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Serious GI Results in COVID-19: Case Report

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A formerly healthy 38-year-old man went to the emergency department in Packalk, New York. He has a fever and suffers from severe stomach pain with nausea and vomiting. He explains that his symptoms suddenly appeared and he has never experienced similar symptoms in the past. However, he attended a local test center a week ago and reported that he was positive for SARS-CoV-2.

Further questioning, he tells the clinician that he has no respiratory symptoms, no diarrhea, and no evidence of blood in his vomit. His medical, surgical and social history is not surprising.

Laboratory test results

Notable findings include a white blood cell count of 12.53 x 10.9/ L and 10,255 ukat / L lipase levels. Calcium, triglycerides, bilirubin, and liver function test results are all within normal limits. Abdominal ultrasonography shows no evidence of inflammation of gallstones or gallbladder, and the bile ducts look normal.

Clinicians recognize patients with acute pancreatitis of unknown cause and perform levitation and droplet separation to prevent SARS-CoV-2 infection. His condition improved with conservative management, including active intravenous fluids and pain management, and he was discharged home with instructions for self-isolation.

After a week

The patient returns to ED and has recurrent severe abdominal pain that spreads to the back with nausea and vomiting. He states that he has no fever or cough and his pain is not related to food intake. He refused to use alcohol or drugs and said he had not had any recent injuries or surgery.

The clinician reviews his medical records, notes his recent positive test for SARS-CoV-2 infection, and places the patient in aerial isolation.

The first vital signs are normal. On physical examination, the patient presents with moderate tenderness to a mild palpation of the upper abdomen and Murphy’s sign is negative.

Laboratory test results

The test results are similar to the previous week, except that the white blood cell count has risen significantly to 14.82×10.9The / L and lipase levels are almost doubled at 20,320 ukat / L. As before, his other test results are not surprising. Abdominal ultrasonography shows that the patient’s gallbladder is normal, free of gallstones, and no bile duct dilation. Abdominal CT scan reveals acute pancreatitis with no indication of chronic pancreatitis.

Clinicians diagnose patients with recurrent idiopathic acute pancreatitis. He is hospitalized and managed with IV fluid, complete bowel rest, and pain management. He will be retested for SARS-CoV-2 viral nucleic acids in nasopharyngeal specimens using an FDA-approved system. The result is positive.

The clinician orders further investigation using magnetic resonance biliary pancreatography and MRI of the abdomen. Test results show no evidence of acute pancreatitis, normal gallbladder, and intrahepatic or extrahepatic bile duct lesions. Hepatitis serology and serum immunoglobulin tests rule out possible autoimmune causes of his pancreatitis. When the patient’s clinical condition stabilizes, he is discharged home with instructions to return if the symptoms recur.

Discussion

Clinician reporting this If Causes of recurrent acute pancreatitis in patients with recent SARS-CoV-2 infection urge other doctors to consider this potential etiology of acute pancreatitis: cases of idiopathic pancreatitis in the absence of respiratory tract Even the symptoms add that further testing of SARS-CoV-2 is needed. In addition, they propose to test pancreatic enzymes in COVID-19 patients with gastrointestinal symptoms to rule out potential unrecognized pancreatic involvement in this population.

Increasing evidence suggests that SARS-CoV-2 infection can lead to a variety of complications. The virus is well known to cause pneumonia and can also damage other organ systems, including the gastrointestinal tract. According to the small Investigation In the pancreatic injury pattern of 52 patients admitted to a hospital in Wuhan, China with COVID-19 pneumonia, the incidence of organ injury was 33% for cardiac injury (abnormal lactate dehydrogenase or creatine kinase levels), liver injury ( Optional aspartate aminotransferase, alanine aminotransferase, γ-glutamyl transferase, or abnormal alkaline phosphatase levels, 17% of pancreatic injuries, amylase (normal range, 0-90 U / L) or lipase (normal range, 0-70) U / L), renal disorder (abnormal creatinine level) 8%, diarrhea 2%.

Case creators note that the possibility of SARS-CoV-2 infection should not be overlooked in patients with gastrointestinal symptoms. They point out that elevated pancreatic enzymes are increasingly reported in patients with COVID-19, citing several case studies describing patients with idiopathic acute pancreatitis. They were admitted to the intensive care unit for SARS-CoV-2 infection, suggesting a coincidental association between idiopathic acute pancreatitis and COVID-19, and were found to have severe idiopathic acute pancreatitis. It points to the report of a close relative once. They add that patients with COVID-19 who have improved respiratory symptoms are still positive for SARS-CoV-2 and are still at risk of developing acute pancreatitis.

Recent Meta-analysis Of the approximately 77,000 inpatient COVID-19 patients, the estimated pool prevalence of underlying disease is as follows:

  • Hypertension: 16.37% (95% CI 10.15% -23.65%)
  • Cardiovascular disease: 12.11% (95% CI 4.40% -22.75%)
  • Smoking history: 7.63% (95% CI 3.83% -12.43%)
  • Diabetes: 7.87% (95% CI 6.57% -9.28%)

As an acute inflammatory process of the pancreas, acute pancreatitis can cause significant morbidity.

The diagnosis of acute pancreatitis requires two of the following three criteria:

  • Characteristic acute upper abdominal pain
  • Elevated serum amylase or lipase is more than 3 times the upper limit of normal values
  • Evidence of acute pancreatitis in diagnostic imaging

Case authors point out that more than 80% of all cases of acute pancreatitis are due to the use of gallstones and alcohol. However, acute pancreatitis can also be caused by hypertriglyceridemia, hypercalcemia, drug therapy, and trauma. Approximately 10% of AP cases are infections involving viruses (eg, ascaris, coxsackie B, and hepatitis), bacteria (eg, mycoplasma pneumoniae and leptospirosis), and parasites (eg, roundworm roundworm, liver sucker). Echinococcosis), which is thought to be caused by sex microorganisms. Clues to the infectivity of pancreatitis can be found in characteristic signs and symptoms associated with certain infectious agents, the case authors say.

The association observed between idiopathic pancreatitis and COVID-19 is interesting, but case authors note that the prevalence and etiology of acute pancreatitis in SARS-CoV-2 infection is not well understood. doing. Researchers have suggested that the angiotensin-converting enzyme 2 receptor (ACE2) plays a role in the etiology of COVID-19, and these transmembrane proteins are highly expressed in pancreatic cells, the authors said. They add.

Recently quoted Investigation This suggests that ACE2 expression in the pancreas can cause pancreatic damage after COVID-19 infection. These researchers point out that some data suggest that approximately 40% of COVID-19 patients present with gastrointestinal symptoms, including abdominal pain. Similarly, in patients with severe SARS-CoV-2 infection, up to 16% have elevated serum amylase and lipase, and 7% show significant pancreatic changes on CT.

However, it remains unclear whether acute pancreatitis in the context of COVID-19 infection is directly associated with the cytopathic effect of local viral replication or indirectly caused by the deleterious immune response produced by the virus. The authors write that there is.

The authors say that the recent diagnosis of COVID-19 and the presentation of recurrent acute pancreatitis in this patient without a known exacerbation of pancreatitis raises the suspicion that there is a causal link between this novel virus and acute pancreatitis. Concludes.

Disclosure

The authors had no disclosure to report.

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