El artículo concluye que el SARS-CoV-2 ha contribuido a la lesión pancreática en pacientes con cetoacidosis diabética. El aumento en los niveles de amilasa y lipasa ocurrieron más frecuencia en nuestros pacientes de lo esperado según
a la literatura, pero esto no parecen estar relacionados con el COVID-19. Además, sugerimos que la cetoacidosis diabética
puede ser una presentación clínica frecuente de diabetes de nueva aparición

Concepción-Zavaleta, Marcio José

Gonzales-Yovera, Jhean Gabriel .

Plasencia-Dueñas, Esteban Alberto

English

Repositorio Institucional EsSalud

Pancreas • Volume 50, Number 2, February 2021 Letters to the Editoremission tomography–computed tomogra-phy, which have alternative diagnosticperformance, were unable to detect AIP.This atypical imaging presentation of AIPprobably reflects a low activity of pancrea-titis. Some reported an AIP patient withatrophic parenchyma.9,10 Although this en-tity of atrophy was unclear, they suggestedchronic inflammation from AIP or fromanother etiology, such as alcohol. This wassimilar to our patient; however, we cannotelucidate the cause for atrophic AIP. This isa potential limitation of our study.Atypical AIP showing an atrophic pa-renchyma without pancreatic enlargementis easily overlooked, and it should be exam-ined carefully to detect occult PDAC. UsingDWI and repeat biopsy might be useful forthe detection of occult cancer in patientssuspected of IgG4-RD.ACKNOWLEDGMENTSThe authors would like to thank Editage(www.editage.com) for English languageediting.T.I. received a grant (KAKENHI 2019-04-01 to 2022-03-31. 19 K07752) from theJapan Society for the Promotion of Science.The authors declare no conflict of interest.Eisho Kanemitsu, MDTakashi Ito, MD, PhDSatoshi Ogiso, MD, PhDTakamichi Ishii, MD, PhDSatoru Seo, MD, PhDDivision of Hepato-Biliary-PancreaticSurgery and TransplantationDepartment of SurgeryGraduate School of MedicineKyoto UniversityKyoto, Japanitotaka@kuhp.kyoto-u.ac.jpMisuzu Okabayashi, MDAkihiko Yoshizawa, MD, PhDDepartment of Diagnostic PathologyKyoto University HospitalKyoto, JapanKojiro Taura, MD, PhDToshihiko Masui, MD, PhDDivision of Hepato-Biliary-PancreaticSurgery and TransplantationDepartment of SurgeryGraduate School of MedicineKyoto UniversityKyoto, JapanREFERENCES1. Stone JH, Zen Y, Deshpande V. IgG4-relateddisease. N Engl J Med. 2012;366:539–551.2. Shimosegawa T, Chari ST, Frulloni L, et al.International consensus diagnostic criteria forautoimmune pancreatitis: guidelines of the© 2021 Wolters Kluwer Health, Inc. All rights reserCopyright International Association of Pancreatology.Pancreas. 2011;40:352–358.3. Inoue H,Miyatani H, Sawada Y, et al. A case ofpancreas cancer with autoimmune pancreatitis.Pancreas. 2006;33:208–209.4. Witkiewicz AK, Kennedy EP, Kennyon L, et al.Synchronous autoimmune pancreatitis andinfiltrating pancreatic ductal adenocarcinoma:case report and review of the literature.Hum Pathol. 2008;39:1548–1551.5. Pezzilli R, Vecchiarelli S, Di Marco MC, et al.Pancreatic ductal adenocarcinoma associatedwith autoimmune pancreatitis. Case RepGastroenterol. 2011;5:378–385.6. Bipat S, Phoa SS, van Delden OM, et al.Ultrasonography, computed tomography andmagnetic resonance imaging for diagnosis anddetermining resectability of pancreaticadenocarcinoma: a meta-analysis. J ComputAssist Tomogr. 2005;29:438–445.7. Kato K, Nihashi T, Ikeda M, et al. Limitedefficacy of (18)F-FDG PET/CT fordifferentiation between metastasis-freepancreatic cancer and mass-formingpancreatitis. Clin Nucl Med. 2013;38:417–421.8. Takakura K, Sumiyama K, Munakata K, et al.Clinical usefulness of diffusion-weighted MRimaging for detection of pancreatic cancer:comparison with enhanced multidetector-rowCT. Abdom Imaging. 2011;36:457–462.9. Takano Y, Nagahama M, Yamamura E, et al. Acase of concurrent pancreatic intraepithelialneoplasia and type 1 autoimmune pancreatitiswith marked pancreatic duct dilatation. Clin JGastroenterol. 