The Epidemiology of Acute Pancreatitis in a Tertiary Care Hospital in Dubai

Abstract

Background:

The prevalence of acute pancreatitis is rising especially in the Western world, but the prevalence remains unknown in most Middle Eastern Countries. Acute pancreatitis has been attributed with multiple etiologies with the two most common being alcohol abuse disorder and gallstones. The incidence and prevalence of it in the United Arab Emirates are yet to be reported.

Materials and Methods:

The Atlanta criteria were used for the diagnosis of acute pancreatitis and applied to patients that have been admitted to a single tertiary center in the year 2021. Several variables were investigated including gender, age, clinical presentation, etiology, radiological and laboratory results, complications, and outcome. Moreover, the Bedside Index for Severity in Acute Pancreatitis score was used to assess and determine the severity of acute pancreatitis in these patients.

Results:

Nineteen patients were identified in our database with 52% being males. The mean age of patients was 41 years. The most frequent presentation was abdominal pain in 100% of our patients. Moreover, the most common etiology identified was idiopathic (52.63%), followed by biliary (21.05%). The mortality rate was 0%.

Conclusion:

This is the first retrospective study in Dubai on acute pancreatitis. Pancreatitis is a life-threatening condition with multiple etiologies. Physicians should consider multifactorial acute pancreatitis in patients with different comorbidities.

INTRODUCTION

Acute pancreatitis is a disorder that has been recognized to be common and increasing in prevalence, especially in the Western side of the world.[1] There are multiple etiologies and risk factors of acute pancreatitis with the two most common being migrating gallstones obstructing the common bile duct and alcohol abuse disorder. The other potential causative etiologies are smoking, hypertriglyceridemia, genetic risk, postendoscopic retrograde cholangiopancreatography (ERCP), hypercalcemia, intraduct papillary mucinous tumor, pancreatic duct injury, infections, and idiopathic.[2,3,4] It is deemed to be a potentially life-threatening condition that is associated with a high risk of morbidity and mortality and can vary in its severity from mild to severe.[5]

The only study published in the United Arab Emirates (UAE) on the epidemiology of acute pancreatitis was in 1990.[6] The study included 61 patients and found the most common etiology to be biliary tract disease.

The incidence and prevalence of acute pancreatitis remain unreported in the Middle East and its impact on morbidity and mortality. A gap in the literature exists and this study aims to highlight this deficiency and stimulate the interest of other researchers in addressing this topic in the Middle East.

MATERIALS AND METHODS

The methods in this study have been reported according to STROBE guidelines. This is a retrospective cross-sectional study, single-center study that reviewed all admissions of acute pancreatitis in Mediclinic Parkview Hospital in 2021. The criteria used for diagnosis of acute pancreatitis were the Atlanta criteria, which required the presence of at least two of the following: (1) new onset of upper abdominal pain or tenderness, (2) elevation in serum levels of pancreatic enzymes of three or more folds, and (3) radiological changes suggestive of acute pancreatitis.[7]

Data collection included the following variables: age at the time of admission, gender, clinical presentation, etiology, radiological and laboratory abnormalities, complications, and outcome. The Bedside Index for Severity in Acute Pancreatitis (BISAP) score was also found to determine the severity of acute pancreatitis. The BISAP score is reliable in determining the risk of unfavorable outcome in patients with acute pancreatitis.[8]

Biliary pancreatitis was diagnosed when there was radiological evidence of biliary obstruction by stones. Alcoholic pancreatitis was based on the patient’s history and excluding other causes. Hypertriglyceridemia-induced pancreatitis was diagnosed based on high triglyceride levels without other abnormalities. Recurrent pancreatitis was diagnosed if a patient had at least two episodes of acute pancreatitis with remission in between. Idiopathic pancreatitis was diagnosed if no etiology of pancreatitis could be identified after a thorough investigation.

Ethical approval has been obtained from the ethical board of Mediclinic Parkview Hospital. No informed consent was required from the patients as there was no patient participation.

RESULTS

The study included 19 patients admitted with acute pancreatitis, out of which only 2 patients required admission to intensive care unit (ICU). Of the 19 patients, 10 (52%) patients were males and 9 (47%) were females. The age of the patients ranged between 5 and 66 years with a mean age of 41 years. The mean age was found to be 42 and 40 years for males and females, respectively. The duration of hospital stay ranged from 1 to 11 days with a mean of 3 days. During the study, the patients were classified into three groups based on their age (1–29 years), (30–59 years), and above 60 years. Most of the patients, 15 patients, were between 30 and 59 years. However, only two patients were identified in each of the other subgroups as shown in Figure 1.

Figure 1.

Age distribution among sample patients with acute pancreatitis

Abdominal pain was found to be the most frequent presentation manifesting in 100% of patients at the time of admission. Other symptoms included vomiting, fever, and weight loss with frequencies of 10 (52.63%), 2 (10.53%), and 2 (10.53%), respectively. During the study, patients were also classified according to the etiology of acute pancreatitis. With a frequency of 11 (52.63%) patients, idiopathic pancreatitis was the most common cause, followed by biliary pancreatitis (21.05%). Alcohol, malignancy, and COVID-related pancreatitis were among the remaining etiologies with a frequency of 1 (5.26%) patient each. These values are demonstrated in Table 1.

Table 1.

