Viral hepatitis that concomitantly causes acute pancreatitis (AP) has been reported but not comprehensively studied. We sought to investigate the frequency of viral hepatitis that concomitantly causes AP, its impact on AP and the clinical features of the disease.
A comprehensive review of PubMed's database of English language until April 12th, 2019 was performed using all relevant MeSH (medical subject headings) keywords. AP diagnosis and severity were defined as per the Revised Atlanta Classification (RAC). Viral infections were diagnosed by serology and/or histology. A diagnosis of viral infection, with a concurrent AP diagnosis, a temporal resolution of both entities and the attempt to exclude the most common etiologies of AP defined viral induced AP. Graft pancreatitis studies and non-English publications were excluded. Two independent blinded reviewers (Z.I, C.R.S.L.) reviewed the publications. Bias risk was assessed with the Murad tool derived from the Newcastle-Ottawa scale.
71 cases of viral hepatitis causing concomitant AP were found. 20 AP cases were attributed to Hepatitis A virus (HAV), 16 AP cases to Hepatitis B virus (HBV), and 35 AP cases to Hepatitis E virus (HEV). Mean ages were 24.3 ± 1.9, 40.5 ± 3.1, and 31.5 ± 3.05 for HAV, HBV, HEV cases respectively. Male to female ratio were 2.25:1, 4.33:1 and 8:1 respectively. 37.5% of HBV AP patients were immunocompromised (IC). Latency of AP from jaundice onset was 6.7 (range: 0-21), 11.9 (0-60), 8.8 (0-37) days respectively. Mean AST levels were 1042 (44-5520), 1550 (514-3200), 362 (71-3690) and ALT levels were 1406 (20-6680), 1894 (72-7521), 1093 (103-5214) respectively. AP severity: mild and moderately severe AP were reported in 80% of HAV-attributed cases, 31.3% of HBV-attributed cases and 82.9% of HEV-attributed cases. Severe AP was reported in 20%, 66.7% and 14.3% of HAV, HBV and HEV-attributed cases respectively. Mortality was reported in 25% of HAV-attributed cases, 56.3% of HBV-attributed cases and 11.8% of HEV-attributed cases. Only one case of HCV-attributed AP was reported. Findings are summarized in Table 1.
Viral hepatitis causing concomitant AP is a rare entity and outcomes vary depending on the type of hepatitis virus. HEV AP appears to have a male predominance. Over one-third of HBV attributed AP occurred in IC patients, with higher mortality. Direct acinar injury by active viral replication has been suggested as the mechanism of injury.