2016;9:266–271.10. Sugiyama T, Tajiri T, Hiraiwa S, et al. A caseof high-grade pancreatic intraepithelialneoplasia concomitant with type 1 autoimmunepancreatitis: the process underlyingboth conditions. Pathol Int. 2019;69:165–171.Pancreatic Enzyme ElevationPatterns in Patients WithDiabetic KetoacidosisDoes Severe Acute RespiratorySyndrome Coronavirus 2 Play aRole?To the Editor:I n Peru, the current number of confirmedcoronavirus disease 2019 (COVID-19)cases exceeds 800,000, with a case fatalityrate of 3.9%. This positions our countryas one of the most affected by the pandemicworldwide. It is known that diabetesmellitusis a risk factor for the development of severeCOVID-19; on the other hand, patients in-fected with COVID-19 have a higher riskved.© 2021 Wolters Kluwer Health, Inc. All rights rof developing new-onset diabetes mellitus,thus creating a 2-way relationship.1Severe acute respiratory syndrome co-ronavirus 2 (SARS-CoV-2) has been shownto have a high affinity for the angiotensinconverting enzyme 2 receptor, which is usedas a gateway.1,2 The experience publishedbased on the 2002 to 2004 SARS-CoVout-break, where the pattern of receptor expres-sion in different human organs was studied,showed abundant angiotensin convertingenzyme 2 immunostaining in the lungs, kid-neys, heart, and pancreatic islets.3Moreover,multiple scientific publications have reporteda higher incidence of diabetic ketoacidosisin patients with COVID-19, which demon-strates increased morbidity and mortality.4It is postulated that the interaction ofSARS-CoV-2 and pancreatic cells inducesa cytopathic effect in those cells, whichcan be manifested as increases in serumamylase and lipase levels above the upperlimit of normality, with a potential risk ofdeveloping acute pancreatitis.1,4 This pan-creatic lesion added to insulin resistancecaused by SARS-CoV-2 infection, in thecontext of a diabetic patient, could implyan increased risk of hyperglycemic crisis.4The revised Atlanta classification pub-lished in 2012 continues to be used for thediagnosis of acute pancreatitis, and accord-ing to this system, 2 of the following 3criteria must bemet: typical abdominal pain,increases in amylase or lipase levels to morethan 3 times the upper limit, and characteris-tic imaging findings. However, amylase ele-vation may also be observed in appendicitis,cholecystitis, intestinal obstruction or ische-mia, and gynecological diseases; likewise,increased lipase levels may also be seen inkidney disease, appendicitis, and cholecysti-tis, among other diseases.5Furthermore, it has been reported thatthe increases in amylase and lipase levelsmay occur in 16% to 25% of cases of dia-betic ketoacidosis, and an increase in lipaseis less specific for the diagnosis of acutepancreatitis in the context of diabeticketoacidosis,6 which highlights the useful-ness of abdominal tomography in these cases.Some cases of pancreatic injury havebeen reported in patients with COVID-19,and of these, some meet the criteria foracute pancreatitis.7–10 One of the first caseseries, published by Wang et al,7 reportedthat, of 52 patients with COVID-19, 17%had elevated amylase and or lipase levels,which appeared to be signs of more seriousdisease on admission. In another series of71 patients with COVID-19, 9 had elevatedlipase on admission, but the increase wasgreater than 3 times the upper limit in only2 of those cases; both presented with diar-rhea, and 1 had active enterocolitis basedon tomography, which suggests that thewww.pancreasjournal.com e19eserved.TABLE1.ClinicalandBiochemicalCharacteristicsofPatientsWithDiagnosisofDiabeticKetoacidosisUponAdmissionSexAge,ySeverityofDKACOVID-19DiagnosisTypicalAbdominalPainBloodTestUponAdmissionAbdominalCTAcutePancreatitispHHCO3−,mmol/LGlucose,mg/dLAST,U/LALT,U/LALP,U/LGGTP,U/LAmylase,U/LLipase,U/L1Male31SevereNoNo6.95.6888172410720361396EdematouspancreasYes2Male66MildNoNo7.2620.55064892121964132421EdematousYes3Male66SevereYes(ELISA)No7.058.6781457822412254284NoabnormalitiesNo4Male36SevereNoYes6.996.1683172892868714,172NoabnormalitiesYes5Male73MildYes(RT-PCR)No7.318.6699282815015651315HipotrophicpancreasNo6Male62SevereNoNo7.2713.726044571652166004837EdematouspancreasYes7Male62ModerateYes(suggestivechestCT)No7.314.6121835182102337106NoabnormalitiesNo8Male48ModerateNoNo7.2311305151647251591004DiffuseedemaofthepancreasYes9Female36SevereYes(RT-PCR)No6.82.542022111492062215NoabnormalitiesNo10Male40ModerateNoNo7.2410.63411728928689143NoabnormalitiesNo11Male63ModerateNoNo7.2511.610464097120109146353NoabnormalitiesNo12Male15ModerateNoYes7.186372828321166425NoabnormalitiesNo13Male45SevereNoYes6.910.5107215131207286558NoabnormalitiesNoSource:DatawereobtainedfromtheEndocrinologyInpatientDepartment,GuillermoAlmenaraNationalHospital,MarchtoJuly2020.Referencevalues:amylase,30–110U/L;lipase,23–300U/L.ALPindicatesalkalinephosphatase;ALT,alanineaminotransferase;AST,aspartateaminotransferase;CT,computedtomography;DKA,diabeticketoacidosis;ELISA,enzyme-linkedimmunoSorbentassay;GGTP,gamma-glutamyltransferase;RT-PCR,reversetranscription–polymerasechainreaction.Letters