key: cord-0724597-p4wvnnhp
authors: Hassan, Wesam; Ramadan, Haidi Karam-Allah
title: COVID-19 and Pneumatosis Intestinalis: An Early Sign of Intestinal Ischemia
date: 2020-11-05
journal: Dig Liver Dis
DOI: 10.1016/j.dld.2020.10.036
sha: 2a8a5889e76ebc5dc5e09ba4ba66dd95aecf1300
doc_id: 724597
cord_uid: p4wvnnhp

nan

Intestinal ischemia in association with COVID-19 had been recently reported. In this journal, Norsa et al recently described the case of a patient with extensive intestinal ischemia [1] , in which they emphasized the need of clinicians to be aware of this complication and suggested the occurrence of COVID-19-induced thromboembolism in that case. Although pneumatosis intestinalis (PI) is a rare radiological sign characterized by the presence of gas in the bowel wall, it can be a sign of impending intestinal ischemia. Furthermore, the presence of portal or portomesentric venous gas along with PI is an ominous sign indicating transmural bowel necrosis [2] . PI is generally diagnosed by abdominal radiography, especially abdominal computed tomography (CT), which reveals gas-filled cysts in the submucosa/serosa of the intestine. The pathogenesis of PI is usually explained by either mechanical theory or bacterial theory. The mechanical theory hypothesizes direct diffusion of intraluminal bowel gas through the intact intestinal mucosal membrane due to increased intraluminal pressure as in blunt trauma, ileus, or pseudo-obstruction. The bacterial theory proposes that gas-forming bacteria enter the submucosa through mucosal breaks as in bowel inflammation, infection, bowel ischemia, or necrosis [3] . COVID-19 virus can cause PI by direct injury of mucosa of the gastrointestinal tract through its attachment to the angiotensin-converting enzyme receptors (ACER2), which are abundantly expressed on enterocytes [4] , or by disruption of the normal colonic gut flora or by bowel ischemia due to thromboembolic complications [5] [6] [7] [8] .

Bhayana et al. reported in their radiological study about four patients with COVID-19 with pneumatosis or portal venous gas observed in abdominal CT. Three of those patients had frank bowel infarction at laparotomy, and one patient with gas in the transverse mesocolon in CT had a corresponding patchy yellow discoloration of the antimesenteric transverse colon of unknown origin [9] .

Herein, we summarize a few recent reports that have described the association of PI with COVID-19 (Table 1 ) [5] [6] [7] [8] . The mean age of the patients was 59 ± 16 years, all patients were males, one of them had no comorbidities, and two patients had abdominal pain. Marked elevation of D-dimer level was observed in one patient. Extensive PI was detected in one patient in the small and large intestines, and two patients had free intraperitoneal air. Portal vein gas was prominent in one patient, and although surgery was indicated in this patient, a conservative approach was undertaken as the blood flow was normal in the superior mesenteric artery origin, and the patient recovered. One patient had renal transplantation and multiple comorbidities; however, his condition improved with the conservative management. In all patients, conservative management with bowel rest, antibiotics, intravenous fluid, or heparin infusion was successful.

Management of PI depends on the overall assessment of patients, considering medical and surgical history, clinical examination, laboratory assessment, and imaging are important in determining the treatment approach. Although PI management is generally conservative, surgery is indicated in complicated cases of perforation, peritonitis, abdominal sepsis, and failed conservative management [10] .

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Toubia [5] Meini et al [6] Kietly et al [ 

Intestinal ischemia in the COVID-19 era

Portal venous gas and pneumatosis intestinalis: ominous findings with an idiopathic aetiology

Pneumatosis intestinalis in the adult: benign to lifethreatening causes

Evidence for gastrointestinal infection of SARS-CoV-2

Pneumatosis Intestinalis in COVID-19

Pneumatosis intestinalis in COVID-19

Extensive pneumatosis intestinalis and portal venous gas mimicking mesenteric ischaemia in a patient with SARS-CoV-2. The Annals of The

Pneumatosis intestinalis in a patient with COVID-19

Abdominal imaging findings in COVID-19: preliminary observations

The spectrum of pneumatosis intestinalis