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Serious Gastrointestinal Symptoms Also Can Signal COVID-19 Infection

Gastrointestinal symptoms shouldn’t be disregarded or considered to be unrelated to COVID-19 infection, according to a new imaging study finding serious bowel abnormalities in some patients. Here’s what pharmacists need to know.  

BOSTON – COVID-19 was originally thought to primarily be a respiratory infection, but, increasingly, clinicians are realizing the effects go far beyond then.

A new study in the journal Radiology, reports evidence that patients with COVID-19 can have bowel abnormalities, including ischemia.

https://pubs.rsna.org/doi/10.1148/radiol.2020201908

Massachusetts General Hospital and Harvard Medical School researchers point out that reports have recently documented that gastrointestinal symptoms, liver injury, and vascular findings are common in novel coronavirus patients. Noting that abdominal imaging findings have not yet been widely reported, the team conducted a retrospective study of 412 patients consecutively admitted to a single quaternary care center from March 27 to April 10, 2020, who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

“Angiotensin converting enzyme 2 (ACE2), a target of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), demonstrates its highest surface expression in the lung, small bowel, and vasculature, suggesting abdominal viscera may be susceptible to injury,” researchers explain.

Overall, 224 abdominal imaging studies were performed in about a third of the patients – 137 radiographs, 44 ultrasounds, 42 CT scans and one MRI. Abdominal imaging was associated with age (odds ratio [OR] 1.03 per year increase, p=0.001) and intensive care unit admission (OR 17.3, p<0.001).

Results indicate that bowel wall abnormalities were seen on 31% of CT scans and were associated with ICU admission (OR 15.5, p=0.01). Bowel findings included pneumatosis or portal venous gas, seen on 20% of CT scans in ICU patients. In addition, surgical correlation in four patients revealed unusual yellow discoloration of bowel in three of them and bowel infarction in two. Researchers report that pathology demonstrated ischemic enteritis with patchy necrosis and fibrin thrombi in arterioles in two patients.

As for right upper quadrant ultrasounds, 87% were performed for liver laboratory findings, and 54) demonstrated a dilated sludge-filled gallbladder suggestive of cholestasis. The four patients with placement of a cholecystostomy tube had negative bacterial cultures.

“Bowel abnormalities and cholestasis were common findings on abdominal imaging of inpatients with COVID-19. Patients who went to laparotomy often had ischemia, possibly due to small vessel thrombosis,” the authors conclude.

“The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), presents an ongoing global threat,” researchers write. “Common clinical features reported in early confirmed infections included fever, cough, and myalgias or fatigue. But as testing capacity and case numbers have increased worldwide, gastrointestinal (GI) symptoms such as diarrhea, nausea/vomiting, abdominal pain, and loss of appetite have been increasingly recognized. Although lung injury is most common, liver injury of uncertain etiology has been observed in patients with COVID-19, with increased frequency in severe cases.”

"We found bowel abnormalities on imaging in patients with COVID-19, more commonly in sicker patients who went to the ICU," added lead author Rajesh Bhayana, MD, an abdominal imaging fellow in the Department of Radiology at Massachusetts General Hospital in Boston.

"Some findings were typical of bowel ischemia, or dying bowel, and in those who had surgery we saw small vessel clots beside areas of dead bowel," Bhayana described. "Patients in the ICU can have bowel ischemia for other reasons, but we know COVID-19 can lead to clotting and small vessel injury, so bowel might also be affected by this."

The researchers offered possible explanations for the range of bowel findings in COVID-19 patients, including direct viral infection, small vessel thrombosis, or nonocclusive mesenteric ischemia. "ACE2 expression is most abundant in lung alveolar epithelial cells, enterocytes of the small intestine.