mesenteric ischamia in covid 19 patients

Document Type : Original Article

Authors

1 surgery department faculty of medicine Al Azhar university Cairo

2 Department of general surgery, Al Azhar university New Damietta, Egypt

Abstract

Abstract:
Background: as covid 19 discovered it’s not only respiratory virus but affect all body system without exclusion
Aim of the work :to show the relation between covid 19 infection and mesenteric ischemia
Material and methods: this study done prospectively on 15 patient with covid 19 and acute mesenteric ischemia admitted to the surgical unite in the new Damietta university hospital managed with surgical interference by laparotomy or conservative with anticoagulants
Results: this study done over 15 patients with positive covid 19 and most of them are old age with comorbidity and as diabetes mellitus the mean age 55.5% abdominal pain is the commons symptoms in 100 of the patient 8 patient underwent laparotomy 53.5 % 6 patient expired 40 %
Conclusion: it is important to understand the relation between the covid 19 infection and thromboembolism in mesenteric vessels prophylactic anticoagulants is corner stone to prevent mesenteric ischemia to prevent ischemia of the intestine

Keywords


INTRODUCTION

In 2019 December the world faced with unknown cause of sever pneumonia., in Wuhan city in china it was sever acute respiratory distress syndrome by corona -2 (SARS- COV-2).1

 on February the world health organization named the outbreak of disease covid 19 virus disease.2 on march2020 World Health Organization declare that outbreak of covid 19 virus is pandemic.3

.by the time of December 2020 about 70million cases diagnosed and 1.5 million deaths.4 at the start of covid 19 there is thought that it affects respiratory system onlyas rapid spread of covid 19 virus infection there is correlation between the covid19 virus infection with thrombosis and thromboembolism. 5

In covid 19 virus there are gastrointestinal manifestationsmesenteric vascular occlusion or thrombosis of big abdominal vessels either arterial or venous is fetal disease 6, if combined with covid 19 infection there is high mortality mesenteric ischemia is fatal disease 80-90%in operated patient and 100%in non-operated patient this mostly because unclear symptoms delaying diagnosis, and irreversible changes that happened in the intestinal wall. 7

the pathology behind the Mesenteric ischemia with covid 19 is unclear for long time, theory of endothelial injury is part of pathogenesis. Real of over amount of inflammatory cytokines like tumor necrosis factor, interleukin 6, Interleukin (IL) -6, IL-8, and IL-1β,is part of cytokines storm which leads to multi organ failure also patient with hypoxia has increases risk of thrombosis especially in immobile patients.8&9

 presentation of mesenteric ischemia is vague of gastrointestinal symptoms, nausea, vomiting, diarrhea, and abdominal distention. Due to non-specific symptoms of mesenteric ischemia the radiological investigation is the main way to diagnosis of this disease.10

 Ultrasonography and abdominal radiology have low sensitivity and specificity C T is main line of radiological diagnosis replacing angiography.10

After diagnosis immediate surgical interference is best way of treatment to avoid the rate of mortality, ICU admission is needed in about 30% of patient with mesenteric ischemia even on anticoagulant.11&12

The aim of this study is to evaluate the diagnosis and treatment of mesenteric ischemia in covid 19 positive patient

PATIENTS AND METHODS

this study is prospective study done on 15 patient presented to emergency room with manifestation of intestinal obstruction in surgical department in the new Damietta Al-Azhar university hospital, Arab republic of Egypt, from first July 2021 to first January 2022.

 preoperative preparations all patients exposed to detailed history examination and all investigation (CBC, liver function, kidney function, coagulation profile x ray of the abdomen chest x-ray, abdominal CT scan and chest C T was done to detect covid 19 with pneumonia) all of them are covid 19 positive d dimer 10 patients male and 5 patient female all patients underwent surgical operation laparotomy

Ethical consent: An approval of the study was obtained from Al-Azhar University Academic and Ethical Committee. Every patient signed an informed written consent for acceptance of the participation in the study. This work has been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for studies involving humans.

RESULTS

This study conducted over 15 patients with demographic distribution according to age, sex, symptoms, signs and anticoagulant

In our study the age of the patients ranges from 16 to 89 year with the mean age is 55.5 %the youngest age is 16 and the oldest is 89.

 6patient are female 40% ,8patient are male 60% with increased the incidence of coagulopathy in male mort than female.

