Advertisement
Correspondence| Volume 53, ISSUE 3, P289-290, March 2021

Download started.

Ok

COVID-19 and pneumatosis intestinalis: An early sign of intestinal ischemia

Published:November 05, 2020DOI:https://doi.org/10.1016/j.dld.2020.10.036

      Keywords

      To the Editor,
      Intestinal ischemia in association with COVID-19 had been recently reported. In this journal, Norsa et al recently described the case of a patient with extensive intestinal ischemia [
      • Norsa L
      • Valle C
      • Morotti D
      • et al.
      Intestinal ischemia in the COVID-19 era.
      ], in which they emphasized the need of clinicians to be aware of this complication and suggested the occurrence of COVID-19-induced thromboembolism in that case. Although pneumatosis intestinalis (PI) is a rare radiological sign characterized by the presence of gas in the bowel wall, it can be a sign of impending intestinal ischemia. Furthermore, the presence of portal or portomesenteric venous gas along with PI is an ominous sign indicating transmural bowel necrosis [
      • Ibrahim A
      • Edirimanne S
      Portal venous gas and pneumatosis intestinalis: ominous findings with an idiopathic aetiology.
      ].
      PI is generally diagnosed by abdominal radiography, especially abdominal computed tomography (CT), which reveals gas-filled cysts in the submucosa/serosa of the intestine. The pathogenesis of PI is usually explained by either mechanical theory or bacterial theory. The mechanical theory hypothesizes direct diffusion of intraluminal bowel gas through the intact intestinal mucosal membrane due to increased intraluminal pressure as in blunt trauma, ileus, or pseudo-obstruction. The bacterial theory proposes that gas-forming bacteria enter the submucosa through mucosal breaks as in bowel inflammation, infection, bowel ischemia, or necrosis [
      • Ho LM
      • Paulson EK
      • Thompson WM
      Pneumatosis intestinalis in the adult: benign to life-threatening causes.
      ].
      COVID-19 virus can cause PI by direct injury of mucosa of the gastrointestinal tract through its attachment to the angiotensin-converting enzyme receptors (ACER2), which are abundantly expressed on enterocytes [
      • Xiao F
      • Tang M
      • Zheng X
      • et al.
      Evidence for gastrointestinal infection of SARS-CoV-2.
      ], or by disruption of the normal colonic gut flora or by bowel ischemia due to thromboembolic complications [
      • Lakshmanan S
      • Toubia N.
      Pneumatosis Intestinalis in COVID-19.
      ,
      • Meini S
      • Zini C
      • Passaleva MT
      • et al.
      Pneumatosis intestinalis in COVID-19.
      ,
      • Kielty J
      • Duggan W
      • O'Dwyer M
      Extensive pneumatosis intestinalis and portal venous gas mimicking mesenteric ischaemia in a patient with SARS-CoV-2.
      ,
      • Aiello P
      • Johnson S
      • Mercado AR
      • et al.
      Pneumatosis intestinalis in a patient with COVID-19.
      ].
      Bhayana et al. reported in their radiological study about four patients with COVID-19 with pneumatosis or portal venous gas observed in abdominal CT. Three of those patients had frank bowel infarction at laparotomy, and one patient with gas in the transverse mesocolon in CT had a corresponding patchy yellow discoloration of the antimesenteric transverse colon of unknown origin [
      • Bhayana R
      • Som A
      • Li MD
      • et al.
      Abdominal imaging findings in COVID-19: preliminary observations.
      ].
      Herein, we summarize a few recent reports that have described the association of PI with COVID-19 (Table 1) [
      • Lakshmanan S
      • Toubia N.
      Pneumatosis Intestinalis in COVID-19.
      ,
      • Meini S
      • Zini C
      • Passaleva MT
      • et al.
      Pneumatosis intestinalis in COVID-19.
      ,
      • Kielty J
      • Duggan W
      • O'Dwyer M
      Extensive pneumatosis intestinalis and portal venous gas mimicking mesenteric ischaemia in a patient with SARS-CoV-2.
      ,
      • Aiello P
      • Johnson S
      • Mercado AR
      • et al.
      Pneumatosis intestinalis in a patient with COVID-19.
      ]. The mean age of the patients was 59 ± 16 years, all patients were males, one of them had no comorbidities, and two patients had abdominal pain. Marked elevation of d-dimer level was observed in one patient. Extensive PI was detected in one patient in the small and large intestines, and two patients had free intraperitoneal air. Portal vein gas was prominent in one patient, and although surgery was indicated in this patient, a conservative approach was undertaken as the blood flow was normal in the superior mesenteric artery origin, and the patient recovered. One patient had renal transplantation and multiple comorbidities; however, his condition improved with the conservative management. In all patients, conservative management with bowel rest, antibiotics, intravenous fluid, or heparin infusion was successful.
      Table 1Characteristics of COVID -19 patients with pneumatosis intestinalis.
      Lakshmanan and Toubia
      • Lakshmanan S
      • Toubia N.
      Pneumatosis Intestinalis in COVID-19.
      Meini et al
      • Meini S
      • Zini C
      • Passaleva MT
      • et al.
      Pneumatosis intestinalis in COVID-19.
      Kietly et al
      • Kielty J
      • Duggan W
      • O'Dwyer M
      Extensive pneumatosis intestinalis and portal venous gas mimicking mesenteric ischaemia in a patient with SARS-CoV-2.
      Aiello et al
      • Aiello P
      • Johnson S
      • Mercado AR
      • et al.
      Pneumatosis intestinalis in a patient with COVID-19.
      Age, sex72, male44, male47, male73, male
      Medical history of comorbiditiesMultiple comorbiditesNegativeAnxiety, obese, obstructive sleep

      apnea
      Diabetes mellitus, hypertension, heart failure, AF,

      aortic valve replacement, renal transplant on chemotherapy
      Clinical presentation:

