S39 A Systematic Review of Cannabis-Induced Acute Pancreatitis: Is "HASH"ing Out the New Increasingly Common Culprit of Pancreatitis?

Introduction: Cannabis is the most frequently used illicit drug in the world. Grant et al. first reported cannabis-induced acute pancreatitis (AP) in 2004. However, after the legal or decriminalized status of cannabis in almost half of the United States, AP could be increasingly recognized in clinical practice. This systematic review aims to increase community awareness by summarizing available clinical evidence on cannabis-related AP. Methods: A systematic search of MEDLINE, Embase, Scopus, and Cochrane was conducted for English-only articles, published between inception and June 15, 2022. Abstracts from major gastroenterology conferences and bibliography lists of relevant studies were also screened. Search terms were "cannabis" and "acute pancreatitis," with all available permutations. The diagnosis of AP was made by fulfilling 2 of the 3 criteria of the Revised Atlanta Classification. Cannabis-induced AP was designated by active cannabis use based on physician or patient reports, or urine drug testing, and the exclusion of alternative causes of AP. Three authors reviewed each paper for eligibility. The search resulted in 298 hits, but 34 articles fulfilled the inclusion criteria, dating from 2004 to 2022. Results: A total of 37 patients with cannabis-induced AP were identified. The mean age of patients was 29.66 ± 10.24 years (range: 16-48 years), with 86% of patients being below age 35. In terms of gender distribution, 89% of cases were reported in males. A temporal relationship between cannabis use and AP onset or cannabis cessation and AP symptom resolution was noted in 64% of patients. Most patients had no comorbidities, and alternative causes were meticulously excluded. Cannabis relapse and recurrent AP were found in 36% of cases. In 32% of patients, cannabis cessation resulted in no recurrent AP. Conclusion: We reiterate that the cannabis use can be an underdiagnosed etiology for AP. The pathogenesis of this causal relationship remains controversial. Notably, cannabis-related AP has often been encountered in young patients. This trend has clear clinical implications as cannabis status changes may exorbitantly increase the occurrence of AP in coming years. Therefore, clinicians should remain cognizant of AP in cannabis users, especially young patients presenting with abdominal pain. Toxicology screening may aid in early diagnosis. Naranjo score can help in causality assessment (Table). Permanent cannabis cessation is imperative in avoiding recurrent AP. Table 1. - Naranjo assessment scale depicting a score of 10 in a case of cannabis-induced pancreatitis (definitive) Naranjo Adverse Drug Reaction Probability Scale Questions Yes No Do not know Patient’s score 1. Are there previous conclusive reports on this reaction? +1 0 0 +1 2. Did the adverse event appear after the suspected drug was administered? +2 -1 0 +2 3. Did the adverse reaction improve when the drug was discontinued or a specific antagonist was administered? +1 0 0 +1 4. Did the adverse event reappear when the drug was re-administered? +2 -1 0 +2 5. Are there alternative causes (other than the drug) that could on their own have caused the reaction? -1 +2 0 +2 6. Did the reaction reappear when a placebo was given? -1 +1 0 7. Was the drug detected in blood (or other fluids) in concentrators known to be toxic? +1 0 0 +1 8. Was the reaction more severe when the dose was increased or less severe when the dose was decreased? +1 0 0 +1 9. Did the patient have a similar reaction to the same or similar drugs in any previous exposure? +1 0 0 10. Was the adverse event confirmed by any objective evidence? +1 0 0 Total score 10 Note: A score of < 1 is doubtful, 1–4 possible, 5–8 probable, and >9 is definitive for adverse drug reaction.