SlideShare ist ein Scribd-Unternehmen logo
1 von 5
Downloaden Sie, um offline zu lesen
Creative Commons 4.0
Gastrointestinal perforation in COVID-19 patients – case series
and review of the literature
Deepak Vermaa, *
, Sarthak Sharmaa
, Lalit Kishore Garga
, Aishwarya Tinaikara
a Department of Surgery, Dr. Sampurnanand Medical College, Jodhpur 342001, Rajasthan, India.
* Corresponding author: Deepak Verma
Mailing address: Department of Surgery, Dr. Sampurnanand
Medical College, Jodhpur 342001, Rajasthan, India.
E-mail: drdeepakv3@gmail.com
Received: 11 December 2020 / Accepted: 24 December 2020
INTRODUCTION
Severe acute respiratory syndrome coronavirus-2
(SARS-CoV 2) caused coronavirus disease and it had af-
fected 5 crore world’s population with 14 lakh deaths.
Since the virus primarily affected respiratory systems,
the initial phase of symptomatology revolved around
respiratory symptoms like dry cough, fever, etc. due
to the involvement of the lungs [1]
. But as time passed,
varied symptoms were increasingly noted either in ad-
dition to respiratory symptoms or in isolation like loss
of smell and taste, myalgia, pain abdomen, diarrhea [2,
3]
. Lately, gastrointestinal symptoms with acute abdo-
men were observed in a few patients, and a diagnosis
of gastrointestinal perforation was made.
As more and more studies poured in regarding the
nature of Severe acute respiratory syndrome coro-
navirus -2 (SARS-CoV 2), theories were postulated
Case Report
regarding the pathogenesis of perforation. Presence of
Angiotension-converting Enzyme (ACE 2) receptors in
the stomach, duodenum, and rectum, thromboembolic
phenomenon leading to ischemia of gut, neuroinvasive
propensity of virus causing dilatation of gut, increase
intraluminal pressure due to constipation and finally
the rare side effect of Tocilizumab used for COVID-19
cases treatment were considered as causes for gastro-
intestinal tract perforation.
We are presenting a case report of three cases pre-
senting as perforation during the course of COVID-19
disease along with a review of the literature regarding
causes of such perforation.
CASE REPORT
Case 1
A 60 years old female was admitted with symptoms
of dry cough, fever, and myalgia and tested positive
for COVID-19 RT-PCR. She was a known case of hypo-
thyroidism (on 75 microgram thyroxine per day). She
was treated with steroids and Rivaroxaban and sent
for home isolation after 7 days. On the 4th
day of her
discharge, she complained of pain abdomen and dis-
tension. Examination revealed distension with guard-
Abstract
Severe acute respiratory syndrome coronavirus-2 (SARS-CoV 2) involving the respiratory tract started in 2019
in Wuhan, China but spread to almost all parts of the world to the extent that it was declared a pandemic by
WHO. As more and more cases are detected, the involvement of systems other than respiratory was observed
and nearly 5 to 50 % of patients have abdominal symptoms like pain and diarrhea. During the course of treat-
ment, few patients developed a rare complication of gastrointestinal perforation. Three cases (two with colonic
perforation and one with gastric perforation) of gastrointestinal perforation in COVID-19 positive patient are
reported in the article with a review of the literature regarding the various hypothesis of intestinal perforation
in these patients.
Keywords: COVID-19; gastrointestinal perforation; severe acute respiratory syndrome coronavirus-2
(SARS-CoV 2); Tocilizumab
Clin Surg Res Commun 2020; 4(4): 13-17
DOI: 10.31491/CSRC.2020.12.064
Metin Onur Beyaz et al 13
ing and rigidity all over the abdomen. Besides other
investigations, COVID-19 RT-PCR was repeated which
was positive. D-Dimer was 953 ng/ml, LDH- 735 U/L,
PT was 30.6 seconds with 2.56 INR. IL-6, Ferritin, and
other investigations were within normal limits. CT tho-
rax was suggestive of multifocal areas of consolidation
in bilateral peripheral lung fields – typical of COVID-19
with a severity score of 17/25 (Figure 1). X-Ray chest
ANT PUBLISHING CORPORATION
Published online: 30 December 2020
