Clinical profile of cannabis-associated acute pancreatitis

Pancreatic Cancer in Chronic Pancreatitis: Pathogenesis and Diagnostic Approach

Chronic pancreatitis is one of the main risk factors for pancreatic cancer, but it is a rare event. Inflammation and oncogenes work hand in hand as key promoters of this disease. Tobacco is another co-factor. During alcoholic chronic pancreatitis, the cumulative risk of cancer is estimated at 4% after 15 to 20 years. This cumulative risk is higher in hereditary pancreatitis: 19 and 12% in the case of PRSS1 and SPINK1 mutations, respectively, at an age of 60 years. The diagnosis is difficult due to: (i) clinical symptoms of cancer shared with those of chronic pancreatitis; (ii) the parenchymal and ductal remodeling of chronic pancreatitis rendering imaging analysis difficult; and (iii) differential diagnoses, such as pseudo-tumorous chronic pancreatitis and paraduodenal pancreatitis. Nevertheless, the occurrence of cancer during chronic pancreatitis must be suspected in the case of back pain, weight loss, unbalanced diabetes, and jaundice, despite alcohol withdrawal. Imaging must be systematically reviewed. Endoscopic ultrasound-guided fine-needle biopsy can contribute by targeting suspicious tissue areas with the help of molecular biology (search for KRAS, TP53, CDKN2A, DPC4 mutations). Short-term follow-up of patients is necessary at the clinical and paraclinical levels to try to diagnose cancer at a surgically curable stage. Pancreatic surgery is sometimes necessary if there is any doubt.

Cannabinoid-Related Acute Pancreatitis: An Update from International Literature and Individual Case Safety Reports

INTRODUCTION

In addition to the growing interest of different cannabinoids for therapeutic purposes, the safety profile of these substances has changed, with the recent identification of new events such as acute pancreatitis.

OBJECTIVE

The aim of this study was to characterize cannabinoid-related acute pancreatitis, based on the recent literature and the analysis of pharmacovigilance data available worldwide.

METHODS

Nine national and international pharmacovigilance databases were requested for individual case safety reports of acute pancreatitis related to cannabinoid exposure. A systematic review was performed searching in PubMed^®, Web of Science^®, and Google Scholar^® for any publication dealing with acute pancreatitis and cannabinoid exposure (cannabis, cannabinoid, cannabidiol, tetrahydrocannabinol, nabilone, dronabinol), to identify case reports, observational studies, clinical trials, or reviews. All queries were updated on 1 January, 2021.

RESULTS

Twenty-two individual case safety reports were identified in the pharmacovigilance databases and 51 in the literature, corresponding to a predominantly young male population (74% of men, median age 28 interquartile range [21-39]) using recreational Cannabis sativa with high intensity. A therapeutic purpose was identified in 13 cases (including tetrahydrocannabinol, cannabidiol, and dronabinol). The outcome was often favorable after dechallenge (except three deaths), and frequent recurrences were observed in the case of rechallenge or sustained consumption. Eleven cross-sectional studies and one ecological study showed an increasing trend of cannabis use in in-patients with acute pancreatitis, with a significantly lower in-hospital mortality.

CONCLUSIONS

This review underlines that acute pancreatitis is a potential adverse effect of cannabinoid use. It remains often unrecognized and can occur during recreational or therapeutic use. The development of the therapeutic use of cannabinoids in frail patients deserves a better investigation of the benefit-risk ratio of these different products.

Pancreatic Disorders in Patients with Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) can involve multiple organ systems, and pancreatic manifestations of IBD are not uncommon. The incidence of several pancreatic diseases is more frequent in patients with Crohn's disease and ulcerative colitis than in the general population. Pancreatic manifestations in IBD include a heterogeneous group of disorders and abnormalities ranging from mild, self-limited disorders to severe diseases. Asymptomatic elevation of amylase and/or lipase is common. The risk of acute pancreatitis in patients with IBD is increased due to the higher incidence of cholelithiasis and drug-induced pancreatitis in this population. Patients with IBD commonly have altered pancreatic histology and chronic pancreatic exocrine dysfunction. Diagnosing acute pancreatitis in patients with IBD is challenging. In this review, we discuss the manifestations and possible causes of pancreatic abnormalities in patients with IBD.

Cannabis-Induced Pancreatitis in a Young Adult Male

Drugs account for 2% of all the causes of acute pancreatitis. To date, there are approximately 26 reported cases of acute pancreatitis associated with the use of cannabis. We report the case of a 20-year-old male who presented with intractable nausea, vomiting, and epigastric pain and a lipase level of 1541 with reportedly no alcohol use, and no evidence of medication, biliary, or autoimmune etiology. However, the patient did endorse heavily smoking cannabis prior to symptom onset. He was instructed to abstain from cannabis use on discharge and has not presented to the hospital since this episode. The reporting of this case aims to increase awareness of cannabis as a differential diagnosis in cases of pancreatitis that is not due to typical etiologies such as gallstones, medications, and alcohol use. There has yet to be definitive evidence as to how cannabis can cause pancreatitis. Further studies must be conducted to better understand the association between cannabis use and acute pancreatitis and the mechanism by which cannabis affects the pancreas.

