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Vol. 43. Issue 1.
Pages 112-116 (January - March 2021)
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Vol. 43. Issue 1.
Pages 112-116 (January - March 2021)
Letter to the Editor
DOI: 10.1016/j.htct.2020.10.959
Open Access
COVID-19 and acute mesenteric ischemia: A review of literature
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Balraj Singh
Corresponding author
bsriar9@gmail.com

Corresponding author at: Saint Joseph’s University Medical Center, 703 Main Street, Paterson, New Jersey 07503, United States.
Department of Hematology & Oncology Saint Joseph’s University Medical Center Paterson, New Jersey, United States
Parminder Kaur
Department of Cardiology, Saint Joseph’s University Medical Center Paterson, New Jersey, United States
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Table 1. Summarizing Clinical characteristics of the COVID-19 patients with AMI.
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Dear Editor,

Coronavirus disease-2019 (COVID-19) caused by SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) has caused global health crisis. Initially considered a respiratory tract pathogen, it can cause multiple organ dysfunction. It has also been described to predispose to venous and arterial thromboembolism; however, limited published data is available regarding mesenteric thrombosis COVID-19. We conducted a rapid review of current scientific literature available in PubMed to identify cases of AMI in in COVID-19 patients- total of 13 cases were found. We delineated clinical characteristics and outcome in these patients. Clinicians should be aware of the life-threatening situation in COVID-19 patients.

A novel coronavirus termed as SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) has been the causative agent of a pandemic that originated in Wuhan China in December 2019. Coronavirus disease-2019 (COVID-19) can present with a wide variety of complications during infection. For optimal management of these patients, understanding of various systemic manifestations and complications of SARS-CoV2 is vital. Although in COVID-19 respiratory symptoms predominate, both arterial and venous thrombosis can occur with COVID-19. Arterial thrombosis reported so far include stroke, acute limb ischemia, acute mesenteric ischemia and acute coronary syndrome.1–4 Limited literature is available regarding acute mesenteric ischemia (AMI). We did an extensive literature review on COVID-19 associated mesenteric thrombosis.

We searched PubMed for this literature review using search terms ‘COVID-19 and mesenteric thrombosis’, ‘COVID-19 and mesenteric ischemia’, and ‘COVID-19 and bowel ischemia’. All the case reports who had COVID-19 associated mesenteric thrombosis so far is reviewed, and relevant data abstracted from these studies in Table 1. COVID-19 diagnosis was made by PCR assay except in one patient it was negative (suspected COVID-19).

Table 1.

Summarizing Clinical characteristics of the COVID-19 patients with AMI.

  Age  Medical history  Presenting signs and symptoms  Timing of AMI diagnoses  Imaging findings  Other site of thrombosis  Treatment  Rx of COVID-19  Outcome 
Case 1 5  55 M  HTN  Nausea, generalized abdominal pain, diarrhea  Day 7  CT scan of the abdomen and pelvis with IV contrast showed thrombus 1.6 cm in length in SMA  None  Laparotomy and SMA thromboembolectomy  HCQ, azithromycin and ceftriaxone  NR 
Case 2 6  47 M  Anxiety, obesity, OSA  Fever, dry cough and vomiting  Day 8  CT of the abdomen revealed diffuse small-bowel distension with widespread pneumatosis, circumferential mural thickening, free fluid, mesenteric free air and portal venous gas  None  Therapeutic heparin  NR  Discharged 
Case 3 7  56 NR  None  Stroke, next day developed abdominal pain and vomiting  Day 2  CT scan showed a free-floating thrombus in the aortic arch associated with an occlusion of the superior mesenteric artery  Stroke  Endovascular thrombectomy and laparotomy with the resection of two meters of the small bowel  NR  NR 
Case 4 8  69 M  None  Epigastric pain, constipation and eructation  Day 1  CT angiogram demonstrated a thrombus in the proximal segment of the superior mesenteric artery with complete occlusion in the right ileocolic branches  None  Small bowel resection and superior mesenteric artery thromboembolectomy  NR  Discharged 
Case 5 9  52 M  None  Cough and fever  Day 13  CT scan showed arterial thrombosis of vessels efferent of the superior mesenteric artery with bowel distension  None  An intestinal resection with stapled side-to side anastomosis was performed  NR  Discharged 
Case 6 10  75 M  None  Abdominal pain, vomiting, cough and SOB  Day 1  CT angiography showed thrombus in the descending thoracic aorta with embolic occlusion of the superior mesenteric artery  None  Catheter‐directed thrombolysis was commenced but the patient developed worsening abdominal symptoms and underwent laparotomy, requiring resection of 150 cm of ischemic small bowel  NR  NR 
Case 7 11  79 F  None  Fever, epigastric abdominal pain  Day 1  CT scan of the chest, abdomen, and pelvis at the arterial and portal phases, showed right-portal vein thrombosis, thrombosis of the distal part of the upper mesenteric vein, proximal thrombosis of the superior mesenteric artery and jejunal artery.  Portal vein and mesenteric vein thrombosis  Superior mesenteric artery thrombectomy and laparotomy with resection of a meter of necrotic ileum and right colon.  NR  Died 
Case 8 19  58 M  None  SOB and abdominal pain  Day 1  CT scan showed dilated small bowel loops, signs of bowel wall ischemia, splenic and renal infarctions without macrovascular arterial occlusion  Concurrent splenic and renal infarcts and 3 weeks later digital necrosis of bilateral feet  Laparotomy was performed, and a partial small bowel resection was done.  NR  SIH 
Case 9 13  9 F  Idiopathic medullar aplasia  Fever, abdominal pain, vomiting, diarrhea  NR  NR  NR  Resection of the ischemic bowel loop with double ileostomy was performed.  NR  Died 
Case 10 15  70 M  None  Abdominal pain, nausea, fever, pain in throat and cough  Day 1  Contrast‐enhanced CT of the abdomen showed acute small bowel hypoperfusion  None  Conservative management  NR  Died 
Case 11 14  28 F  ET  Abdominal pain and vomiting  Day 5  Abdominal CT scan showed segmental small bowel ischemia  Superior mesenteric and portal vein thrombosis  Laparotomy -Bowel resection  NR  Discharged 
Case 12 14  56 M  HTN, DM, obesity  ARDS  Day 9  CT scan showed bowel ischemia and mesenteric venous gas in proximal jejunum  None  Laparotomy -Bowel resection  NR  SIH 
Case 13 14  67 M  Chronic bronchitis, diabetes, and heart transplantation  ARDS  Day 6  CT scan showed inflammatory segmental ileitis with a localized thickening of one small bowel loop and edema  None  Conservative management  NR  Died 

