Seasonal Variation in the Onset of Acute Pancreatitis Zakaur Rab Siddiqui et al

Original Article

Zakaur Rab Siddiqui*

Seasonal Variation in the Onset of Aatif Inam**
Muhammad Saaiq***
Acute Pancreatitis Niaz-ud-din****
Muhammad Zaheer*****
Shabana Jamal******
Background and Objectives: In the last few years, several studies have been Tanwir Khaliq*******
conducted to document the existence of seasonal variation in the onset of various Syed Aslam Shah********
diseases. Acute Pancreatitis is a common disorder with potentially devastating
consequences. The aim of the present study was to determine as to whether or not acute * Postgraduate Trainee
pancreatitis shows a rhythmic seasonal variation as well. ** Assistant Professor
Study Design: Descriptive study. *** Senior Registrar
**** Postgraduate Trainee
Place and Duration: Department of surgery, Pakistan Institute of Medical Sciences ***** Senior Registrar
(PIMS), Islamabad from October 01, 2005 to September 30, 2006. ****** Assistant Professor
Patients and Method: All patients presenting with acute pancreatitis in the period of ******* Associate Professor
study were included in the study. Diagnosis was made on the basis of clinical features, ******** Professor and Head,
physical examination, laboratory data (serum amylase greater than 5 times normal), Department of General Surgery,
ultrasonography, CT scan and peroperative findings in patients who underwent surgery. Pakistan Institute of Medical Sciences
(PIMS), Islamabad.
The month of each event were recorded both into four 3 months periods (according to
seasons) and into twelve One month intervals. For all subjects with acute pancreatitis the
presence or absence of the two leading specific risk factors (alcoholism and biliary tract
disease), was carefully investigated.
Results: Out of 121 patients, there was male predominance with a male: female ratio of
1.2:1. The mean age was 42+16.5. Around 82% of the patients presented in emergency with
pain, nausea and vomiting as the main symptoms. In 48 cases ( 39.7% ) the aetiological
factor for acute pancreatitis was gallstones while alcoholic pancreatitis was present in 15
cases (12.4%).Deaths from acute pancreatitis were 9 (4 males and 5 females), accounting for
7.4% mortality rate. Their mean age was 50±6 years, significantly higher than that of
survived subjects 44±17 years (p<0.05). Among the subgroups of fatal events, 3 had
gallstones (33.3%, P> 0.05) and 4 had chronic alcoholism (44.4%, P > 0.05). A peak of higher
frequency of events was found in the period September - December for the total samples
and in particular for males and subgroups of subjects with gallstones and chronic
alcoholism. The percentage of fatal events was significantly higher in October - December
(n =5), 37.2% of acute pancreatitis are observed in that period, and more than 50% of total
deaths occurred during the last three months of the year i.e. during the colder months. Address for Correspondence:
Dr. Zakaur Rab Siddiqui
Conclusion: This study shows the existence of a circannual variation in the onset of Postgraduate trainee
acute pancreatitis, with a significantly higher frequency of events in the monsoon and Department of Surgery
winter, especially for patients with cholelithiasis or alcoholism. Moreover, events occurring Pakistan Institute of Medical Sciences
during the colder months seem to be characterized by a higher mortality rate. Islamabad.
Key Words: Acute Pancreatitis, Seasonal variations. E-mail: drzaka2003@yahoo.com

characterized by an acute onset and treated by

Introduction the emergency department, including paralysis of
It is shown in many studies that circannual cranial nerves,7 microcristalline arthritis,8 herpes
variation exists in the onset of several diseases, zoster infection, epistaxis,10 urinary retention.11 In
9

especially those characterized by an abrupt onset,
for example, fatal pulmonary embolism1, 2 ischemic
and hemorrhagic stroke3, 4 and rupture of aortic
aneurysms5, 6. Seasonal specific patterns have also
been reported for a series of miscellaneous diseases
the last few years several studies have investigated
gastroenterologic diseases and seasonal etiological
patterns have been reported for the onset of peptic
ulcer12-15 and exacerbation of inflammatory bowel
diseases16-18.

Ann. Pak. Inst. Med. Sci. 2007; 3(3): 171-174 171

Seasonal Variation in the Onset of Acute Pancreatitis Zakaur Rab Siddiqui et al

The aim of this study was to determine the carefully investigated.

clinical pattern of acute pancreatitis with special
reference to aetiology, seasonal variation in the
occurrence and outcome in our set up.
Patients and Method
This descriptive study was undertaken at the
department of surgery, Pakistan Institute of Medical
Sciences (PIMS), Islamabad from October 01, 2005 to
September 30, 2006. PIMS is a 1200 bedded tertiary
care hospital receiving patients from the twin cities of
Islamabad and Rawalpindi, Azad Jammu Kashmir and
upper Punjab. The study prospectively included 121
adult patients of either sex by convenience sampling
technique. All patients presenting with acute pancreatitis
in the period of study were included in the study.
Diagnosis was always made on the basis of clinical
features, physical examination, laboratory data (serum
amylase greater than 5 times normal), sonography, CT
scan and preoperative findings among patients who
underwent surgical exploration. The month of each
event were recorded both into four 3 - month periods
(according to seasons) and into twelve one month
intervals. For all subjects with acute pancreatitis the
presence or absence of the two leading specific risk
factors (alcoholism and biliary tract disease), was
Results
Out of 121 patients, there was male
predominance with a male: female ratio of 1.2:1. The
mean age was 42+16.5 years. Most of the patients
(82%) presented in emergency with pain, nausea and
vomiting as the main symptoms. In 48 cases (39.7%)
the aetiological factor for acute pancreatitis was
gallstones while alcoholic pancreatitis was present in
15 cases (12.4%). Deaths from acute pancreatitis
were 9 (4 males and 5 females), accounting for 7.4%.
Among the subgroups of fatal events, 3 had gallstones
(33.3%, P>0.05), and 4 had chronic alcoholism (44.4%,
P>0.05). Table I shows the monthly distribution by
gender and subgroups by risk factors. The peak of
frequency of acute attacks of pancreatitis was noted
in the period of September - December for the total
samples (Table II). Biliay pancreatitis showed peak
in July, October and December while alcoholic
pancreatitis showed the first peak in the months of
July and August and the second peak in October-
December (Table I). The percentage of fatal events was
significantly higher in October - December (n = 5) and
more than 50% of total deaths occurred during the
colder months.

