BACKGROUND Intestinal ischemia has been described in case reports of patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease (coronavirus disease 19, COVID-19). AIM To define the clinical and histological, characteristics, as well as the outcome of ischemic gastrointestinal manifestations of SARS-CoV-2 infection. METHODS A structured retrospective collection was promoted among three tertiary referral centres during the first wave of the pandemic in northern Italy. Clinical, radiological, endoscopic and histological data of patients hospitalized for COVID-19 between March 1 st and May 30 th were reviewed. The diagnosis was established by consecutive analysis of all abdominal computed tomography (CT) scans performed. RESULTS Among 2929 patients, 21 (0.7%) showed gastrointestinal ischemic manifestations either as presenting symptom or during hospitalization. Abdominal CT showed bowel distention in 6 patients while signs of colitis/enteritis in 12. Three patients presented thrombosis of main abdominal veins. Endoscopy, when feasible, confirmed the diagnosis (6 patients). Surgical resection was necessary in 4/21 patients. Histological tissue examination showed distinctive features of endothelial inflammation in the small bowel and colon. Median hospital stay was 9 d with a mortality rate of 39%. CONCLUSION Gastrointestinal ischemia represents a rare manifestation of COVID-19. A high index of suspicion should lead to investigate this complication by CT scan, in the attempt to reduce its high mortality rate. Histology shows atypical feature of ischemia with important endotheliitis, probably linked to thrombotic microangiopathies.

Purpose Pulmonary embolism (PE) in COVID-19 patients can play a key role in precipitating clinical conditions. We aimed to evaluate PE distribution on CTA and to investigate any possible association with D-dimer (DD), pulmonary stage of disease and prognosis. Method COVID-19 patients of two affiliated Hospitals, undergone a CTA examination for PE suspicion, were retrospectively enrolled. Comorbidities, laboratory tests and clinical outcomes (hospitalization, discharge, death) were assessed. A parenchymal stage (early, progressive, peak, absorption) for lung involvement was assigned. Results A cohort of 114 patients (mean age 61 years; 26.3% females) with severe COVID-19 pneumonia were evaluated. At last follow-up 25 (21.9%) were hospitalized, 72 (63.2%) discharged, 17 (14.9%) dead. Eighty-eight patients (77.2%) had at least one comorbidity, being cardiovascular ones the most frequent (44.7%). CTA revealed PE in 65 patients (57%), with concomitant pulmonary trunk and/or main arteries involvement in 16.9%. PE defects were ubiquitous in 18.5% of cases. The predominant parenchymal stages were the progressive (24.6%) and peak (67.7%). DD levels showed a significant correlation with PE occurrence and extent in pulmonary branches, despite anticoagulant therapies; trend of correlation with pulmonary stages was also noted. Conclusions PE is a frequent complication in severe COVID-19 patients, particularly during central parenchymal stages and despite ongoing anticoagulant therapy. CTA and DD levels play a crucial role in the assessment of suspected PE, despite anticoagulant therapies, along with proper information about lung involvement extent.

Purpose To report ischemic and haemorrhagic abdominal complications in a series of COVID-19 patients. To correlate these complications with lung involvement, laboratory tests, comorbidities, and anticoagulant treatment. Methods We retrospectively included 30 COVID-19 patients who undergone abdomen CECT for abdominal pain, between March 16 and May 19, 2020. Ischemic and haemorrhagic complications were compared with lung involvement (early, progressive, peak or absorption stage), blood coagulation values, anticoagulant therapy, comorbidities, and presence of pulmonary embolism (PE). Results Ischemic complications were documented in 10 patients (7 receiving anticoagulant therapy, 70%): 6/10 small bowel ischemia (1 concomitant obstruction, 1 perforation) and 4/10 ischemic colitis. Main mesenteric vessels were patent except for 1 superior mesenteric vein thrombosis. Two ischemia cases also presented splenic infarctions. Bleeding complications were found in 20 patients (all receiving anticoagulant treatments), half with active bleeding: hematomas in soft tissues (15) and retroperitoneum (2) and gastro-intestinal bleeding (3). Platelet and lymphocyte were within the normal range. d-Dimer was significantly higher in ischemic cases (p < 0.001). Most of the patients had severe lung disease (45% peak, 29% absorption), two patients PE. Conclusions Ischemic and haemorrhagic abdominal complications may occur in COVID-19 patients, particularly associated to extended lung disease. CT plays a key role in the diagnosis of these potentially life- threatening conditions.