Multimodal ultrasound imaging with conventional B-mode, elastography, and parametric analysis of contrast-enhanced ultrasound (CEUS): A novel approach to assess small bowel manifestation in severe COVID-19 disease

Abstract

The aim was to describe the small bowel morphology with conventional B-mode and elastography and additionally to evaluate dynamic effects of COVID-19 associated small bowel microvascularization using CEUS with color coded perfusion parameters. Thirteen patients with severe COVID-19 acute respiratory distress syndrome (ARDS) were investigated. 13 patients required intensive care treatment with mechanical ventilation. Five patients required extracorporeal membrane oxygenation (ECMO). Contrast-enhanced ultrasound (CEUS) was performed by an experienced investigator as a bolus injection of up to 2.4 ml sulfur hexafluoride microbubbles via a central venous catheter. In the parametric analysis of CEUS, the flare of microbubbles over time is visualized with colors. This is the first work using parametric analysis of CEUS to detect perfusion differences in the small bowel. Parametric analysis of CEUS in the intestinal phase was carried out, using DICOM loops for 20 seconds. In 5 patients, parametric analysis revealed intraindividual differences in contrast agent behavior in the small bowel region. Analogous to the computed tomography (CT) images parametric analysis showed regions of simultaneous hyper- and hypoperfusion of the small intestine in a subgroup of patients. In 5 patients, the parametric image of transmural global contrast enhancement was visualized. Our results using CEUS to investigate small bowel affection in COVID-19 suggest that in severe COVID-19 ARDS systemic inflammation and concomitant micro embolisms may lead to disruption of the epithelial barrier of the small intestine. This is the first study using parametric analysis of CEUS to evaluate the extent of small bowel involvement in severe COVID-19 disease and to detect microemboli. In summary, we show that in COVID-19 the small bowel may also be an important interaction site. This is in line with the fact that enterocytes have been shown to a plenitude of angiotensin converting enzyme (ACE)-2 receptors as entry sites of the virus.

Morphology and Function of Red Blood Cells in COVID-19 Patients: Current Overview 2023

“…Loss of RBC deformability and/or increased aggregability favors the development of thrombotic processes in the microcirculation [18,52]. This has previously been described in COVID-19 patients [10,53], especially when platelets are also activated [54][55][56]. Loss of RBC deformability and/or increased aggregability favors the development of thrombotic processes in the microcirculation [18,52].…”

“…Loss of RBC deformability and/or increased aggregability favors the development of thrombotic processes in the microcirculation [18,52]. This has previously been described in COVID-19 patients [10,53], especially when platelets are also activated [54][55][56].…”

Current Developments and Role of Intestinal Ultrasound including the Advent of AI

“…The parametric imaging CEUS potential has also been explored by Tews H. et al in patients with severe COVID-19 disease to evaluate the presence of small bowel barrier disruption or microemboli. They found two subsets of patients, one showing early contrast enhancement in the bowel wall layers probably as an expression of systemic inflammation, and the other showing delayed contrast enhancement as an expression of microembolization-related hypoperfusion [66].…”

Oral manifestations of COVID-19: A review

“…Investigations were conducted on 13 patients who had severe acute respiratory distress syndrome (ARDS) caused by COVID-19. In conclusion, it was demonstrated that the small bowel may also be a critical interaction location in COVID-19 [29]. antibiotics, systemic acyclovir, and photo biomodulation therapy (PBMT) were recommended for oral lesions [30].…”