Insufficient etiological workup of COVID-19-associated acute pancreatitis: A systematic review

Table 1 Characteristics of included studies

Ref.	Study design	Study population	AP, n (%)	Description
Aloysius et al[29], United States	Case report	One AP patient with COVID-19	1 (100)	36-year-old obese female presenting with AP. No sign of biliary pathology, denies alcoholism, TG unremarkable
Anand et al[44], United Kingdom	Case report	One AP patient with COVID-19	1 (100)	A 59-year-old cholecystectomized woman with minimal alcohol consumption, readmitted with abdominal symptoms five days after discharge with doxycycline for co-infection. CT showed signs of AP on a formerly atrophic pancreas
Gou et al[21], China	Case report	Four “pancreatic disease” patients with COVID-19 pneumonia	1 (25)	One female with AP (51), biliary etiology confirmed, showed initial COVID-19 symptoms 18 d after admission
Hadi et al[45], Denmark	Case report	Three family members with COVID-19	2 (67)	Idiopathic AP in mother (68) and daughter (47), both requiring intensive care and ventilation
Hossain et al[23], United States	Retrospective cohort	119 COVID-19 patients presenting at ER with non-respiratory symptoms	3/32 (9.4)	Out of the 101 instances where abdominal/pelvic CT was obtained, 32 had acute/significant findings, including three cases of pancreatitis. No more information available on these patients
Li et al[22], China	Retrospective cohort	25 death cases with COVID-19	1 (4)	A 56-year-old male patient had AP as an “underlying disease”–it is not clear whether this is from his medical history or was present concomitantly
Meireles et al[46], Portugal	Case report	One AP patient with COVID-19	1 (100)	36-year-old female, AP symptoms started on day 11 of disease, US and CT showed no signs of biliary pathology/ischemia. No information on alcohol consumption. Negatively screened for multiple viruses
Morrison et al[20], United States	Case report	Two cases of acute hypertriglyceridemia in COVID-19 patients	1 (50)	Acute hypertriglyceridemia-induced AP after treatment with tocilizumab, ritonavir, lopinavir, ribavirin, hydroxychloroquine, and propofol

AP n (%) is the number (percentage) of patients with acute pancreatitis. COVID-19: Coronavirus disease 2019; AP: Acute pancreatitis; US: Ultrasonography; CT: Computed tomography.

Table 2 Diagnostic and etiological workup and quality assessment of the studies

Ref.	Diagnostic workup			COVID-19 (PCR)	Etiological workup									Quality of case reports
	Abdominal pain	Enzyme elevation (3 x)	Imaging		Biliary	Alcohol	HTG (> 11.5 mmol/L)	Drug	Hyper-calcemia	Ischemia	Auto-immunity	Viral (except nCoV)	Anatomy	JBI Overall rating ( /8)	Written according to CARE
Aloysius et al[29], United States	+	+	-	+	?	-	-	-	?	?	?	?	-	3	No
Anand et al[44], United Kingdom	+	?	+	+	?	-	?	+	?	?	?	?	-	0	No
Hadi et al[45], Denmark	?	+	+	+	?	-	-	?	-	+	?	?	?	4	No
	+	+	?	+	?	?	?	+	-	+	?	?	?	2
Meireles et al[46], Portugal	+	+	-	+	?	-	-	-	-	-	-	-	-	1	No
Morrison et al[20], United States	?	+	?	+	?	?	+	+	?	+	?	?	?	1	No

The Atlanta criteria were used for diagnosis. Biliary microlithiasis was included in the “biliary” etiology, so endoscopic ultrasonography or magnetic resonance cholangiopancreatography was needed to rule out this factor. Ischemia was considered in the case of shock and vasopressor therapy and was ruled out by computed tomography angiogram. Anatomical malformations were ruled out by computed tomography. The two columns on the right demonstrate the quality of included case reports based on the risk of bias according to the overall Joanna Briggs Institute Critical Appraisal score and adherence to Case Report guidelines on reporting cases. CARE: Case Report Guidelines; JBI: Joanna Briggs Institute; PCR: Polymerase chain reaction.