Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) is infecting patients all over the world, causing respiratory symptoms which can be fatal in a minority of cases. Additionally, there is an unknown number of people who had been infected but never had symptoms. On the other hand there case reports of atypical symptoms or atypical clinical presentations of SARS-CoV2, which are causing fear among doctors and patients. The gap between the disease and what we know about it is still apparently huge. To decrease this gap and fight the fear serious scientific work must be done so that valid conclusions can be taken. A conclusion/treatment based on weak proves can do such harm as the disease itself.
Gastrointestinal manifestations have been described in some patients (39%) with SARS-COV2 infection. Additionally, more than half the patients with gastrointestinal infection had positive test for SARS-CoV2 RNA in stools. According to some authors this suggests the virus can replicate in bowel cells. It looks like COVID-19 might cause hypercoagulation, thrombi formation and ischemia. Does the virus causes bowel ischemia? To answer this question the ischemia must undoubtedly be linked to the SARS-CoV2 infection. It becomes even harder because CT characteristics of bowel infection by SARS-CoV2 are unclear, as well as the natural history.
In May 2020 was published in “Surgery” a paper reporting 3 cases of patients with bowel ischemia linked to SARS-CoV2 infection. It got my attention, but after reading it some questions arose. The first patient was a 28 yo female who resorted to the emergency room because of an acute abdomen without respiratory symptoms. A CT scan showed a superior mesenteric vein thrombosis plus portal vein thrombosis, a portal vein cavernoma, and no signs of bowel ischemia. Anticoagulation was initiated and on day 5 abdominal pain increased. Another CT scan showed a segmental small bowel ischemia, and a segmental bowel resection was performed. A second-look laparotomy 48h later allowed for anastomosis. On postoperative day 1 the patient presented respiratory symptoms and SARS-CoV2 was diagnosed. The authors concluded that the bowel ischemia was caused by the SARS-CoV2 infection. Was it? They also say there was no past medical history, but the patient had already a portal vein thrombosis with cavernoma and signs of portal hypertension. This is not a sudden pathology. This relevant past medical history was not well explored by the authors. Was the patient suffering from another form of hypercoagulation status? Why did she had a portal vein thrombosis? For how long to form a cavernoma? Since she was not tested for SARS-CoV2 at admission (only 8 days after), how can we assure she was already infected? In fact, the infection was only diagnosed when respiratory symptoms arose. Mean incubation period is 8.29 days, according to a recent publication in Sciences Advance.
Patient 2 and 3 were two male patients, 56yo and 67yo respectively, who were intubated and admitted to the Intensive Care Unit because of SARS-CoV2 infection (diagnosed by oral swabs and thoracic CT scan). One week later (day 9 and 6), both patients had a “brutal degradation” and multiorgan failure, and high doses of noradrenalin were initiated. Physical examination was described as normal but abdominal CT scan was performed in both patients. CT scan of patient 2 was suggestive of small bowel ischemia but with patent arterial axis, a Non Oclusive Mesenteric Ischemia (NOMI) I would say. Segmental small bowel resection was performed because of transmural necrosis. CT scan of patient 3 showed an inflammatory segmental ileitis with segmental small bowel wall thickening. Non-operative treatment was offered and the patient recovered. The authors point the SARS-CoV2 infection as the cause of the ischemia with micro-thrombi and inflammatory infiltrates in pathology. Was it? How can we say the high doses of noradrenalin were not the cause of an apparently NOMI? Can we assure SARS-CoV2 can cause a bowel inflammation? Or at least can we take that conclusion from these data?
I am not saying SARS-COV2 do not cause bowel ischemia or some kind of bowel inflammation, which might be possible since the virus can replicate in the bowel cells. I am only questioning the strength of this kind of data. To take valid conclusions which will change or influence our medical practice more consistent data are necessary. These 3 reported cases are important because they rise the hypothesis of a relationship between SARS-CoV2 and bowel ischemia and/or inflammation. Sharing ideas and experiences is what makes science go forward. For this the authors have my respect and applause. However, I believe those data are not enough to say “acute abdomen induced by SARS-CoV2 infection”. More studies are necessary to take this conclusion, and all cases must be deeply explored for all possible etiologies of bowel ischemia and inflammation. Do not ever forget that conclusions based on weak data can have severe consequences on patient’s health before we realize that. There is a huge political and social pressure to control COVID-19, but science must not go with the flow…
A final word about one conclusion I believe is important. “Early abdominal CT in patients with unexplained worsening status during COVID-19” should be advised. Since there is the suspicious of a potential relationship between SARS-CoV2 and bowel ischemia, which can present non-specific and non-exuberant abdominal signs and symptoms, all doctors must be aware of it and perform an abdominal CT scan. This will allow for an early surgical treatment.
Do not be afraid to share ideas, experience and knowledge. Only by doing so, we will evolve. Read, study and learn. Then question everything you have read.
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon
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