showed bilateral consolidation with gas under the dia-
phragm (Figure 2).
Exploratory laparotomy revealed a fecal-purulent col-
lection of 2 liters with dense adhesion and 1 cm size
perforation over the anterior wall of the upper one-
third of the rectum. The surrounding rectal wall was
oedematous. Repair of perforation with decompressing
transverse loop colostomy was done. The patient was
treated in ICU with antibiotics, fluconazole, low mo-
lecular weight heparin. Repeated RT-PCR for COVID-19
was negative on the 6th
post-operative day. She was
discharged from the hospital on the 11th
post-operative
day.
Case 2
A 24-year female was admitted to the Department of
Obstetric with full-term pregnancy and labor pains.
She was subjected to emergency Lower segment ce-
sarean section. On the fifth postoperative day, she
complained of severe pain abdomen, vomiting, and
distension of the abdomen. The patient had tachy-
cardia with abdominal distension and obliteration of
liver dullness. Being immediate post-partum period,
guarding and rigidity were not appreciated due to the
lax abdominal wall. CT chest revealed atypical viral
pneumonitis (Figure 3). X-Ray was showing a massive
pneumoperitoneum (Figure 4) and COVID-19 RT-PCR
was positive. D-Dimer was 3000 ng/ml, IL6 – 127 pg/
ml and LDH was 800 U/L. Patient was subjected to
emergency exploratory laparotomy. There was 1.5 L of
fecal-purulent fluid in the peritoneal cavity with adhe-
sion and a 1.5 cm size perforation on the anterior wall
of the caecum and edema of the caecal wall. Primary
closure with decompressing loop ileostomy was done.
Oxygenation supplementation, Meropenam antibiotics
with low molecular weight heparin, and steroid were
given. The patient recovered and was discharged with
an ileostomy.
Deepak Verma et al 14
Figure 1: Chest CT scan of case 1 showing patchy consolidation
of COVID-19 (Score 17/25).
Figure 2: X-Ray Flat plate abdomen in erect posture showing
gas under the diaphragm (Case 1).
Figure 3: CT scan chest showing atypical viral pneumonitis
(COVID-19) of case 2.
spread to all other parts of the world becoming a pan-
demic. India is the second most affected country across
the world (nearly one billion cases) with a mortality of
about 1.5 %. Since it primarily affects the respiratory
system, symptoms such a fever, dry cough, dyspnea,
and respiratory illness represent the most common
manifestation [1]
.
Since the virus and illness are relatively new, symptom-
atology is not very well understood and as the number
of cases is increasing, various new symptoms like loss
of smell and taste, etc. have also been reported. Ap-
proximately 5 to 50% of the cases have gastrointestinal
symptoms [2]
like pain abdomen, diarrhea, and vomiting
[3]
. Detection of COVID-19 virus in stool [4]
and a poten-
tial fecal-oral transmission route has been suggested [5]
.
The various mechanism by which the gastrointestinal
tract is affected in COVID-19 has been postulated. High
expression of the angiotensin-converting enzyme (ACE)
2 receptor in the epithelium of the stomach, duodenum,
and rectum [6]
with SARS-CoV 2 binding to these recep-
tors to gain entrance to host cell [7]
is the key mecha-
nism of involvement of gastrointestinal tract.
Studies have stated that critically ill patients with CO-
VID-19 are more likely to have a hypercoagulable state,
with the manifestation of intravascular coagulation
due to local damage [8, 9]
. This may lead to ischemia of
the entire gut with colonic perforation as a part of the
septic and thromboembolic phenomenon caused by
viral infection directly and indirectly.
SARS-CoV 2 RNA was mainly detected in the cytoplasm
of gastrointestinal epithelial cells indicating infection
and replication of the virus in these cells leading to lo-
cal damage [10]
.
Since the neuroinvasive propensity has been demon-
strated as a common feature of coronavirus, a neuronal
injury should be regarded as a possible pathogenetic
mechanism [11]
. This causes an imbalance of the auto-
nomic innervation of the colon, altered colonic motil-
