bind to these receptors and cause pancreatic injury 5 .

Our study aimed to report the point prevalence, risk factors, and outcomes of hospitalized patients with COVID-19 presenting with acute pancreatitis in a large health system and to compare outcomes of pancreatitis in patients without COVID-19.

This is a retrospective observational cohort study of patients 18 years or older admitted to twelve hospitals within the Northwell Health System from March 1, 2020-June 1, 2020 during the COVID-19 pandemic in New York. Institutional Review Board approval was obtained for this study. Patients were identified as presenting with acute pancreatitis on admission if they met all three of the following criteria: 1) lipase greater than three times the upper limit of normal, 2) cross sectional imaging (computed tomography or magnetic resonance imaging) showing pancreatitis, and 3) characteristic upper abdominal pain at admission 6 . Those with acute pancreatitis and COVID-19 were compared to a group of patients with acute pancreatitis but without COVID-19. Patient charts were manually reviewed not only to confirm the diagnosis of pancreatitis, but also to determine its etiology (See supplemental methods section for details). The primary outcomes of mortality, length of stay, need for mechanical ventilation, and development of pancreatic necrosis were compared between the two groups. Patient characteristics are listed in Table 1 for both groups. The Charlson comorbidity index (CCI) and bedside index of severity in acute pancreatitis (BISAP) scores were equivalent between both groups. There were a higher proportion of Black and Hispanics with pancreatitis in the COVID positive group compared to the COVID negative group (p=0.03). Among the group of patients who were COVID-19 negative, gallstone and alcohol etiologies were most common at 34% and 37% respectively, similar to that of the general population 7 . However among patients with COVID-19, these etiologies only accounted for 16% and 6% of cases respectively. Rather, idiopathic pancreatitis was the most common etiology in this group at 69% compared to 21% in patients who were COVID-19 negative (p<0.0001).

After controlling for clinical relevant factors in an adjusted multivariate analysis (See Supplemental Methods) among patients with pancreatitis, the association of Black and Hispanic race with COVID-19 remained statistically significant (OR 4.48; p=0.01 and OR 5.07; p=0.006). With regards to outcomes (Supplemental Table 1 Our report has the following strengths: 1) Our definition of pancreatitis is in line with the accepted standard Atlanta Classification 8 , 2) the results are from a large health system and thus we are able to show an association for a disease process with a low prevalence, 3) we have a diverse patient population across race and ethnicity in our health system with hospitals in Long Island, Manhattan, Queens, and Staten Island which makes our results more generalizable, and 4) a manual chart review was performed to confirm that all patients in this report presented with pancreatitis on admission. The retrospective nature of the study has inherent limitations. Additionally, the number of patients with pancreatitis and COVID-19 was relatively low (n=32). However, this is the largest report to date on this disease process. Finally, by including all three criteria for pancreatitis in our definition, we may be underestimating the rate of pancreatitis (the diagnosis usually requires two of the three criteria). However, we felt including diagnostic lipase levels and J o u r n a l P r e -p r o o f imaging was important for the accuracy of the diagnosis. Including characteristic abdominal pain on admission ensured that patients were presenting with pancreatitis.

In conclusion, we report on the point prevalence of a novel finding of SARS-CoV-2 presenting as acute pancreatitis. We also show that Black and Hispanic races with pancreatitis were more likely to be diagnosed with COVID-19 after multivariate analysis.

Further large studies are needed to confirm our findings. mg/dl 2 . Post-ERCP pancreatitis was defined as pancreatitis occurring after an ERCP per accepted consensus criteria 5 . Acute on chronic pancreatitis was defined as pancreatitis occurring in the setting of already diagnosed chronic pancreatitis per established guidelines 6, 7 . Idiopathic pancreatitis was defined as no etiology discovered after laboratory and imaging tests per standard guidelines 2 .

Patient characteristics, labs, imaging, presence of pancreas necrosis, length of stay, mortality, need for mechanical ventilation, and disease severity scores were abstracted.

Overall incidence of pancreatitis was calculated based on total hospital admissions during the time period. Incidence of pancreatitis among COVID-19 patients was calculated based on the total number of patients admitted with COVID-19.

J o u r n a l P r e -p r o o f

Univariate and bivariate analysis was performed using students' t-test or ANOVA for comparison of continuous variables, and Chi square test for comparison of categorical variables. Multivariate analysis was performed using proc logistic and the model controlled for diabetes mellitus, gender, hypertension, congestive heart failure, chronic obstructive pulmonary disease