Acute Mesenteric Ischemia and Ischemic Bowel Complications in Patients with COVID-19: A Six-Case Series

Abstract

Background: Coronavirus disease 2019 (COVID-19) is associated with systemic inflammation, endothelial dysfunction, and thromboembolic complications. Acute mesenteric ischemia is an uncommon but life-threatening abdominal manifestation that may rapidly progress to bowel infarction, gangrene, or perforation. Materials and Methods: We describe six reverse transcription-polymerase chain reaction-confirmed COVID-19 patients who developed acute mesenteric ischemia or related ischemic bowel complications during the first pandemic wave between March and October 2020. Clinical presentation, laboratory findings, chest and abdominal computed tomography (CT) findings, operative details, histopathology, anticoagulation, and short-term outcomes were reviewed. Results: The patients included three men and three women aged 50–73 years. All had acute abdominal symptoms and were subjected to emergency laparotomy and bowel resection. Three patients had superior mesenteric artery thrombosis, one of whom had splenic artery thrombosis and another had portal venous gas. One patient developed sigmoid-colon ischemia with suspected partial inferior mesenteric artery thrombosis, one had probable non-occlusive mesenteric ischemia, and one developed ischemic ileal perforation without major-vessel thrombosis. Four patients had pneumatosis intestinalis or coli. All six cases had transmural ischemic necrosis with fibrin thrombi in intraluminal or submucosal vessels on histopathological examination. Five patients received unfractionated heparin, and one patient with probable non-occlusive mesenteric ischemia did not receive anticoagulation. The early postoperative mortality rate was 66.7% (4 patients). At 3-month follow-up, the two survivors were asymptomatic. Conclusion: Intestinal ischemia associated with COVID-19 can be caused by large-vessel arterial thrombosis, non-occlusive ischemia, or microvascular thrombosis and can manifest as bowel gangrene or perforation. In patients with COVID-19, persistent or severe abdominal symptoms should be evaluated promptly with contrast-enhanced CT and early surgical evaluation. Even with emergency intervention, mortality is high after the development of transmural bowel necrosis.