ity, and dilatation of the colon.
Critically ill ICU patients due to COVID-19 are mostly
kept nil orally and can also have stress-related muco-
sal damage with ulceration. These patients become
significantly constipated contributing to increased in-
traluminal pressure [12]
. Colonic dilatation and increase
intraluminal pressure can precipitate perforation of
the gastrointestinal tract particularly the stomach,
duodenum, and colon. Studies have demonstrated the
detectable presence of coronavirus RNA in stools of in-
fected patients [10, 13]
. Perforation in COVID-19 patients
has been reported in various studies [2,14]
. A combina-
Clin Surg Res Commun 2020; 4(4): 13-17
DOI: 10.31491/CSRC.2020.12.064
Deepak Verma et al 15
Case 3
A 21-year-old male patient presented in a surgical
emergency with a history of pain, fever, cough, vomit-
ing, and distension of the abdomen. Clinical examina-
tion revealed a distended abdomen with guarding and
rigidity along with pyrexia. No previous history of drug
intake or acid peptic disease was present. X-Ray flat
plate abdomen revealed gas under the diaphragm. CO-
VID-19 RT-PCR was positive. Other routine investiga-
tions were normal except for an INR of 2.14. D-Dimer,
IL-6, and LDH were marginally raised. Emergency
exploratory laparotomy was done and there was in-
flamed thick omentum with 2 L of bile stained purulent
fluid. 0.5 cm size perforation was seen on the anterior
wall of the stomach at the pre-pyloric region. Closure
of perforation with Graham’s patch and LMWH, anti-
biotics, corticosteroids, and oxygen supplementation
were administered. The patient was discharged on the
11th
post-operative day.
DISCUSSION
Severe acute respiratory syndrome coronavirus-2
(SARS-CoV 2) cause novel coronavirus disease. Al-
though it started in Wuhan, China in 2019, now it had
Figure 4: Presence of gas under diaphragm case 2.
ANT PUBLISHING CORPORATION
Published online: 30 December 2020
Consent for publication
Written consent was obtained from the individual case
for publication of images used in this paper.
REFERENCES
1.	 Zhu, N., Zhang, D., Wang, W., Li, X., Yang, B., Song, J., ... &
Niu, P. (2020). A novel coronavirus from patients with
pneumonia in China, 2019. New England Journal of Med-
icine.
2.	 Neto, I. J. F. C., Viana, K. F., da Silva, M. B. S., da Silva, L.
M., de Oliveira, G., da Silva Cecchini, A. R., ... & Robles, L.
(2020). Perforated acute abdomen in a patient with CO-
VID-19: an atypical manifestation of the disease. Journal
of Coloproctology.
3.	 Kotfis, K., & Skonieczna-Żydecka, K. (2020). COVID-19:
gastrointestinal symptoms and potential sources of
2019-nCoV transmission. Anaesthesiol Intensive Ther
2020; 52 (1).
4.	 Jin, X., Lian, J. S., Hu, J. H., Gao, J., Zheng, L., Zhang, Y. M., ...
& Yu, G. D. (2020). Epidemiological, clinical and virologi-
cal characteristics of 74 cases of coronavirus-infected
disease 2019 (COVID-19) with gastrointestinal symp-
toms. Gut, 69(6), 1002-1009.
5.	 Gu, J., Han, B., & Wang, J. (2020). COVID-19: gastrointes-
tinal manifestations and potential fecal–oral transmis-
sion. Gastroenterology, 158(6), 1518-1519.
6.	 Zhao, D., Yao, F., Wang, L., Zheng, L., Gao, Y., Ye, J., ... & Gao,
R. (2020). A comparative study on the clinical features
of COVID-19 pneumonia to other pneumonias. Clinical
Infectious Diseases.
7.	 Wong, S. H., Lui, R. N., & Sung, J. J. (2020). Covid‐19 and
the digestive system. Journal of gastroenterology and
hepatology, 35(5), 744-748.
8.	 Song, Y., Liu, P., Shi, X. L., Chu, Y. L., Zhang, J., Xia, J., ... &
Wang, M. Y. (2020). SARS-CoV-2 induced diarrhoea as
onset symptom in patient with COVID-19. Gut, 69(6),
1143-1144.
9.	 Wang, W., Gao, R., Zheng, Y., & Jiang, L. (2020). COVID-19
with spontaneous pneumothorax, pneumomediastinum
and subcutaneous emphysema. Journal of travel medi-
cine, 27(5), taaa062.
10.	 Tian, Y., Rong, L., Nian, W., & He, Y. (2020). gastrointes-
tinal features in COVID‐19 and the possibility of faecal
transmission. Alimentary pharmacology & therapeutics,
51(9), 843-851.