Acute and Severe Acute Pancreatitis and the Effect of Cannabis in States Before and After Legalization Compared With States Without Legalized Cannabis

OBJECTIVES

Cannabis legalization has increased its use. The incidence of acute pancreatitis (AP) and severe acute pancreatitis (SAP) has also increased. In this study, data on pancreatitis were obtained from 2 states before and after cannabis legalization and compared with 2 states without legalized cannabis.

METHODS

Data were extracted from State Inpatient Databases from the states of Colorado and Washington before recreational cannabis legalization (2011) and after legalization (2015). Arizona and Florida were used as the nonlegalized cannabis states. Multivariable logistic regression models were fit for AP and SAP to determine a trend difference between legalized and nonlegalized cannabis states.

RESULTS

Cannabis use, AP, and SAP increased in all states. The increase in AP and SAP was not significantly different between the states that legalized cannabis use and those that did not. Legalized cannabis states had lower charges for AP and SAP and shorter length of hospitalizations.

CONCLUSIONS

The trend of AP and SAP increased during the study period, but this was not correlated to cannabis use. Cannabis users had lower hospitalization costs and hospital stay. The effects of other confounders such as cannabis dose and delivery methods, alcohol, tobacco, and others need to be studied further as use increases.

Adverse events of recreational cannabis use reported to the French addictovigilance network (2012-2017)

AIMS

To describe the adverse events (AEs) of recreational cannabis use in France between 2012 and 2017.

METHODS

AEs related to recreational cannabis use, alone or in combination with alcohol and/or tobacco reported to the French Addictovigilance Network were analysed (excluding cannabidiol and synthetic cannabinoids).

RESULTS

Reporting of AEs tripled between 2012 (n = 179, 6.3%, 95% confidence interval [CI] = 5.4-7.2) and 2017 (n = 562, 10.1%, 95% CI = 9.3-10.9), reaching 2217 cases. They concerned mainly men (76.4%) and users aged between 18 and 34 years (18-25: 30.9%; 26-34: 26.3%, range: 12-84 years). Cannabis was mainly inhaled (71.6%) and exposure was most often chronic (64.2%). Many types of AEs were reported: psychiatric (51.2%), neurological (15.6%), cardiac (7.8%) and gastrointestinal (7.7%), including unexpected AEs (n = 34, 1.1%). The most common effect was dependence, ranging from 10.1% (95% CI = 7.9-12.3) to 20.3% (95% CI = 17.3-23.2) over the study period. Cannabinoid hyperemesis syndrome (n = 87, 2.8%) emerged from 2015. Deaths accounted for 0.2% of all AEs (4 men and 3 women aged on average 35 years). A chronic pattern of cannabis use was reported in 4 of them (intracranial hypertension in the context of lung cancer, suicide, cerebral haematoma, neonatal death with concomitant chronic alcohol use), while in the other cases the toxicological analysis identified cannabis use (ruptured aneurysm and unknown aetiology).

CONCLUSION

This study showed a multitude of AEs related to recreational cannabis use, including unexpected AEs and deaths. It highlights the problem of dependence and the emergence of cannabinoid hyperemesis syndrome.

The Impact of Cannabis Consumption on Mortality, Morbidity, and Cost in Acute Pancreatitis Patients in the United States: A 10-Year Analysis of the National Inpatient Sample

OBJECTIVES

The aim of this study was to identify the prevalence of cannabis use among all patients admitted with acute pancreatitis (AP) in the United States and to investigate the impact of cannabis use on AP mortality, morbidity, and cost of care.

METHODS

The National Inpatient Sample database from 2003 to 2013 was queried for all patients with AP and active exposure to cannabis. Outcomes included in-hospital mortality, length of stay, inflation adjusted charges, acute kidney injury, acute respiratory distress syndrome, and shock. Results were adjusted for age, sex, race, Charlson comorbidity index, median income quartile, and hospital characteristics.

RESULTS

More than 2.8 million patients with AP patients were analyzed. Cannabis-exposed (CE) patients' prevalence was 0.3%. Patients exposed to cannabis were younger and mostly males compared with non-cannabis-exposed patients. After adjusting for these factors, the CE group had significantly lower inpatient mortality compared with the noncannabis group (odds ratio, 0.17; 95% confidence interval, 0.06-0.53). Cannabis-exposed patients also had decreased length of stay, inflation-adjusted charges, acute kidney injury, ileus, shock, acute respiratory distress syndrome, and parenteral nutrition requirement.

