LAUSR

We read with great interest the study by Pandanaboyana et al. The COVID-19 PAN collaborative study was a large international study that provided updated clinical evidence that has deepened our understanding of the relationship between COVID-19 and acute pancreatitis (AP). However, we question some details in the article. In this study, although the severity of AP was defined, the definition of AP itself was not clear. The definition of AP used in studies can vary widely, which may lead to differences in the population included and thus to different conclusions. To explore the relationship between the two diseases, the definition of AP needs to be relatively strict, including a combination of enzymatic changes, imaging changes and typical symptoms, as enzymatic changes alone in patients with COVID-19 appear to be unreliable for the definition of pancreatitis. 4 Furthermore, this study did not further analyse the reasons for the high mortality rate in patients with both AP and COVID-19. An analysis of the reasons for the increased mortality of patients with AP in the SARSCoV-2 positive group may further clarify the relationship between the two diseases. The deaths associated with pancreatitis suggest that SARSCoV-2 infection may exacerbate pancreatic injury, while deaths due to respiratory failure may be more likely to be related to features of COVID-19 itself. We wish to highlight two aspects of the relationship between COVID-19 and AP. Existing studies have confirmed that concomitant SARSCoV-2 infection in patients with AP leads to further disease deterioration, leading to more severe disease and mortality. 5 This may be attributed to the exaggerated immune dysfunction, subsequent cytokine storms and endothelial damage that occur under proinflammatory conditions. 6 However, it remains unclear whether SARSCoV-2 infection directly leads to pancreatitis. Although the ACE2 receptor is expressed on pancreatic acinar and islet cells, the probability of patients with COVID-19 developing AP during the disease course is very low, 8 even in patients with a history of pancreatitis. Based on the above evidence, the focus in clinical practice may depend on various aspects of the relationship between COVID-19 and AP. In patients hospitalised for AP who become infected with SARSCoV-2, active early intervention could reduce the likelihood of developing severe disease. In COVID-19 patients without AP in the initial stage, the incidence of related AP is low; the cause of AP in those who develop it later in the disease course is unclear. Whether active monitoring and treatment are needed still needs further discussion.