11.	 Conde, G., Pájaro, L. D. Q., Marzola, I. D. Q., Villegas, Y. R.,
& Salazar, L. R. M. (2020). Neurotropism of SARS-CoV 2:
Mechanisms and manifestations. Journal of the neuro-
logical sciences.
12.	 Kangas-Dick, A., Prien, C., Rojas, K., Pu, Q., Hamshow, M.,
Wan, E., ... & Wiesel, O. (2020). Gastrointestinal perfora-
tion in a critically ill patient with COVID-19 pneumonia.
tion of factors like mucosal damage, ulceration, over-
distension of the bowel, and increased intraluminal
pressure contribute to the perforation of the bowel.
Tocilizumab, a monoclonal IL-6 receptor antibody, is
used in rheumatoid arthritis and its use was identi-
fied as a risk factor associated with lower intestinal
perforation, which had been reported as a rare but
serious complication in a clinical trial of this drug [15]
.
The mechanism of intestinal perforation in patients
receiving Tocilizumab is not fully understood, but prior
diverticulitis has been noted as a risk factor [15]
. Since
there is no elevation of C-Reactive protein in these
patients there is some delay in the diagnosis of per-
foration. Tocilizumab is also used in the treatment of
cytokine release syndrome associated with severe CO-
VID-19 [16]
. Other authors have also warned about the
possibility of the risk of intestinal perforation while
using Tocilizumab in COVID-19 patients [17]
. However,
in the cases reported in this study, Tocilizumab was not
used in any patient for COVID-19 treatment.
Diagnosis of gastrointestinal perforation can easily
be made by history of pain, distension of abdomen,
guarding and rigidity, and radiographic evidence of
pneumoperitoneum. In a clinically stable patient, CT
abdomen is more sensitive investigation along with CT
chest to predict outcome post-surgery. Early operative
intervention carries a better prognosis. Delay in the
diagnosis of gastrointestinal perforation is associated
with a poor prognosis due to compromised respiratory
status, septicemia, edema of gut precluding optimum
closure of gut, and high incidence of the thromboem-
bolic phenomenon. However, in cases diagnosed later
with the poor general condition, drainage of the peri-
toneal cavity at the bedside with non-operative conser-
vative management can be attempted although with a
guarded prognosis.
DECLARATIONS
Authors’ contributions
Deepak Verma participated in surgical treatment and
wrote the article. Sarthak Sharma carried out treat-
ment and recordkeeping and data acquisition. Lalit
Kishore Garg checked the article and supervised the
patient’s care. Aishwarya Tinaikar followed the patient
in outcome point.
Conflict of interest
The authors declared that there are no conflicts of in-
terest to disclose.
Deepak Verma et al 16
Clin Surg Res Commun 2020; 4(4): 13-17
DOI: 10.31491/CSRC.2020.12.064
Deepak Verma et al 17
SAGE open medical case reports, 8, 2050313X20940570.
13.	 Zhang, W., Du, R. H., Li, B., Zheng, X. S., Yang, X. L., Hu, B.,
... & Zhou, P. (2020). Molecular and serological investiga-
tion of 2019-nCoV infected patients: implication of mul-
tiple shedding routes. Emerging microbes & infections,
9(1), 386-389.
14.	 De Nardi, P., Parolini, D. C., Ripa, M., Racca, S., & Rosati,
R. (2020). Bowel perforation in a Covid-19 patient: case
report. International Journal of Colorectal Disease, 1.
15.	 Strangfeld, A., Richter, A., Siegmund, B., Herzer, P., Rock-
witz, K., Demary, W., ... & Listing, J. (2017). Risk for lower
intestinal perforations in patients with rheumatoid
arthritis treated with tocilizumab in comparison to
treatment with other biologic or conventional synthetic
DMARDs. Annals of the rheumatic diseases, 76(3), 504-
510.
16.	 Zhang, C., Wu, Z., Li, J. W., Zhao, H., & Wang, G. Q. (2020).
The cytokine release syndrome (CRS) of severe CO-
VID-19 and Interleukin-6 receptor (IL-6R) antagonist
Tocilizumab may be the key to reduce the mortality. In-
ternational journal of antimicrobial agents, 105954.
17.	 Vikse, J., & Henry, B. M. (2020). Tocilizumab in COVID-19:
beware of risk of intestinal perforation. International
Journal of Antimicrobial Agents.

