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Key findings

  • Two weeks into a patient's ICU course, a 47-year-old man with COVID-19 was noted to have abdominal distension with grimacing on palpation of the right lower quadrant
  • Computed tomography demonstrated evidence of small-bowel ischemia with perforation but widely patent mesenteric vessels
  • Surgical exploration revealed necrotic bowel extending from the ligament of Treitz to the transverse colon, with a perforation of the terminal ileum
  • Patent mesenteric vasculature and an antimesenteric pattern of involvement, along with reports of hypercoagulability in patients with COVID-19, suggest the necrosis occurred as a result of microvascular thrombosis and associated inflammation

In patients who are critically ill with COVID-19, multiple extrapulmonary manifestations of the disease have been observed, including hypercoagulability, acute renal failure and myocardial injury. In the Journal of Gastrointestinal Surgery, Rajshri M. Gartland, MD, clinical fellow in Surgery at Massachusetts General Hospital, and George C. Velmahos, MD, PhD, division chief of Trauma, Emergency Surgery and Surgical Critical Care, report another manifestation: catastrophic bowel necrosis.

Case Report

A 47-year-old man with type 2 diabetes presented to the emergency department with a five-day history of shortness of breath, cough and fevers. He was intubated on arrival because of hypoxia and respiratory distress, and a test for SARS-CoV-2 was positive.

The patient was treated with antibiotics for methicillin-sensitive Staphylococcus aureus pneumonia, and his respiratory status steadily improved. However, two weeks into his ICU course, he was noted to have rising leukocytosis, hypotension requiring escalating vasopressor support and abdominal distension with grimacing on palpation of the right lower quadrant.

Computed tomography demonstrated evidence of small-bowel ischemia with perforation. The mesenteric vessels were widely patent.

The patient was taken urgently to the operating room for exploration and was found to have necrotic bowel extending from the ligament of Treitz to the transverse colon, with a perforation of the terminal ileum. The necrosis had unusual characteristics:

  • Extensive regions of bright yellow discoloration rather than the usual purple–black ischemic changes; these areas were extremely thin and friable
  • Distribution varying between circumferential involvement and patchy involvement along the antimesenteric side of the small bowel
  • Clear demarcation of the borders of ischemia without anatomic transition zones

Given the extent of involvement and the patient's critically ill status, the injury was deemed to be unsurvivable, and the abdomen was closed. The patient died in the ICU shortly after transitioning to comfort measures only. The family declined an autopsy.

Underlying Mechanism Unknown

Similar cases of bowel necrosis in intubated COVID-19 patients have been encountered at Mass General. In this patient, the patent mesenteric vasculature and antimesenteric pattern (as well as previous reports of hypercoagulability in COVID-19 patients) suggest the necrosis occurred as a result of microvascular thrombosis and associated inflammation.

The potential for direct tissue injury from SARS-CoV-2 RNA in the gastrointestinal tract is under investigation, and results may provide further insight into the underlying mechanism of bowel ischemia in COVID-19.

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