DISCUSSION
We have been detected that 23% of patients with COVID-19 infection had pancreatic enzyme elevations. And there was a relationship between pancreatic enzyme elevation and severity of COVID-19 infection, hemodynamic instability and MODS.
Although 10,9% of patients with mild COVID-19 infection had elevated amylase, This rate was 34,9% in patients with severe COVID-19 infection. It has been detected that causes of pancreatic enzyme elevation were hypotension and ischemia in severe infection. Elevated amylase levels were 10,3% and 44,2% in patients with normal mean arterial pressure and with low arterial pressure (<60 mmHg) respectively. Out of 316 patients with a high level of amylase, 36.7% of patients recovered and 63.3% of patients died. 53% of patients with ischemic hepatitis had concurrently amylase and lipase elevations. And also next to liver and intestinal damage, pancreatic damage might occur in shock with the decreased blood flow to the gastrointestinal system.
In a study over the relation between COVID-19 infection and pancreas, it has been reported that pancreatic damage was found 1-2% and 17% in patients with mild and severe infection consecutively. Additionally, it has been reported that pancreatic damage can be exacerbated with systemic inflammation. Amylase and lipase elevation, suggesting pancreatic damage, has been reported between 8.5%-17,3% in patients with COVID-19. Moreover, it has been stated that there were higher enzyme levels in severe patients.14-15-16-17Paralel to these studies, hemorrhagic and necrotic changes with focal pancreatitis were detected in one of the autopsy studies 5/11 (45,5%) and in the other study 2/8 (25%).
These changes without clinical signs have been attributed to ischemia and end-organ damage.18-19 Therefore, it is quite difficult to use the elevated lipase and amylase developing in COVID-19 infection as a prognostic indicator. Since enzyme elevation occurs in the intensive care period where the disease is severe and requires mechanical ventilation. At this stage, most patients have single or multiple organ failure and receive vasopressor support. Therefore, the high amylase level is a result of the severity of COVID-19 infection.
As a result, although ACE-2 receptors are expressed highly in pancreatic tissue, pancreatic enzyme elevations occurring in COVID-19 infection might be result of severity of disease and hemodynamic instability. Otherwise, there would have been many pancreatitis caused by ACE-2 receptors. Despite over a hundred million cases, pancreatitis remained only at the level of case reports.20-21