Weitere ähnliche Inhalte

Was ist angesagt?

ABDOMINAL TUBERCULOSIS (STUDY OF 50 CASES)
ABDOMINAL TUBERCULOSIS (STUDY OF 50 CASES)ABDOMINAL TUBERCULOSIS (STUDY OF 50 CASES)
ABDOMINAL TUBERCULOSIS (STUDY OF 50 CASES)KETAN VAGHOLKAR
 
LAPAROSCOPIC VERSUS OPEN APPENDICECTOMY IN ADULTS. (STUDY OF 50 CASES)
LAPAROSCOPIC VERSUS OPEN APPENDICECTOMY IN ADULTS. (STUDY OF 50 CASES)LAPAROSCOPIC VERSUS OPEN APPENDICECTOMY IN ADULTS. (STUDY OF 50 CASES)
LAPAROSCOPIC VERSUS OPEN APPENDICECTOMY IN ADULTS. (STUDY OF 50 CASES)KETAN VAGHOLKAR
 
Perforated Peptic Ulcer Discussion
Perforated Peptic Ulcer DiscussionPerforated Peptic Ulcer Discussion
Perforated Peptic Ulcer DiscussionAR Muhamad Na'im
 
Reoperation for Hirschsprung Disease Research Article
Reoperation for Hirschsprung Disease Research ArticleReoperation for Hirschsprung Disease Research Article
Reoperation for Hirschsprung Disease Research ArticleAlexander Coe
 
Non variceal upper gi bleeding ijrpp
Non variceal upper gi bleeding   ijrppNon variceal upper gi bleeding   ijrpp
Non variceal upper gi bleeding ijrpppharmaindexing
 
Post Ercp duioenal Perforation ( a review of litearture)
Post Ercp duioenal Perforation ( a review of litearture)Post Ercp duioenal Perforation ( a review of litearture)
Post Ercp duioenal Perforation ( a review of litearture)Saade umeed Welfare society
 
Egypt j bronchol_2016_10_3_243_193629
Egypt j bronchol_2016_10_3_243_193629Egypt j bronchol_2016_10_3_243_193629
Egypt j bronchol_2016_10_3_243_193629Saher Farghly
 