      Fever

      Respiratory symptoms

      GIT Symptoms


      Yes

      No

      Diffuse abdominal pain and bleeding per rectum


      Yes

      Cough, chest pain

      No


      Yes

      Dry cough

      Acute abdomen


      No

      Acute respiratory failure

      No
      PI diagnosis:

      CT abdomen



      PI in mid ascending colon



      PI in caecum, RT colon with intraperitoneal free bubbles


      PI in caecum, proximal ileum and Jejunum with mesenteric free air


      PI in transverse and ascending colon
      Additional CT abdomen finding

      Portal vein gas
      Descending, sigmoid wall thickening

      No
      No

      No
      Bowel distension

      Yes
      No

      No
      D- dimer (ng/mL)NAIncreasing from 1248 to 3398NANA
      Oxygen therapy

      Management of PI

      NA

      Bowel rest

      Hydration

      IV antibiotics

      Yes

      Ciprofloxacin plus metronidazole
      Mechanically ventilated

      Unfractionated heparin infusion

      Vasopressor

      Crystalloid fluid

      Mechanically ventilated

      Metronidazole
      OutcomeComplicated by sepsis, cardiac ischemia, renal insufficiency, and respiratory failure due to severe COVID 19Improved

      ImprovedImproved
      Explained mechanism of PI

      - COVID19-induced ischemic colitis .- Bowel wall damage and microbiota impairment due to

      SARS-COV-2 infection.

      Thromboembolic

      mechanism was excluded by doppler ultrasound on IVC, ileac, femoral, popliteal and infrapopliteal venous axis. Chest CT showed no pulmonary emboli
      - SARS-COV-2 causes atrophy of the lymphoid follicles.

      That lead to increased mucosal permeability allowing dissection of the gas in the bowel wall.

      - Multiple risk factors for PI is present with organ transplant.

      - Antibiotics therapy during ICU admission disrupted microbiota of the gut,

      - Direct damage of the bowel wall integrity by COVID-19 virus.

      AF: atrial fibrillation, GIT: gastrointestinal tract, PI: pneumatosis intestinalis, CT: computed tomography, IVC: inferior vena cava, NA: not available.
      Management of PI depends on the overall assessment of patients, considering medical and surgical history, clinical examination, laboratory assessment, and imaging are important in determining the treatment approach. Although PI management is generally conservative, surgery is indicated in complicated cases of perforation, peritonitis, abdominal sepsis, and failed conservative management [
      • Peter SDS
      • Abbas MA
      • Kelly KA
      The spectrum of pneumatosis intestinalis.
      ].

      Declaration of Competing Interest

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

      Funding

      This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

      References

        • Norsa L
        • Valle C
        • Morotti D
        • et al.
        Intestinal ischemia in the COVID-19 era.
        Diges Liver Dis. 2020; 52: 1090-1091
        • Ibrahim A
        • Edirimanne S
        Portal venous gas and pneumatosis intestinalis: ominous findings with an idiopathic aetiology.
        J Surg Case Rep. 2019; 2019: rjy352
        • Ho LM
        • Paulson EK
        • Thompson WM
        Pneumatosis intestinalis in the adult: benign to life-threatening causes.
        Am J Roentgenol. 2007; 188: 1604-1613
        • Xiao F
        • Tang M
        • Zheng X
        • et al.
        Evidence for gastrointestinal infection of SARS-CoV-2.
        Gastroenterology. 2020; 158 (e3): 1831-1833
        • Lakshmanan S
        • Toubia N.
        Pneumatosis Intestinalis in COVID-19.
        Clin Gastroenterol Hepatol. 2020;
        • Meini S
        • Zini C
        • Passaleva MT
        • et al.
        Pneumatosis intestinalis in COVID-19.
        BMJ Open Gastroenterol. 2020; 7e000434
        • Kielty J
        • Duggan W
        • O'Dwyer M
        Extensive pneumatosis intestinalis and portal venous gas mimicking mesenteric ischaemia in a patient with SARS-CoV-2.
        Ann R Coll Surg Engl. 2020; 102: e145-e147
        • Aiello P
        • Johnson S
        • Mercado AR
        • et al.
        Pneumatosis intestinalis in a patient with COVID-19.
        BMJ Case Rep CP. 2020; 13e237564
        • Bhayana R
        • Som A
        • Li MD
        • et al.
        Abdominal imaging findings in COVID-19: preliminary observations.
        Radiology. 2020; 201908
        • Peter SDS
        • Abbas MA
        • Kelly KA
        The spectrum of pneumatosis intestinalis.
        Arch Surg. 2003; 138: 68-75