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Bowel Ischemia in COVID-19 Infection: One-Year Surgical Experience
John O Hwabejire1, Haytham M A Kaafarani1, Hassan Mashbari1
1Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, 548305Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
Insights
COVID-19 can cause lethal bowel ischemia, a severe gastrointestinal complication. Surgical evaluation is crucial for patients with symptoms like vasopressor use, abdominal distension, or feeding intolerance.
Area of Science:
- Gastroenterology
- Infectious Diseases
- Surgical Pathology
Background:
- Coronavirus disease 2019 (COVID-19) is a multisystemic illness.
- Bowel ischemia is a severe gastrointestinal complication of COVID-19.
- Limited data exists on the surgical management of COVID-19-associated bowel ischemia.
Purpose of the Study:
- To describe the surgical experience with bowel ischemia in COVID-19 patients.
- To characterize the clinical presentation and outcomes of bowel ischemia in COVID-19 patients.
Main Methods:
- Retrospective analysis of 20 patients treated for COVID-19 with confirmed bowel ischemia via exploratory laparotomy.
- Data collected from March 2020 to March 2021.
- Analysis of medical records and intra-operative findings.
Main Results:
- Eighty percent of patients required vasopressors, 70% had abdominal distension, and 50% had gastric feeding intolerance.
- Ischemia involved the large bowel (80%), small bowel (60%), or both (40%).
- Mortality was 33%, with 40% experiencing thromboembolic complications despite anticoagulation.
Conclusions:
- Bowel ischemia is a life-threatening COVID-19 complication with distinct gross and histologic features.
- Clinical signs like vasopressor use, abdominal distension, and feeding intolerance warrant surgical assessment.
- High rates of thromboembolic events highlight the need for vigilant management.
Background:
COVID-19 is a deadly multisystemic disease, and bowel ischemia, the most consequential gastrointestinal manifestation, remains poorly described. Our goal is to describe our institution's surgical experience with management of bowel ischemia due to COVID-19 infection over a one-year period.
Methods:
All patients admitted to our institution between March 2020 and March 2021 for treatment of COVID-19 infection and who underwent exploratory laparotomy with intra-operative confirmation of bowel ischemia were included. Data from the medical records were analyzed.
Results:
Twenty patients were included. Eighty percent had a new or increasing vasopressor requirement, 70% had abdominal distension, and 50% had increased gastric residuals. Intra-operatively, ischemia affected the large bowel in 80% of cases, the small bowel in 60%, and both in 40%. Sixty five percent had an initial damage control laparotomy. Most of the resected bowel specimens had a characteristic appearance at the time of surgery, with a yellow discoloration, small areas of antimesenteric necrosis, and very sharp borders. Histologically, the bowel specimens frequently have fibrin thrombi in the small submucosal and mucosal blood vessels in areas of mucosal necrosis. Overall mortality in this cohort was 33%. Forty percent of patients had a thromboembolic complication overall with 88% of these developing a thromboembolic phenomenon despite being on prophylactic pre-operative anticoagulation.
Conclusion:
Bowel ischemia is a potentially lethal complication of COVID-19 infection with typical gross and histologic characteristics. Suspicious clinical features that should trigger surgical evaluation include a new or increasing vasopressor requirement, abdominal distension, and intolerance of gastric feeds.
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