title: Frequency and prognosis of acute pancreatitis associated with fulminant or non-fulminant acute hepatitis A: A systematic review.
abstract: BACKGROUND
  Acute pancreatitis (AP) in patients with fulminant viral hepatitis is well recognized and its mortality depends on the severity of hepatitis rather than pancreatitis. Acute pancreatitis associated with non-fulminant acute hepatitis A (AHA) has been rarely described, and is considered to have a benign course with good response to conservative management.
  
  
  OBJECTIVE
  To perform a systematic review of the frequency and prognosis of AP associated with fulminant or non-fulminant AHA.
  
  
  BACKGROUND
  An increasing number of reports describe AP associated with AHA. Some life-threatening complications related to AP may occur, and death has been reported. In addition, it is possible that early diagnosis of these cases may help in reducing the morbidity and mortality.
  
  
  METHODS
  Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, Scopus, Google Scholar, and reference lists of relevant articles.
  
  
  METHODS
  All available studies discussing AP associated with fulminant or non-fulminant AHA.
  Two blinded independent observers extracted and assessed the frequency of AP associated with AHA based on large studies including all cases of AHA observed during a prolonged period of time, diagnosis of AHA based on anti-HAV IgM, diagnosis of fulminant hepatitis (FH) based on the American Association for the study of Liver Diseases (AASLD) position paper, diagnosis of AP based on the American College of Gastroenterology (ACG) guidelines, diagnosis of AP associated with AHA based on Makharia's association, and diagnosis of AP severity based on the Revision of the Atlanta Classification (RAC). We have developed a tool for risk of bias assessment of case reports and case-series and applied it to the included studies.
  
  
  RESULTS
  The frequency of reported AP associated with AHA is 0-0.1%. Thirty-eight publications with a total of 54 patients meeting the inclusion criteria have been published. Twenty-two studies had a low risk for bias, 10 had moderate risk and 6 had high risk. Patients originated from all continents but most of them were from Asia. The median age at diagnosis was 16 years (range: 2-81) with a male to female ratio of 2. The median interval between the onset of jaundice and onset of AP pain was 4 days (range: 0-30). AP was severe in 9% of patients. The median hospital stay for AP was 8 days (range: 3-35). Most cases occur in patients without FH (94%). Mortality was reported in 2 patients (3.7%).
  
  
  CONCLUSIONS
  Acute pancreatitis associated with AHA is rare with an estimated frequency of 0-0.1%. Fifty-four documented cases, mostly in Asian patients, have been reported. The median age of patients is 16 years with a M/F ratio of 2. Acute pancreatitis occurs less than one week after the onset of jaundice and mostly in patients without FH. Acute pancreatitis in this setting is severe in 9% of patients with a mortality rate similar to all other causes of AP.
authors.affiliation: Digestive Center for Diagnosis and Treatment, 29 Ayar Street, Damascus, Syria.
authors.forename: Samir
authors.initials: S
authors.lastname: Haffar
authors.affiliation: Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA. Electronic address: Bazerbachi.Fateh@mayo.edu.
authors.forename: Fateh
authors.initials: F
authors.lastname: Bazerbachi
authors.affiliation: Department of Library Services, Mayo Clinic, Rochester, MN, USA.
authors.forename: Larry
authors.initials: L
authors.lastname: Prokop
authors.affiliation: Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
authors.forename: Kymberly D
authors.initials: KD
authors.lastname: Watt
authors.affiliation: Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
authors.forename: M Hassan
authors.initials: MH
authors.lastname: Murad
authors.affiliation: Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
authors.forename: Suresh T
authors.initials: ST
authors.lastname: Chari
mesh_terms: D006801:Humans; D006506:Hepatitis A / Q000150:complications / Q000473:pathology; D010195:Pancreatitis / Q000209:etiology / Q000473:pathology
keywords: Acute liver failure; Hepatitis; Hepatitis A virus; Humans; Pancreatitis; Revised Atlanta criteria (RAC); Systematic review; Virology