15 patients presenting with abdominal pain 100% of the patient, 5patient presented with bleeding per rectum and hematemesis,33.3% one patient presented with nausea

6.6%.5patient started with LMWH33.3%,5patientwith acetyl salicylic acid (ASA) 33.3% and 5patients with no anticoagulant 33.3%and

5 patients with comorbidity diabetes mellitus and hypertension 33.3% 8patients underwent laparotomy 53.3% all exploration laparotomy resection anastomosis done for them, and intraoperative diagnosis of intestinal ischemia and 3patients no intervention20%,2patient of them 13.3% with anticoagulant not fit for surgery 9patients discharged in good condition,3patient20% of the expired patient were explored and 2patient 13.3%expired without intervention.

the mod of diagnosis as follow 9 patients diagnosed with PCR (polymerase chain reaction) by swab from the nasopharynx, for the covid 19about 60%and 5 patients diagnosed with CT chest about 33.4% with the characteristic ground glass appearance of covid 19, one patient diagnosed by both CT chest and PCR 6.6%. 9 patients discharged in good condition and 6 patients expired 40%, it is very high incidence of mortality when compared with non-pandemic time in usual situations.

 

Fig 1: Intestinal gangrene.

 

Fig 2: Intestinal gangrene after excision.

 

Fig 3: Colonic gangrene.

 

Fig 4: Colonic gangrene after excision

 

 

Character

number

age

Sex

Complaint

Ct

ASA–APT

D dimer

Outcome

comorbidity

Intervention

Diagnosis of covid 19

1

16

F

Abdominal pain

+vomiting

+

ASA

 

Discharge

 

Exp lap

PCR

2

39

F

Vomiting

+

LMWH

 

Discharge

 

Exp lap

PCR

3

33

M

Abd pain

+

NO

 

Discharge

 

Exp lap

PCR

4

89

M

Abd p

-

NO

 

Died

DM

Hypertensive

Exp lap

CT

5

40

F

Nausea

-

ASA

 

Discharge

 

Act

PCR

6

89

M

Lower git bleeding

+

LMWH

 

Died

IHD D M

No

CT

7

65

M

Hematemesis

+

NO

 

Died

 

Exp lap

PCR

8

60

F

Abd pain

-

ASA

 

Died

 

Exp lap

 

9

55

M

Abd pain distension

+

NO

 

Discharge

 

 

PCR+CT CHEST

10

60

M

LGIT bleeding + Abd pain

+

LMWH

 

Discharge

 

Epl lap

CT

11

67

F

Hematemesis

+

LMWH

 

Died

DM I HD

No

PCR

12

43

M

Abd pain

-

ASA

 

Discharge

 

Exp lap

PCR

13

67

M

Distention

+

NO

 

Discharge

 

Exp lap

CT

14

80

M

Nausea

+

ASA

 

Died

OBESITY

No

PCR

15

66

F

Hematemesis

+

LMWH

 

Discharge

HYPERNTION

Act

PCR

Table 1: Demographic distribution of the patient. (ASA: acetyl salicylic acid; APT: antiplatelet therapy; LMWH: low molecular weight heparin. ACT; anticoagulant therapy. CT; cat scan. PCR; polymerase chain reaction; DM: diabetes mellitus. IHD; ischemic heart disease; Exp; lap exploration laparotomy.

 

DISCUSSION

The first case of covid 19 was discovered in Wuhan city in China at December 2019 as pneumonia of unknown cause during the spread of pandemic. 13

 the health provider notice that it affects all body organ without exception through the coagulopathy acute mesenteric ischemia is rare fatal condition that has had high incidence of mortality 60 to 80 % but in our study, we notice high mortality rate during the period of covid 19 than the period of non-covid.14&15

 The exact pathology that causes severe intestinal injury with ischemia not known exactly but some theories can explain this effect, the first explanation is the hypercoagulable state that induced by covid 19, endothelial injury and hypoxia that result from respiratory affection can cause mesenteric thrombosis at any vessels especially in small vessels

sub mucosal blood vessels lead to ischemic necrosis of the intestinal wall with the embolic effect other theory is the direct invasion of the endothelial by the virus covid 19 through binding with angiotensin converting enzymes 2expressing on the endothelium.16&17

another theory is immune complex mediated vacuities e causing injury to the endothelium.18

elevated level of fibrinogen and factor VIII lead to hyper viscosity and extracellular thrombotic micro particles the final theory is long standing recumbence in the ICU for the covid 19 patients can causes stasis and predisposing for thrombosis.19

in our study most of the patient was admitted to ICU unit before getting AMI after infection of covid 19 patient get dehydrated and hemodynamically unstable also predisposed to thrombosis.

 In our patient we expect the intestinal ischemia in hospitalized patient with vague gastrointestinal manifestation as nausea, vomiting, abdominal pain, diarrhea, abdominal distention either in patients presented with those manifestation in emergency room or patient hospitalized with this manifestation.

The comorbidity and mimic symptoms with other disease can mislead in diagnosis of mesenteric ischemia that why most of the cases are discovered late we depend on the computerized tomography in the diagnosis in previous reports decide that thrombosis of small sub mucosal vessels but during the time of covid in patient positive there is occlusion of big vessels. 20&21

In our study we notice predominance in male than female and diabetes is the common comorbidities than others, most of the patients underwent laparotomy and bowel resection, little number managed with anticoagulant and thrombolytic due to unfitness to surgery.

