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The study by Pandanaboyana et al 1 showed that acute pancreatitis (AP) patients with COVID-19 had a significantly higher mortality than those without COVID-19. Nevertheless, a similar trend of mortality was found by another observational cohort study.2 The true prevalence and outcomes of AP in patients with COVID-19 are not known. The aim of this study was to conduct a meta-analysis to determine the pooled prevalence and clinical outcomes of AP in patients with COVID-19.
PubMed, Embase, Scopus and Cochrane library were searched for outcome studies of adult patients with AP and COVID-19 published before 15 September 2021 (online supplemental file 1). Excluded were studies that either did not use the revised Atlanta criteria for AP diagnosis or reported patients with COVID-19 with a prior history of pancreatitis. Patients were divided into three groups: group I—AP with COVID-19, group II—AP without COVID-19 and group III—COVID-19 without AP. The primary endpoint was mortality (both in-hospital or 30-day). Secondary endpoints were pooled prevalence of AP and other clinical outcomes. The overall pooled prevalence and mortality were assessed for group I with a random-effects model and Freeman–Tukey double arcsine transformation using R statistical software (V.4.1.0). Heterogeneity was assessed using the I2 statistic and Cochran Q test. Publication bias was assessed using the funnel plots and Egger’s test. Other analyses were performed using Review Manager (V.5.4).
Eleven studies were included (online supplemental file 1),1–11 of which six were multicentre and eight were retrospective. The pooled prevalence of AP in patients with COVID-19 was 3.1% (95% CI 1.6% to 5.1%, I2=98.3%; figure 1A) comprising 183 with AP among 88 635 patients with COVID-19 in seven studies. The pooled mortality was 18.5% (95% CI 12.6% to 25.1%, I2=40%; figure 1B) comprising 74 patients out of 384 who had both AP and COVID-19 in 11 studies. The visual inspection of the funnel plot indicated relative symmetry (online supplemental file 1), and Egger’s test showed no evidence of significant publication bias for mortality (p=0.087).
Compared with AP patients without COVID-19 (group II), patients with AP and COVID-19 (group I) had a higher proportion of males (five studies), unknown/idiopathic aetiology (five studies), greater severity of AP (Bedside Index of Severity in Acute Pancreatitis (BISAP) in four studies), increased risk of pancreatic necrosis (four studies), ICU admission (three studies), persistent organ failure (two studies) and need for mechanical ventilation (two studies). The mortality of group I was increased compared with group II (five studies) and group III (four studies; table 1).
This meta-analysis is the first systematic evaluation of the prevalence and outcome of AP in patients with COVID-19. Comparing AP patients with or without COVID-19 is striking. The increased prevalence of unknown/idiopathic aetiology in patients with concomitant disease suggests that SARS-CoV-2 might itself cause AP in some patients (possibly via a higher density of ACE2 receptors). The overall pooled prevalence was low at 3.1%, but this might be an underestimate as two studies2 7 excluded patients that developed AP during hospitalisation. Sensitivity analysis with these two studies excluded showed that the pooled prevalence of AP was 6.7%. Patients with AP and COVID-19 had a high pooled mortality (18.5%) and significantly worse clinical outcomes. There was no significant difference in ICU admission rate between groups I and III who both had COVID-19 even though AP and COVID-19 both cause systemic inflammatory response and multiple organ dysfunction.
This study does not necessarily represent the global situation, drawing data only from the USA, China and European countries. However, it clearly shows that patients with concomitant AP and COVID-19 have a high risk of adverse outcomes and almost a 20% chance of dying. This study is limited by the small number of included studies, the low event rate and high heterogeneity due to differences in study design and methodology. However, this is the best available data and the meta-analysis can be updated after publication of more prospective studies.
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Contributors Concept and design: FY, JW and DF; acquisition, analysis and interpretation of data: FY, YH, TL, YF, CS, YX, JW and DF; drafting of the manuscript: FY; critical revision of the manuscript: JW and DF. All authors finally approved the manuscript.
Funding The research was supported by the National Key R&D Program of China No.2017YFC1308604 (Dr Yang).
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.
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