Systematic Reviews
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Apr 7, 2023; 29(13): 2050-2063
Published online Apr 7, 2023. doi: 10.3748/wjg.v29.i13.2050
Occam’s razor or Hickam’s dictum-COVID-19 is not a textbook aetiology of acute pancreatitis: A modified Naranjo Score appraisal
Thomas Zheng Jie Teng, Branden Qi Yu Chua, Puay Khim Lim, Kai Siang Chan, Vishal G Shelat
Thomas Zheng Jie Teng, Branden Qi Yu Chua, Puay Khim Lim, Vishal G Shelat, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
Thomas Zheng Jie Teng, Branden Qi Yu Chua, Puay Khim Lim, Kai Siang Chan, Vishal G Shelat, Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
Vishal G Shelat, Surgical Science Training Centre, Tan Tock Seng Hospital, Singapore 308433, Singapore
Author contributions: Teng TZJ, Chua BQY and Lim PK contributed equally to this work; Teng TZJ, Chua BQY and Lim PK performed the literature search, data collection and wrote the manuscript; Chan KS wrote the manuscript and revised the manuscript; Shelat VG conceptualised the study design and idea, and revised the manuscript; All authors have read and approve the final manuscript.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Kai Siang Chan, MBBS, Doctor, Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore. kchan023@e.ntu.edu.sg
Received: December 8, 2022
Peer-review started: December 8, 2022
First decision: February 15, 2023
Revised: February 21, 2023
Accepted: March 21, 2023
Article in press: March 21, 2023
Published online: April 7, 2023
Processing time: 119 Days and 23.7 Hours
ARTICLE HIGHLIGHTS
Research background

Acute pancreatitis (AP) is a disease spectrum ranging from mild to severe disease. During the coronavirus disease 2019 (COVID-19) pandemic, numerous reports of AP have been published, with most authors concluding a causal relationship between COVID-19 and AP.

Research motivation

Published reports or case series of COVID-19-induced AP are retrospective in nature and are unable to accurately determine the cause-effect relationship between COVID-19 and AP.

Research objectives

This study aims to establish whether COVID-19 is a cause of AP by proposing a scoring system i.e. the modified Naranjo scoring system.

Research methods

A systematic review was conducted on PubMed, World of Science and Embase for articles reporting COVID-19 and AP from inception to August 2021. Exclusion criteria were cases of AP which were not reported to be due to COVID-19 infection, age < 18 years old, review articles and retrospective cohort studies. The original 10-item Naranjo scoring system (total score 13) was devised to approximate the likelihood of a clinical presentation to be secondary to an adverse drug reaction. We modified the original scoring system into a 8-item modified Naranjo scoring system (total score 9) to determine the cause-effect relationship between COVID-19 and AP. A cumulative score was decided for each case presented in the included articles. Interpretation of the modified Naranjo scoring system is as follows: ≤ 3: Doubtful, 4-6: Possible, ≥ 7: Probable cause.

Research results

The initial search resulted in 909 articles, with 740 articles after removal of duplicates. A total of 67 articles were included in the final analysis, with 76 patients which had AP reported to be due to COVID-19. The mean age was 47.8 (range 18-94) years. Majority of patients (73.3%) had ≤ 7 d between onset of COVID-19 infection and diagnosis of AP. There were only 45 (59.2%) patients who had adequate investigations to rule out common aetiologies (gallstones, choledocholithiasis, alcohol, hypertriglyceridemia, hypercalcemia and trauma) of AP. Immunoglobulin G4 testing was conducted in 9 (13.5%) patients to rule out autoimmune AP. Only 5 (6.6%) patients underwent endoscopic ultrasound and/or magnetic resonance cholangiopancreatogram to rule out occult microlithiasis, pancreatic malignancy and pancreas divisum. None of the patients had other recently diagnosed viral infections apart from COVID-19 infection, or underwent genetic testing to rule out hereditary AP. There were 32 (42.1%), 39 (51.3%) and 5 (6.6%) patients with doubtful, possible, and probable cause-effect relationship respectively between COVID-19 and AP.

Research conclusions

Current evidence is weak to establish a strong link between COVID-19 and AP. Investigations should be performed to rule out other causes of AP before establishing COVID-19 as an aetiology.

Research perspectives

The use of our proposed modified Naranjo score may help to determine whether COVID-19 is a likely etiology of AP and may assist clinicians in making useful clinical decisions.