M: male; F: female; NR: not reported; HTN: hypertension; OSA: obstructive sleep apnea; ET: essential thrombocytosis; DM: diabetes; SOB: shortness of breath; ARDS: acute respiratory distress syndrome; CT: computed tomography; SMA: superior mesenteric artery; HCQ: hydroxychloroquine; SIH: Still in hospital (at the time of writing of respective manuscript).

Clinical characteristics of the COVID-19 patients with AMI are summarized in Table 1.5–15 The median age of the patient was 56 years (range 9–79 years). We found total of 13 patients- 9 were male, 3 female and for 1 patient sex was not reported. AMI can occur as a presenting feature or a late complication of COVID-19 during hospitalization (median 7 days). 6 patients had pre-existing comorbidities while 7 patients had none. The pre-existing conditions reported were hypertension, diabetes, obesity, obstructive sleep apnea, anxiety, idiopathic medullar aplasia, chronic bronchitis, essential thrombocytosis, and cardiac transplantation. Presenting symptoms were nausea, vomiting, abdominal pain, diarrhea, fever, cough, shortness of breath, eructation, pain in throat and stroke. The diagnosis of AMI was made by contrast enhanced computed tomography. 4 patients had concurrent thrombosis at other sites – case 3 had stroke, case 7 had portal and mesenteric vein thrombosis, case 8 had splenic and renal infarcts and case 11 had superior mesenteric and portal vein thrombosis. 10 patients had surgery, 2 patients had conservative management and 1 was started on therapeutic anticoagulation with heparin. Out of 13 patients, 4 patients died.

Acute mesenteric ischemia is a rare abdominal emergency and is associated with high rates of morbidity and mortality. Prompt diagnosis requires a high index of suspicion and early contrast computed tomography imaging. The exact pathological mechanism leading to the complication of AMI in COVID-19 is not well understood at present, possibilities include - direct invasion of bowel tissue by the virus given expression of angiotensin converting enzyme 2 on enterocytes, the target receptor for SAR-Cov-2 or viral infection of the endothelial cell leading to diffuse endothelial inflammation or increased procoagulant factors like factor VIII, von Willebrand factor, fibrinogen or virus induced cytokine storm leading to coagulation and fibrinolysis activation.16–18 Additional explanations for the hypercoagulability may be the presence of high numbers of prothrombotic circulating microvesicles which are cytoplasmic microparticles stemming from platelets or monocytes and Neutrophil extracellular traps (NETs) released from activated neutrophils, constitute a mixture of nucleic DNA, histones and nucleosomes.18Treatment of this life-threatening condition includes surgical resection of the necrotic bowel, restoration of blood flow to the ischemic intestine and supportive measure - gastrointestinal decompression, fluid resuscitation, hemodynamic support. Health care providers should have high index of suspicion regarding this life-threatening complication of COVID-19 so that timely intervention can be done.

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