 The accurate result of AMI with covid 19 is difficult from this study as complete follow up and current status of patient has not reported there is limitation in the study.

CONCLUSION

In acute mesenteric ischemia it is important to understand its relevance in all patients with gastrointestinal symptoms the clinician should be aware about the hypercoagulability stat in covid 19 patient and uses of prophylactic anticoagulants in hospitalized patients should be considered to reduce the morbidity and mortality

  1.  

    1. Coronavirus disease (COVID-19). (2022, February 23). Www.Who.Int. https://www.who.int/emergencies/diseases/novel-coronavirus-2019
    2. WHO Director-General’s remarks at the media briefing on 2019-nCoV on 11 February 2020. (2020, February 11). Www.Who.Int. https://www.who.int/director-general/speeches/detail/who-director-general-s-remarks-at-the-media-briefing-on-2019-ncov-on-11-february-2020
    3. World Health Organization. Director-General’s opening remarks at the media briefng on COVID-19—11 March 2020. https:// www.who.int/dg/speeches/detail/who-director-general-s-openi ng-remarks-at-the-media-briefing-on-covid-19---11-march-2020. Updated March 11, 2020. Accessed March 15, 2020.
    4. World Health Organization. Weekly epidemiological update-15 December 2020 [Internet]. [cited 21 December 2020]. Available from: https://www.who.int/publications/m/item/weeklyepidemiological-update---15-december-2020 3
    5. Henry BM, Vikse J, Benoit S, et al. Hyper inflammation and derangement of renin-angiotensin-aldosterone system in COVID-19: A novel hypothesis for clinically suspected hyper coagulopathy and microvascular immunothrombosis. Clin Chim Acta. 2020; 507:167-73.
    6. Abou-Ismail MY, Diamond A, Kapoor S, et al. The hypercoagulable state in COVID-19: Incidence, pathophysiology, and management. Thromb Res. 2020; 194:101-15.
    7. Oldenburg WA, Lau LL, Rodenberg TJ, et al. Acute mesenteric ischemia: a clinical review. Arch Intern Med. 2004; 164(10):1054-62.
    8. Meduri GU, Kohler G, Headley S, Tolley E, et al. Inflammatory cytokines in the BAL of patients with ARDS. Persistent elevation over time predicts poor outcome. Chest. 1995;108(5):1303-14.
    9. Yao XH, Li TY, He ZC, et al. A pathological report of three COVID-19 cases by minimal invasive autopsies. Zhonghua Bing Li Xue Za Zhi. 2020; 49(5):411-7.
    10. Kanasaki S, Furukawa A, Fumoto K, et al. Acute Mesenteric Ischemia: Multidetector CT Findings and Endovascular Management. Radiographics. 2018; 38(3):945-61.
    11. Adaba F, Askari A, Dastur J, et al. Mortality after acute primary mesenteric infarction: a systematic review and meta-analysis of observational studies. Colorectal Dis. 2015;17(7):566-77.
    12. Helms J, Tacquard C, Severac F, et al. High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study. Intensive Care Med. 2020; 46(6):1089-98.
    13. World Health Organization. Coronavirus disease (COVID-19)-World Health Organization [Internet]. [cited 21 December 2020]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019 19
    14. Lodigiani C, Iapichino G, Carenzo L, et al. Humanitas COVID-19 Task Force. Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Milan, Italy. Thromb Res. 2020; 191:9-14.
    15. Heys SD, Brittenden J and Crofts TJ. Acute mesenteric ischaemia: the continuing difficulty in early diagnosis. Postgrad Med J. 1993; 69:48-51.
    16. Parry AH, Wani AH and Yaseen M. Acute Mesenteric Ischemia in Severe Coronavirus-19 (COVID-19): Possible Mechanisms and Diagnostic Pathway. Acad Radiol. 2020; 27(8):1190.
    17. Ackermann M, Verleden SE, Kuehnel M, et al. Pulmonary Vascular Endothelialitis, Thrombosis, and Angiogenesis in Covid-19. N Engl J Med. 2020; 383(2):120-8.
    18. Roncati L, Ligabue G, Fabbiani L, et al. Type 3 hypersensitivity in COVID-19 vasculitis. Clin Immunol. 2020; 217:108487.
    19. Maier CL, Truong AD, Auld SC, et al. COVID-19-associated hyperviscosity: a link between inflammation and thrombophilia?. Lancet. 2020; 395(10239):1758-9.
    20. Doulberis M, Panagopoulos P, Scherz S, et al. Update on ischemic colitis: from etiopathology to treatment including patients of intensive care unit. Scand J Gastroenterol. 2016; 51(8):893-902.
    21. Balaban DV, Baston OM and Jinga M. Abdominal imaging in COVID-19. World J Radiol. 2021;13(7):227-32.