Table I: Monthly Distribution of Acute Pancreatitis by Gender and Risk Factors

Males Females Biliary Tract Disease Alcoholism Fatal Cases

Total
Month (n = 67, (n = 54, (n = 48, (n = 15, (n = 9,
(n = 121)
55.4%) 44.6%) 39.7%) 12.4%) 7.4%)

January 08(6.6%) 05(7.5%) 03(5.6%) 02(4.2%) 01(6.7%) 1(11.1%)

February 06(5.0) 03(4.5) 03(5.6) 03(6.2) 01(6.7) 0

March 06(5.0) 02(3.0) 04(7.4) 01(2.0) 0 0

April 05(4.1) 03(4.5) 02(3.7) 01(2.0) 0 1(11.1)

May 07(5.8) 04(6.0) 03(5.6) 03(6.2) 0 0

June 07(5.8) 06(9.0) 01(1.9) 03(6.2) 01(6.7) 0

July 10(8.3) 06(9.0) 04(7.4) 06(12.5) 02(13.3) 0

August 12(9.9) 04(6.0) 08(14.8) 04(8.3) 03(20.0) 1(11.1)

September 14(11.6) 08(11.9) 06(11.1) 05(10.4) 01(6.7) 1(11.1)

October 14(11.6) 05(7.5) 09(16.7) 08(16.7) 02(13.3) 2(22.2)

November 15(12.4) 11(16.4) 04(7.4) 04(8.3) 02(13.3) 1(11.1)

December 17(14.0) 10(14.9 ) 07(13.0) 08(16.7) 02(13.3) 02(22.2)

Ann. Pak. Inst. Med. Sci. 2007; 3(3): 171-174 172

Seasonal Variation in the Onset of Acute Pancreatitis
Table II: Seasonal Distribution of Acute Pancreatitis
January-March
n (%)
n (%)
Total 121(100%) 20(16.5)
Fatal cases 9(7.4) 01(11.1)
Discussion
Early identification of patients with acute
pancreatitis is important as in severe attacks there is
increased risk of death.
To our knowledge, there were only a few
recent studies in medical literature, which aimed to
evaluate the seasonal variation in the onset of acute
pancreatitis.19 In a study by Lankisch PG et al19 a total
of 263 cases were observed for a period of 9 years in a
German hospital, no correlation between admissions
and a specific month or season was found, other earlier
reports were mostly hypotheses.20, 21 However, a study
by Gallerani M et al22 instead showed a clear seasonal
variation in the onset of acute pancreatitis characterized
by a higher frequency in the spring, with a maximum
morbidity and mortality in November to December. This
pattern was particularly evident for patients with
cholelithiasis and chronic alcoholism. Similarly, seasonal
peak was noted by Saead AA et al23 and Räty S et al24
in the winter season. Our study also showed a peak
in the onset of disease in the months of July-August
and September-December i.e. in the monsoon and
winter season. It is difficult to give a definite explanation
for such a temporal pattern. Seasonal and circannual
patterns have been reported for the prevalence of
Helicobacter pylori infection14, or for relapses of
inflammatory bowel disease23. Also in low temperature
in tropics increased incidence of acute pancreatitis has
been documented25.
At present we do not know enough about
seasonal biological changes potentially affecting onset
of acute pancreatitis, e.g., secretion of pancreatic
enzymes, biliary acids. However, it is possible that
variations in physiological functions with seasonal
change may be associated with an increased risk of
colder months (October-December). This is particularly
interesting when considering that both the mean age of
subjects and the incidence of risk factors (gallstones,
alcoholism) in the subgroup of fatal cases were higher
compared with those in the subgroup of non fatal
events. Thus, it seems that acute events of pancreatitis
occurring in the colder months may be more at risk
in terms of severity and mortality. However it is
recommended that there is need for further studies on
Ann. Pak. Inst. Med. Sci. 2007; 3(3): 171-174
Zakaur Rab Siddiqui et al
April-June July-September October-December
n (%) n (%) n (%)
19(15.7) 36(29.7) 46(38.0)
01(11.1 ) 02(22.2) 05(55.6)
larger samples as to further elucidate these findings.
Conclusion
This study shows the existence of a circannual
variation in the onset of acute pancreatitis, with a
significantly higher frequency of events in the monsoon
and winter, especially for patients with cholelithiasis or
alcoholism. Moreover, events occurring during the
colder months seem to be characterized by a higher
mortality rate.
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