Severe bowel complications in SARS-CoV-2 patients receiving protocolized care

Abstract

Introduction and aims A case series of ten patients that received protocolized care for SARS-CoV-2 infection and developed severe gastrointestinal complications, is presented. The aim of our study was to contribute to the ongoing discussion regarding gastrointestinal complications related to SARS-CoV-2 infection. After reviewing the current literature, ours appears to be the first detailed case series on the topic. Materials and methods A retrospective filtered search of all patients admitted to our hospital for SARS-CoV-2 infection, who developed severe gastrointestinal complications, was performed. All relevant data on hospital patient management, before and after surgery, were collected from the medical records. Results Of the 905 patients admitted to our hospital due to SARS-CoV-2 infection, as of August 26, 2020, ten of them developed severe gastrointestinal complications. Seven of those patients were men. There were four cases of perforation of the proximal jejunum, three cases of perforations of the ascending colon, one case of concomitant perforation of the sigmoid colon and terminal ileum, one case of massive intestinal necrosis, and one preoperative death. Three right colectomies, four intestinal resections, one Hartmann’s procedure with bowel resection, and one primary repair of the small bowel were performed. The mortality rate of the patients analyzed was 50%. Conclusion Spontaneous bowel perforations and acute mesenteric ischemia are emerging as severe, life-threatening complications in hospitalized SARS-CoV-2 patients. More evidence is needed to identify risk factors, establish preventive measures, and analyze possible adverse effects of the current treatment protocols.

Acute Mesenteric Ischemia in COVID-19 Patients

“…Gastrointestinal features in COVID-19 disease are relatively frequently reported, varying from less than 10% in early studies from China [ 7 , 8 ] to 30–60%, in other reports [ 9 , 10 ]. In an extensive study on 1992 hospitalized patients for COVID-19 pneumonia from 36 centers, Elmunzer et al [ 7 ] found that the most frequent clinical signs reported were mild and self-limited in up to 74% of cases, consisting of diarrhea (34%), nausea (27%), vomiting (16%), and abdominal pain (11%).…”

“…However, the significance of fecal elimination of viral ARN is still not fully understood in the transmission chain of the SARS-CoV-2 infection. On the other hand, disturbance of lung-gut axis, prolonged hospitalization in ICU, and the pro coagulation state induced by SARS-CoV-2 endothelial damage was incriminated for bowel ischemia, resulting in intestinal necrosis and perforation [ 8 , 9 , 15 ]. Early recognition and treatment of gastrointestinal ischemia are extremely important, but it is often challenging in hospitalized COVID-19 patients with severe illness.…”

Intestinal ischemia in COVID-19 patients: A case series

“…By international consensus, as recorded in treatment guidelines by both the WHO and the NIH, corticosteroids are incorporated in the standard care protocol for COVID-19 [55,56]. Although no evidence suggests an increased risk in intestinal ischemia due to steroid therapy, increased risk of gastrointestinal perforation and an increased mortality and morbidity in the context of bowel perforation and bowel surgery has been described [39]. In our series, two patients developed anastomotic or stump leakage after surgery, one of whom was receiving corticosteroids at the time of ischemia.…”

How the COVID-19 pandemic affected the severity and clinical presentation of diverticulitis

“…Furthermore, our findings can also be attributed to COVID-19 having extrapulmonary manifestations. For example, several studies showed that COVID-19 enters digestive cells through ACE-2 receptors and can cause a myriad of responses, such as inflammation and gut microbial dysbiosis [ 16 , 17 ]. Case reports have even reported that COVID-19 can exacerbate underlying gastrointestinal ailments, leading to complications, such as bowel perforation [ 11 , 17 ].…”