to the Editor Pancreas • Volume 50, Number 2, February 2021elevation of this enzyme may be due to theenteric involvement of the virus, althoughthis elevation can also be explained by othere20 www.pancreasjournal.comCopyright ©causes.8 Other published cases include a26-year-old woman with no evidence ofrespiratory symptoms who presented with© 2021 2021 Wolters Kluwer Health, Inc. All rights relipase elevation and associated symptoms;her presentation was compatible with acutepancreatitis, which evolved favorably withfasting.9 A family is also described, in which5 members who tested positive for SARS-CoV-2 infection; of these, 3 required admis-sion to the intensive care unit for severerespiratory compromise, and 2 were diag-nosed with severe acute pancreatitis.10Based on our experience in the endo-crinology inpatient department of a socialsecurity hospital in Peru from March 2020to July 2020, we have treated 13 patientswith diabetic ketoacidosis with remissioncriteria, of whom 6 were severe cases, 5were moderate cases, and 2 were mild cases;overall, we registered 12 patients withrecent-onset diabetes. Likewise, 9 patientspresented with high levels of amylase and/or lipase on admission, tomographic signsof acute pancreatitis were observed in 4 pa-tients, and 5 patients met the criteria foracute pancreatitis. Abdominal pain wasnot a common feature because this symp-tom was present in only 3 cases, 1 of whichmet the criteria for acute pancreatitis. Fourpatients had diagnosis of COVID-19, noneof them had pancreatic abnormalities by to-mography, only 1 had a significant eleva-tion of amylase, but none met the criteriafor acute pancreatitis (Table 1).Finally, according to these data, wecannot conclude that SARS-CoV-2 hascontributed to pancreatic injury in patientswith diabetic ketoacidosis. The increase inamylase and lipase levels occurred morefrequently in our patients than expected ac-cording to the literature, but this does notseem to be related to COVID-19. In addi-tion, we suggest that diabetic ketoacidosismay be a frequent clinical presentation ofnew-onset diabetes.The authors declare no conflict ofinterest.Esteban Alberto Plasencia-Dueñas, MDMarcio José Concepción-Zavaleta, MDDivision of EndocrinologyGuillermo Almenara Irigoyen National HospitalLima, Perúesteban_alberto147@hotmail.comJhean Gabriel Gonzáles-Yovera, MDDivision of GastroenterologyGuillermo Almenara Irigoyen National HospitalLima, PerúREFERENCES1. Chee YJ, Tan SK, Yeoh E. Dissecting theinteraction between COVID-19 and diabetesmellitus. J Diabetes Investig. 2020;11:1104–1114.2. Hamming I, Timens W, Bulthuis ML, et al.Tissue distribution of ACE2 protein, theWolters Kluwer Health, Inc. All rights reserved.served.Pancreas • Volume 50, Number 2, February 2021 Letters to the Editorfunctional receptor for SARS coronavirus. Afirst step in understanding SARS pathogenesis.J Pathol. 2004;203:631–637.3. Yang JK, Lin SS, Ji XJ, et al. Binding of SARScoronavirus to its receptor damages islets andcauses acute diabetes. Acta Diabetol. 2010;47:193–199.4. Goldman N, Fink D, Cai J, et al. Highprevalence of COVID-19-associated diabeticketoacidosis in UK secondary care. DiabetesRes Clin Pract. 2020;166:108291.5. Tenner S, Baillie J, DeWitt J, et al. AmericanCollege of Gastroenterology guideline:management of acute pancreatitis. Am JGastroenterol. 2013;108:1400–1415; 1416.6. Rizvi AA. Serum amylase and lipase in diabeticketoacidosis. Diabetes Care. 2003;26:3193–3194.7. Wang F, Wang H, Fan J, et al. Pancreatic injurypatterns in patients with coronavirus disease 19pneumonia.Gastroenterology. 2020;159:367–370.8. McNabb-Baltar J, Jin DX, Grover AS, et al.Lipase elevation in patients with COVID-19.Am J Gastroenterol. 