CONCLUSIONS

Cannabis-exposed hospitalized patients with AP had lower age-adjusted, mortality, morbidity, and hospitalization-cost than non-cannabis-exposed patients.

A Rare Case of Cannabis-induced Acute Pancreatitis

Acute pancreatitis is a sudden inflammatory condition of the pancreas, caused mainly by gallstones and alcohol abuse. A significant proportion of acute pancreatitis cases remain idiopathic. Recent reports have highlighted cannabis use as an etiology of acute pancreatitis. A few case reports are available that report the association of cannabis with acute pancreatitis. Considering the global use of cannabis medically and illicitly, it becomes imperative to explore this adverse effect of cannabis use especially in idiopathic cases of acute pancreatitis. Here, in this report, we present a case of acute pancreatitis with no obvious cause. The patient was a 48-year-old female with no history of alcohol use. She had a history of cholecystectomy with normal serum triglycerides and calcium levels. The patient was consuming marijuana (cannabis) daily for the last three years. The diagnosis of cannabis-induced acute pancreatitis was made in the patient after other causes were excluded. It is difficult to distinguish cannabis-induced pancreatitis as there are no clear and specific associated clinical features. The diagnosis of cannabis-induced pancreatitis becomes even more challenging due to the use of multiple drugs. It becomes difficult to point out the causative agent among the multitude of drugs. Hence, a detailed history of drug intake in cases of acute pancreatitis may help to identify the candidature of the drugs in the pathogenesis of the disease. In view of the increasing illicit and medical use of cannabis, it becomes quintessential for clinicians to consider pancreatitis as a possible adverse effect of cannabis.

Cannabis Use Is Associated With Increased Risk of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: Analysis of the US Nationwide Inpatient Sample Database, 2004-2014

OBJECTIVE

The aim of this study was to investigate the impact of cannabis on post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP).

METHODS

The US Nationwide Inpatient Sample was queried to identify patients who underwent endoscopic retrograde cholangiopancreatography pancreatitis from 2004 to 2014. Cannabis use was identified by International Classification of Diseases, Ninth Edition codes, and patients in remission were excluded. Poisson regression models were used to derive adjusted incidence risk ratios (IRRs) for outcomes.

RESULTS

Among 37,712 patients with PEP, 0.4% had documented cannabis use disorder. From 2004 to 2014, the rate of PEP and cannabis use increased (8.9%-11.0% [P < 0.01] and 0.20%-0.70% [P < 0.01], respectively). Univariate analysis demonstrated cannabis was associated with increased risk of PEP (IRR, 1.70; 95% confidence interval [CI], 1.50-1.90; P < 0.01). On multivariate analysis, cannabis use was an independent predictor of PEP (IRR, 1.2; 95% CI, 1.1-1.4; P = 0.004). Cannabis was not associated with in-hospital death (IRR, 0.15; 95% CI, 0.02-1.04; P = 0.06) but was associated with shorter hospital stay (IRR, 0.96; 95% CI, 0.94-0.98; P < 0.001) and lower costs (IRR, 0.91; 95% CI, 0.91-0.92; P < 0.001).

CONCLUSIONS

Cannabis use was associated with an increase in PEP without significant increase in mortality.

Is There an Effect of Cannabis Consumption on Acute Pancreatitis?

BACKGROUND AND AIM

Twenty-percentage of acute pancreatitis (AP) cases is labeled as idiopathic. Cannabis remains the most frequently used illicit drug in the world. The aim of this study was to identify the prevalence of cannabis use among all patients with a first episode of AP, particularly in those labeled as idiopathic etiology, and determine any effect on AP severity.

METHODS

Retrospective cohort of all consecutive patients admitted with a first episode of AP at a large tertiary referral hospital from 01/2013 through 12/2014. AP was identified by ICD9 code, or lipase ≥ 3 times the upper limit of normal and abdominal pain consistent with AP. Cannabis users (CU) were identified via history or urine toxicology.

RESULTS

Four hundred and sixty patients were included. 54% were men, with a mean age of 48 years (range 17-89 years). Forty-eight patients (10%) were identified as CU. After adjusting for admission SIRS, age, and gender, cannabis use was not found to be an independent risk factor for persistent SIRS, AKI, ARDS, pancreatic necrosis, mortality, ICU admission, length of stay, in-hospital infections, nor recurrent AP. Of note, AKI was least common among non-CU compared to CU (OR 0.4; p = 0.02; CI 0.2-0.9) and non-CU had a higher admission BISAP score (≥ 2) compared to CU (OR 2.5; p = 0.009; CI 1.2-4.9).

CONCLUSION

This is the largest study to date examining cannabis use in AP. Cannabis use was found across almost all etiologies of AP with a prevalence of 10% (48 cases), and in 9% (9 cases) of so-called idiopathic AP cases in this cohort, which could account as an association for approximately 2% of all AP cases. Cannabis use did not independently impact AP severity or mortality.