key: cord-1052952-xlmyt3zy authors: Ignat, Mihaela; Philouze, Guillaume; Aussenac-Belle, Lucie; Faucher, Vanina; Collange, Olivier; Mutter, Didier; Pessaux, Patrick title: Small bowel ischemia and SARS-CoV-2 infection: an underdiagnosed distinct clinical entity date: 2020-05-04 journal: Surgery DOI: 10.1016/j.surg.2020.04.035 sha: be4e7c32132debde8b16a6da4c7d029066d63957 doc_id: 1052952 cord_uid: xlmyt3zy nan Gastrointestinal symptoms have been described in up to 39% of SARS-CoV-2 infected patients (1). Evidence for SARS-CoV-2 gastrointestinal infection was already demonstrated in a series of 73 patients, with 53% of patients tested positive for SARS-CoV-2 RNA in stool, possibly by the mediation through the viral host receptor ACE2, which stained positive in the cytoplasm of gastrointestinal epithelial cells (2) . This data suggests that the virus can actively replicate in the bowel, but the computed tomography (CT) rendering of the gastrointestinal infection and its significance for the natural history of the disease remain unclear. This is a retrospective case series of 3 SARS-CoV-2 infected patients who developed an acute abdomen during the COVID-19 outbreak in Strasbourg (France) in March 2020. The lack of knowledge concerning CT findings of SARS-CoV-2 gastrointestinal infection and the prognosis of such findings presented a challenge when deciding whether or not to operate these highly frail patients. Patients included: a 28-year-old woman (Patient 1), and two men aged 56 and 67 years (Patient 2 and Patient 3, respectively). Their medical history was the following: none for patient 1 (P1); high blood pressure, obesity (BMI of 39), and diabetes for Acute abdomen was inaugural in P1, with abdominal pain and vomiting. Clinical examination showed abdominal guarding. Abdominal CT-scan was performed and showed superior mesenteric and portal vein thrombosis, and no sign of ischemia ( Figure 1A ). There were also signs of segmental portal hypertension with gastric varices and portal cavernoma evocative of a previous episode of thrombosis. Anticoagulation was started, with an initial good evolution, followed by a sudden increase in abdominal pain and generalized abdominal contracture on day 5 of the medical treatment. There was no respiratory sign at this point in the evolution. Abdominal CT-scan was performed, demonstrating segmental small bowel ischemia ( Figure 1B ). Emergency surgery was performed, confirming an 80cm long jejunal ischemia. Bowel resection and temporary laparostomy were performed. A second-look procedure was performed 48 hours later, and allowed for a double jejunostomy and abdominal wall closure. The postoperative course was complicated by an acute respiratory distress syndrome on day 1 and SARS-CoV-2 infection was diagnosed. The evolution in the Intensive Care Unit (ICU) was subsequently good and the patient was discharged from ICU on day 7. The diagnosis of essential thrombocythemia was established. Pathological findings confirmed the presence of transmural necrosis with several thrombi in the lamina propria and in the submucosa ( Figure 1C ). The patient could be discharged on postoperative day 17. Patients 2 and 3 were admitted for acute respiratory distress syndrome (ARDS). The SARS-CoV-2 infection was confirmed on admission both by means of RT-PCR from nasopharyngeal swabs and thoracic CT-scan, which demonstrated bilateral viral pneumonia. They were admitted to the ICU, and intubated rapidly. After an initial good evolution, both patients presented with a brutal degradation, multiple organ 5 failure, and hemodynamic instability necessitating high doses of noradrenalin, respectively on day 9 (P2), and on day 6 (P3) from ICU admission. The abdominal clinical exam was nevertheless normal (of note, patients were under sedation and curare). CT of the abdomen and thorax was performed. In patient 2, CT findings were suggestive of ischemia of the first bowel loop, with mesenteric venous gas. However, a permeable arterial axis was observed ( Figure 1D ). Emergency surgery was performed. The bowel was thickened on a 30cm long bowel loop, which was centered by 2 areas of transmural necrosis. Bowel resection and laparostomy were performed. A second-look procedure and double ostomy were performed 48 hours later. Pathological findings confirmed the inflammatory necrosis of the mucosa, which was completely replaced by phantom cells. Several blood clots were seen in the lamina propria and in the submucosa, and the parietal layers were dissociated due to edema and inflammatory infiltrates ( Figure 1E ). The postoperative course was slowly favorable, despite the presence of acute renal failure necessitating dialysis. Patient 2 was still in the ICU at the time of manuscript submission. In patient 3, CT-scan findings were suggestive of an inflammatory segmental ileitis with a localized thickening of one small bowel loop and edema ( Figure 1F ). Decision to continue medical treatment and not to perform exploratory laparotomy was made for P3, not only based on the CT findings suggestive of an uncomplicated bowel inflammation, but also on his burdened medical history and respiratory status. The evolution led to exitus in the next 24 hours. This study describes the clinical and the CT features of 3 patients presenting with an acute abdomen induced by SARS-CoV-2 infection. In two patients, the clinical exam 6 was strictly normal, and this did not exclude major bowel complications. This suggests that abdominal CT should be systematically performed in patients with an unexplained degradation of their status after an initial good evolution. In patient 1, the mesenteric and portal vein thrombosis shown by the first CT was a few days later followed by intestinal transmural necrosis, in spite of effective anticoagulation. In patients 1 and 2, the presence of micro-thrombi and inflammatory infiltrates seemed to be at the origin of the ischemic event, as the rest of the bowel was strictly normal (i.e. with no sign of generalized low flow). Consequently, questions are raised regarding the natural history of bowel inflammation towards ischemia in the presence of SARS-CoV-2 infection. COVID-19 might also favor a hypercoagulation status, thrombi formation and ischemia, as recently advocated for the etiology of acro-ischemia (3) . Mucosal ischemia might further induce a massive spread of the viruses from the bowel epithelium (2) and this could be the cause of the patients' deterioration. This assumption should be further investigated. However, these findings advocate for a reactive approach with early abdominal CT in patients with unexplained worsening status during COVID-19. Exploratory laparotomy and potentially bowel resection should be further considered if signs of small bowel involvement were detected. Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan Evidence for gastrointestinal infection of SARS Coagulopathy and Antiphospholipid Antibodies in Patients with Covid-19 Figure 1. Abdominal CT-scan and pathological findings in SARS-CoV-2 infected patients A. CT-scan shows mesenteric and portal vein thrombosis (arrowheads) in a young female patient (P1) with essential thrombocythemia, as a first sign and prior to respiratory symptoms revealing CT-scan shows bowel infarction in the first bowel loop (arrowheads), 5 days after admission of the P1, prompting emergency laparotomy and bowel resection Pathological findings of P1 (Hematoxylin and eosin stain, 200 X magnification): small bowel necrosis; arrowheads show micro-thrombi in the lamina propria and the submucosa CT-scan shows signs of bowel ischemia (arrowheads) and mesenteric venous gas (arrow) in the proximal jejunum in a 56-year-old male patient (P2) with acute respiratory distress syndrome (ARDS) Pathological findings of P2 (Hematoxylin and eosin stain, 200 X magnification): small bowel necrosis; arrowheads show micro-thrombi and arrow shows edema and inflammatory infiltrates in the submucosa -scan shows an inflammatory bowel loop with thickening and edema (arrowhead) in a 67-year-old male patient with acute respiratory distress syndrome (ARDS) The authors would also like to thank Guy Temporal for the English editing and proofreading.Author Contributions: All authors had full access to all data in the study and take responsibility for the integrity of the data. Funding / Support: none.