2020;115:1286–1288.9. Miao Y, Lidove O, Mauhin W. First case ofacute pancreatitis related to SARS-CoV-2infection. Br J Surg. 2020;107:e270.10. Hadi A, Werge M, Kristiansen KT, et al.Coronavirus disease-19 (COVID-19) associatedwith severe acute pancreatitis: case report onthree family members. Pancreatology. 2020;20:665–667.A Novel Strategy ofEndoscopicUltrasonography-GuidedPancreatic Duct Drainage forPancreatic Fistula AfterPancreaticoduodenectomyTo the Editor:FIGURE 1. A, A contrast-enhanced computed tomography image showing fluid collection ofthe POPF, which was percutaneously drained from the epigastric region withbeige-colored, digestive juice of greater than 200 mL/d. B, A fluoroscopic image of thepancreatic duct, which was clearly described, although not dilated, by contrastexamination from the percutaneous drain. C, A fluoroscopic image of the EUS-guidedtransgastric approach showing the pancreatic duct of 2 mm in size that was puncturedwith a 19-gauge needle at the distal pancreas through the posterior gastric wall under EUSguidance using a convex array echoendoscope. D, A fluoroscopic image after placement ofa 7-Fr single pigtail type plastic stent from the posterior gastric wall to the pancreatic duct. E,An endoscopic image showing a deployed 7-Fr single pigtail type plastic stent in thepancreatic duct. F, A computed tomography image taken 1 week after EUS-guided drainageshowing considerable shrinkage of the fluid collection by POPF.P ostoperative pancreatic fistula (POPF) is acommon and potentially life-threateningcomplication after pancreatoduodenectomy.1,2The optimal treatment for the InternationalStudy Group for Pancreatic Fistula–definedpancreatic fistula is not well defined.2 Fordecades, primary catheter drainage has beenbecoming a less invasive alternative torelaparotomy. However, current treatmentsrequire patients to withstand prolonged, un-comfortable percutaneous drainage and areexposed to the risk of bleeding and infec-tion.3 Herein, we report a case of refractoryPOPF after pancreatoduodenectomy thatwas successfully managed by endoscopicultrasonography (EUS)-guided pancreaticduct drainage (EUS-PD).A 78-year-oldman underwent pancrea-toduodenectomy with lymph node dissec-tion for distal bile duct cancer (T1bN0M0,© 2021 Wolters Kluwer Health, Inc. All rights reserCopyright stage IA). A reconstruction procedure wasperformed with the modified Child method.The pancreatic parenchymawas soft and anendo-to-side pancreaticojejunostomy wasaccomplished by duct-to-mucosa anasto-mosis (modified Blumgart technique) witha 4-Fr external stent and 2 closed suctiondrains at the ventral and dorsal sides. Histurbid drainage juice contained amylase ofgreater than 10,000 IU/mL on postopera-tive day (POD) 3. Both drains were re-moved on POD 22/25, respectively, afterthe drainage amount decreased and inflam-mation improved; however, a percutaneousdrainage was added because fluid col-lected at the pancreatic anastomotic siteon POD 29. Three weeks later, a rupturedpseudoaneurysm of common hepatic arteryved.© 2021 Wolters Kluwer Health, Inc. All rights rdeveloped and was successfully treated bytranscatheter arterial embolization usingcoiling. The characteristics and amount ofdrainage did not change with a beige-colored, digestive juice of greater than200 mL/d despite 3 months of percutane-ous drainage (Fig. 1A). In addition, thepancreatic duct was clearly described, al-though not dilated, by contrast examinationfrom percutaneous drain (Fig. 1B).The procedure of EUS-PD via trans-gastric approach was performed on POD90. The distal part of the main pancreaticduct (MPD) was punctured with a 19-gaugeneedle under EUS guidance using a convexarray echoendoscope (GF-UCT260-AL5;Olympus Medical Systems, Tokyo, Japan),followed by the insertion of a 0.025-in guidewww.pancreasjournal.com e21eserved.

Pancreatic Enzyme Elevation Patterns in Patients With Diabetic Ketoacidosis: Does Severe Acute Respiratory Syndrome Coronavirus 2 Play a Role?

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Pancreatic Enzyme Elevation Patterns in Patients With Diabetic Ketoacidosis: Does Severe Acute Respiratory Syndrome Coronavirus 2 Play a Role?

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