Study of clinical and etiological profile of community acquired pneumonia in ...
Study of clinical and etiological profile of community acquired pneumonia in ...Study of clinical and etiological profile of community acquired pneumonia in ...
Study of clinical and etiological profile of community acquired pneumonia in ...iosrjce
 
Splenic Abscess: a mysterious entity
Splenic Abscess: a mysterious entitySplenic Abscess: a mysterious entity
Splenic Abscess: a mysterious entityiosrjce
 
Pulmonary Paragonimiasis in Manipur, India – A Prospective Cross-sectional st...
Pulmonary Paragonimiasis in Manipur, India – A Prospective Cross-sectional st...Pulmonary Paragonimiasis in Manipur, India – A Prospective Cross-sectional st...
Pulmonary Paragonimiasis in Manipur, India – A Prospective Cross-sectional st...iosrjce
 
Fungal Infections in the Intensive Care Unit and Antifungals
Fungal Infections in the Intensive Care Unit and AntifungalsFungal Infections in the Intensive Care Unit and Antifungals
Fungal Infections in the Intensive Care Unit and AntifungalsParthasarathi Ghosh
 
Cryptic Disseminated Tuberculosis: a Secondary Analysis of Previous Hospital-...
Cryptic Disseminated Tuberculosis: a Secondary Analysis of Previous Hospital-...Cryptic Disseminated Tuberculosis: a Secondary Analysis of Previous Hospital-...
Cryptic Disseminated Tuberculosis: a Secondary Analysis of Previous Hospital-...fahmi khan
 
Interstitial pulmonary fibrosis
Interstitial pulmonary fibrosisInterstitial pulmonary fibrosis
Interstitial pulmonary fibrosisashish ranjan
 
A Retrospective Analysis of Complications of Pelvic Exenteration - A Single I...
A Retrospective Analysis of Complications of Pelvic Exenteration - A Single I...A Retrospective Analysis of Complications of Pelvic Exenteration - A Single I...
A Retrospective Analysis of Complications of Pelvic Exenteration - A Single I...Premier Publishers
 

Was ist angesagt? (18)

ABDOMINAL TUBERCULOSIS (STUDY OF 50 CASES)
ABDOMINAL TUBERCULOSIS (STUDY OF 50 CASES)ABDOMINAL TUBERCULOSIS (STUDY OF 50 CASES)
ABDOMINAL TUBERCULOSIS (STUDY OF 50 CASES)
 
Disseminated Intra-Abdominal Hydatidosis: A Case Report
Disseminated Intra-Abdominal Hydatidosis: A Case Report   Disseminated Intra-Abdominal Hydatidosis: A Case Report
Disseminated Intra-Abdominal Hydatidosis: A Case Report
 
Ulcera perforada
Ulcera perforadaUlcera perforada
Ulcera perforada
 
LAPAROSCOPIC VERSUS OPEN APPENDICECTOMY IN ADULTS. (STUDY OF 50 CASES)
LAPAROSCOPIC VERSUS OPEN APPENDICECTOMY IN ADULTS. (STUDY OF 50 CASES)LAPAROSCOPIC VERSUS OPEN APPENDICECTOMY IN ADULTS. (STUDY OF 50 CASES)
LAPAROSCOPIC VERSUS OPEN APPENDICECTOMY IN ADULTS. (STUDY OF 50 CASES)
 
Perforated Peptic Ulcer Discussion
Perforated Peptic Ulcer DiscussionPerforated Peptic Ulcer Discussion
Perforated Peptic Ulcer Discussion
 
Reoperation for Hirschsprung Disease Research Article
Reoperation for Hirschsprung Disease Research ArticleReoperation for Hirschsprung Disease Research Article
Reoperation for Hirschsprung Disease Research Article
 
Non variceal upper gi bleeding ijrpp
Non variceal upper gi bleeding   ijrppNon variceal upper gi bleeding   ijrpp
Non variceal upper gi bleeding ijrpp
 
