Study Finds Gastrointestinal Complications Likely in Critically Ill COVID-19 Patients
Key findings
- In this series of 141 critically ill patients with COVID-19, 74% developed at least one gastrointestinal complication during their ICU stay
- Transaminitis was the most common hepatobiliary complication (67% of patients), and more than half of patients had a hypomotility complication
- 58 patients were diagnosed with an ileus, of whom four developed bowel ischemia requiring emergent surgery and bowel resection
- Two additional patients had an Ogilvie-like syndrome, and in one of them extensive necrosis was identified that required total colectomy and an end ileostomy
- 14-day patient mortality was 15%, but it was 40% among patients requiring abdominal surgery
Critically ill COVID-19 patients have a high incidence of gastrointestinal complications, according to a case series reported in the Annals of Surgery by Haytham M.A. Kaafarani, MD, MPH, director of the Center for Outcomes & Patient Safety in Surgery (COMPASS) and Trauma & Emergency Surgery, George C. Velmahos, MD, PhD, division chief of Trauma, Emergency Surgery and Surgical Critical Care, and colleagues at Massachusetts General Hospital.
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Study Cohort
The report concerns 141 patients with severe COVID-19 who were admitted to the ICU at Mass General between March 13 and April 12, 2020. All had SARS-CoV-2 infection confirmed by polymerase chain reaction testing. 45% had a gastrointestinal symptom on hospital presentation.
The median Sequential Organ Failure Assessment (SOFA) score on ICU admission was 5 and 91% of patients required mechanical ventilation. 74% developed at least one gastrointestinal complication during their ICU stay.
Classification of Complications
Hepatobiliary complications: Transaminitis was the most common hepatobiliary complication (67% of patients). The mean highest values of aspartate aminotransferase and alanine aminotransferase were 420.7 U/L and 479.0 U/L, respectively, 7.5-fold and 12-fold higher than physiological values. Four patients developed acute acalculous cholecystitis and one developed acute pancreatitis.
Hypomotility complications occurred in half of the patients.
Ileus and bowel ischemia: 58 patients (56%) had an ileus diagnosed clinically and/or radiologically. Four patients with severe ileus had findings concerning for bowel ischemia and were taken to the operating room on days 11, 14, 15 or 22 of hospitalization, respectively, for exploratory laparotomy.
Two of these patients were found to have extensive patchy bowel necrosis involving half to two-thirds of the bowel length, despite patent proximal mesenteric vessels on computed tomography, perhaps suggesting microvessel thrombosis. The necrotic bowel appeared bright yellow in contrast to the common finding of purple–black.
Another patient developed hepatic ischemia and necrosis and had similar areas of yellow discoloration on the antimesenteric side of the small bowel, without frank transmural necrosis. The fourth patient had ischemia without frank necrosis of the terminal ileum.
Colonic paralytic ileus: Two additional patients were diagnosed with a colonic paralytic ileus, clinically identical to colonic pseudo-obstruction (Ogilvie's syndrome) on day 6 or 14 of hospitalization. One of these patients underwent exploratory laparotomy that identified patchy areas of necrosis of the entire colon; a total colectomy and an end ileostomy were performed.
Mortality
The 14-day patient mortality was 15%, but mortality was 40% among patients requiring abdominal surgery.
Front-line clinicians should be made aware of these potential complications and should keep a high index of suspicion for cases that warrant surgical consultation.
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