Watch out! The duty received in acute necrotizing pancreatitis, and finally found out that it was new!

Be wary of atypical symptoms of COVID-19.

The recent outbreak is fierce, let's review 1 case of acute pancreatitis caused by the new crown.

Case introduction

Patient, female, 67 years old.

Main complaint: Epigastric pain with nausea and vomiting for 1 day.

Comorbidities: history of hypertension, controllable. Denial of history of diabetes and cholelithiasis.

Past history: laparotomy + small bowel resection anastomosis due to superior mesenteric artery embolism 1 year ago; apixaban was regularly taken after surgery.

Personal history: denial of smoking and alcohol abuse; denial of close contact with COVID-19 patients.

Vital signs: body temperature 37.5 °C, heart rate 112 beats / min, blood pressure 158/ 90 mmHg. (Unfortunately, the original report did not describe the results of the abdominal examination)

Diagnosis and treatment

In view of the patient's previous medical history, it is first necessary to consider whether adhesion intestinal obstruction has occurred, and secondly, it is also necessary to be vigilant about whether the mesenteric vascular embolism has occurred again, and at the same time, the patient's symptoms should be distinguished from acute pancreatitis and acute gastroenteritis.

Therefore, the patient received a direct pelvic enhancement CT and found that there was no significant enhancement of the pancreatic head pancreas, while a widespread effusion of fluid around the pancreas suggested that necrotizing pancreatitis was possible (Figure 1 left). No significant thrombosis was seen in subsequent CTAs and disease progression was detected (Figure 1, right). Ultrasound shows no signs of biliary stones. Laboratory tests found that blood amylase 1483U/L, liver enzymes, bilirubin, IgG4, etc. are normal, and the remaining indicators are shown in Figure 2.

Figure 1: Abdominal enhancement CT on the left and CTA after doing it on the right

Figure 2: Patient laboratory test results

According to the revised Atlanta Standards, the diagnosis of acute pancreatitis requires at least two of the following three:

Abdominal pain characteristic of pancreatitis;

Serum amylase or lipase is elevated to 3 times or more than normal levels;

Characteristic manifestations of pancreatitis are found on CT, magnetic resonance, or abdominal ultrasound.

There is no doubt that the diagnosis of acute pancreatitis in this patient is clear. But what causes acute pancreatitis? There is currently no clear evidence of the most common biliary factors, autoimmune pancreatitis is not considered due to normal IgG4, and patients do not have risk factors such as hyperlipidemia and alcoholism. At this moment, the throat swab results of the patient's admission screening came out - positive for the new crown!

The patient was then quickly isolated. Doctors mainly gave conservative treatment such as fluid resuscitation, but the effect was not obvious. Due to the increase in the patient's respiratory rate (26 beats / min), oxygen saturation can only be maintained at 96% at the oxygen flow rate of 2 L / min, so it is sent to the ICU for further monitoring and treatment, and under the guidance of clinical microbiologists, antibiotics such as meropenem, metronidazole, and clindamycin have been given successively.

Figure 3: Chest X-ray after transfer to the ICU shows two atelectasis

It is worth mentioning that no antivirals, anti-inflammatory drugs or other experimental drugs against COVID-19 were used during ICU treatment, nor did supportive treatments such as mechanical ventilation or inotropes were used.

The patient recovered after 10 days and returned to the general ward and is currently undergoing rehabilitation therapy.

Lessons learned

Acute pancreatitis has a variety of causes, the most common being biliary and alcohol abuse, although in 10% to 20% of cases there is no clear cause. Some pathogens, including viruses, bacteria and parasites, have also been shown to infect the pancreas. According to literature reports, common viruses that can cause pancreatitis are: mumps virus, Coxsackie B virus and hepatitis A virus. Severe pancreatitis caused by the coronavirus has been found in pigeons, but there have been no similar reports in humans.

A study of 52 patients with COVID-19 found that blood amylase or lipase abnormalities occurred in 17% of cases, suggesting that these patients may have pancreatic damage. Look at the study dialectically, though, after all, the pancreas is not the only source of amylase, and gastroenteritis can also cause elevated pancreatin. In addition, studies have confirmed that 18% of COVID-19 patients have gastrointestinal symptoms, so it is not possible to directly equate elevated pancreatin with pancreatitis.

In the 2003 SARS outbreak, studies used immunohistochemistry and in situ hybridization to examine the cadavers of SARS patients, and the presence of SARS virus antigens and RNA was found in the pancreatic tissue, confirming that SARS virus can infect the pancreas. The genetic sequence similarity of the new coronavirus and THE SARS virus is as high as 79.6%, and the expression of the receptor ACE2 of the new coronavirus in the pancreatic tissue is even higher than that of the lung tissue, and there is reason to think that the new crown virus can infect the pancreas. Although the exact pathogenesis of pancreatitis is unclear, it tends to be considered as cytopathy directly caused by local replication of the virus.

The most serious consequence of COVID-19 is a cytokine storm caused by a disordered inflammatory response throughout the body. Acute severe pancreatitis can also cause systemic inflammatory response syndromes and even multi-organ dysfunction. A variety of inflammatory factors, such as tumor necrosis factor-α, interleukin IL-6 and IL-10, all play a key role in the course of acute pancreatitis and new coronary pneumonia.

Therefore, if acute pancreatitis and COVID-19 exist at the same time, this process may be accelerated. For clinicians, this is quite difficult to deal with. If secondary infection recurs from acute pancreatitis, interventions such as necrosis removal and drainage may be required, posing a significant risk of exposure to healthcare workers involved in the procedure.

In short, this case reminds us to pay close attention to the possibility of pancreatitis caused by the new crown virus during the epidemic period, and also pay attention to personal protection.

Source of case:

Kumaran NK, Karmakar BK, Taylor OM. Coronavirus disease-19 (COVID-19) associated with acute necrotising pancreatitis (ANP). BMJ Case Reports CP 2020;13:e237903.

bibliography:

1. Wang F, Wang H, Fan J, et al. Pancreatic injurypatterns in patients with coronavirus disease 19 pneumonia. Gastroenterology2020;159:367–70.

2. Ding Y, He L, Zhang Q, et al. Organdistribution of severe acute respiratory syndrome (SARS) associated coronavirus(SARS-CoV) in SARS patients: implications for pathogenesis and virustransmission pathways. J Pathol 2004;203:622–30.

3. Liu F, Long X, Zhang B, et al. Ace2 expressionin pancreas may cause pancreatic damage after SARS-CoV-2 infection. ClinGastroenterol Hepatol 2020;18:2128–30.

This article was first published: Medical Professions Surgical Channel

Author: A poisonous squid

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