Etiologies of acute pancreatitis in sample patients

Etiology	Frequency (%)
Idiopathic	10 (52.63)
COVID-19 related	1 (5.26)
Multifactorial	1 (5.26)
Biliary pancreatitis	4 (21.05)
Malignancy	1 (5.26)
Post-ERCP	1 (5.26)
Alcoholic	1 (5.26)

ERCP=Endoscopic retrograde cholangiopancreatography

The severity of pancreatitis was determined using the BISAP score. Ten (53%) patients had mild pancreatitis, 7 (37%) had moderate pancreatitis, and 2 (10%) had severe pancreatitis as shown in Figure 2. Body mass index was calculated for 16 of the patients; it ranged between 16 and 36 with a mean of 24.89.

Figure 2.

Severity of acute pancreatitis based on Bedside Index for severity in acute pancreatitis score

Both pediatric patients (5 and 7 years) included in the study had idiopathic pancreatitis. Idiopathic pancreatitis was also the most prevalent etiology in those between 30 and 59 years. However, in the two patients above the age of 60 years, pancreatitis was secondary to malignancy and COVID-19 infection. The etiological frequency distribution among age groups is demonstrated in Figure 3.

Figure 3.

Distribution of etiologies of acute pancreatitis among age groups

Out of the 19 patients, 3 (15.79%) had recurrent pancreatitis. Two of those patients, a 55-year-old male and a 7-year-old boy, had idiopathic pancreatitis. The third patient, a 66-year-old male, had pancreatitis secondary to malignancy. Ultrasound detected pseudocyst formation in only 3 of the 19 patients included in the study. There was no mortality in this group of patients.

DISCUSSION

Our study included all patients presenting to a Tertiary Care Hospital with pancreatitis in the year 2021. The only study in the UAE on acute pancreatitis was published in 1987.[6] While our study included 19 patients, Al-Karawi et al. in Saudi Arabia had 218 patients.[9] Another study in Saudi Arabia by Al Lehibi et al. included 107 patients.[10] Similarly in Oman, a study reviewed 174 patients retrospectively over 6 years.[11]

In our study, the males (10) are almost equal to the females (9). Other studies had different demographics regarding gender. Al-Karawi et al. had a female-to-male ratio of 1.3:1, which is similar to our study.[9] Similarly in Saudi Arabia, Al Lehibi et al. reported 53% males in their cohort, which is very similar to Albulushi et al.’s study in Oman, who had 54% males in their study.[10,11] In contrast, 70 females versus 21 males were reviewed in a retrospective study in Jamaica.[12]

As for age, we included all age groups. Other studies such as in Oman by Albulushi et al., included only patients above 18 years of age.[9] We had a 7-year-old boy in our cohort, and he had idiopathic pancreatitis as radiological imaging and laboratory testing revealed no other etiology. Similarly, a retrospective study from the Medical University of Silesia found that idiopathic acute pancreatitis was the most among their pediatric cohort.[13] They also reported one child to have congenital spherocytosis with extrahepatic and intrahepatic cholestasis, which was discovered on radiological imaging. Furthermore, Reid et al. in Jamaica included patients with an age range of 2–86 years, including both children and adults.[12]

The mean hospital stay in our study was 3 days, which is fairly similar to other studies. In Lebanon, the mean hospital stay was 4 days.[14] In Jamaica, a study found the mean hospital stay to be 9.51 ± 8.28 days.[10] The hospital stay varies depending on the severity of the acute pancreatitis and the complications present.

As for the etiological groups, idiopathic was the most common cause (52.6%), followed by 4 (21%) patients with biliary pancreatitis. Other etiologies included malignancy, COVID-19 induced, multifactorial, alcoholic, and post-ERCP pancreatitis. This is different from other studies reported in the region, as they reported biliary causes to be the most common etiology, as in the UAE in 1987.[6] In addition, two studies in Saudi Arabia reported biliary pancreatitis to be the most common.[4,5] Our second-most common cause was idiopathic pancreatitis, which is similar to what El Halabi et al. found in Lebanon.[14] However, in Oman, the most common cause was biliary tree disease followed by alcoholic pancreatitis and then idiopathic pancreatitis.[11] While Al-Karawi reported postoperative pancreatitis in 10 patients, we did not have any patients with this etiology.[9]

Two patients were admitted to the ICU, both being middle aged. Three patients developed pancreatic pseudocyst. Other studies had higher complication rate, and that could be due to the larger cohort that they had. Al-Karawi reported 26 patients having complications, with most of them being above 55 years of age.[9] In Saudi Arabia, the most common complications were pancreatic pseudocysts.[10] In Oman, chronic pancreatitis was the most common complication followed by pancreatic pseudocysts.[11] In the literature, the most common local complications after acute pancreatitis include pancreatic fluid collection, pancreatic pseudocyst, and acute necrotic collections.[12]

In terms of COVID-19-induced pancreatitis, we had two patients of which one of them also had recurrent pancreatitis. The pancreatic duct and acinar cells express ACE2, which the SARS-CoV-2 uses to enter the cell. A case report was able to isolate a sample of SARS-CoV-2 in a pancreatic pseudocyst in a patient with acute pancreatitis.[15] However, a study de-Madaria and Capurso found that associations between acute pancreatitis and SARS-CoV-2 infection are more likely to be casual.[16]

One limitation of our study is the small sample size and selection bias. The next step would be a multi-center study that investigates the epidemiology of acute pancreatitis in Dubai and different etiologies in a multicultural society. Future studies should also have a larger sample size and investigate other variables including laboratory findings.

CONCLUSION

The prevalence of acute pancreatitis in Dubai has never been reported in the literature, and it requires patient samples from different hospitals. This is the first retrospective study on the epidemiology of acute pancreatitis in a Tertiary Hospital in Dubai. Rising cases of acute pancreatitis have been noticed during COVID-19, which requires future studies on the pathophysiology and appropriate management. It is important to recognize early acute pancreatitis and treatable etiologies to reduce mortality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.