Post Ercp duioenal Perforation ( a review of litearture)
Post Ercp duioenal Perforation ( a review of litearture)Post Ercp duioenal Perforation ( a review of litearture)
Post Ercp duioenal Perforation ( a review of litearture)
 
Egypt j bronchol_2016_10_3_243_193629
Egypt j bronchol_2016_10_3_243_193629Egypt j bronchol_2016_10_3_243_193629
Egypt j bronchol_2016_10_3_243_193629
 
Study of clinical and etiological profile of community acquired pneumonia in ...
Study of clinical and etiological profile of community acquired pneumonia in ...Study of clinical and etiological profile of community acquired pneumonia in ...
Study of clinical and etiological profile of community acquired pneumonia in ...
 
Splenic Abscess: a mysterious entity
Splenic Abscess: a mysterious entitySplenic Abscess: a mysterious entity
Splenic Abscess: a mysterious entity
 
Pulmonary Paragonimiasis in Manipur, India – A Prospective Cross-sectional st...
Pulmonary Paragonimiasis in Manipur, India – A Prospective Cross-sectional st...Pulmonary Paragonimiasis in Manipur, India – A Prospective Cross-sectional st...
Pulmonary Paragonimiasis in Manipur, India – A Prospective Cross-sectional st...
 
Fungal Infections in the Intensive Care Unit and Antifungals
Fungal Infections in the Intensive Care Unit and AntifungalsFungal Infections in the Intensive Care Unit and Antifungals
Fungal Infections in the Intensive Care Unit and Antifungals
 
Cryptic Disseminated Tuberculosis: a Secondary Analysis of Previous Hospital-...
Cryptic Disseminated Tuberculosis: a Secondary Analysis of Previous Hospital-...Cryptic Disseminated Tuberculosis: a Secondary Analysis of Previous Hospital-...
Cryptic Disseminated Tuberculosis: a Secondary Analysis of Previous Hospital-...
 
Interstitial pulmonary fibrosis
Interstitial pulmonary fibrosisInterstitial pulmonary fibrosis
Interstitial pulmonary fibrosis
 
A Retrospective Analysis of Complications of Pelvic Exenteration - A Single I...
A Retrospective Analysis of Complications of Pelvic Exenteration - A Single I...A Retrospective Analysis of Complications of Pelvic Exenteration - A Single I...
A Retrospective Analysis of Complications of Pelvic Exenteration - A Single I...
 
C0621115
C0621115C0621115
C0621115
 
Hope for IPF
Hope for IPFHope for IPF
Hope for IPF
 

Ähnlich wie Gastrointestinal perforation in covid 19 patients – case series and review of the literature

Digestive Manifestations During Infection with COVID-19: Experience of A Moro...
Digestive Manifestations During Infection with COVID-19: Experience of A Moro...Digestive Manifestations During Infection with COVID-19: Experience of A Moro...
Digestive Manifestations During Infection with COVID-19: Experience of A Moro...semualkaira
 
Digestive Manifestations During Infection with COVID-19: Experience of A Moro...
Digestive Manifestations During Infection with COVID-19: Experience of A Moro...Digestive Manifestations During Infection with COVID-19: Experience of A Moro...
Digestive Manifestations During Infection with COVID-19: Experience of A Moro...semualkaira
 
COVID-19 Testing Centers PowerPoint Templates.pptx
COVID-19 Testing Centers PowerPoint Templates.pptxCOVID-19 Testing Centers PowerPoint Templates.pptx
COVID-19 Testing Centers PowerPoint Templates.pptxKhushbooPriyaMishra
 
Case report :systemic torulopsis after gastric bypass operation
Case report :systemic torulopsis after gastric bypass operationCase report :systemic torulopsis after gastric bypass operation
Case report :systemic torulopsis after gastric bypass operationAhmed Bahnassy
 
GI Manifestation in COVID 19 Patient
GI Manifestation in COVID 19 PatientGI Manifestation in COVID 19 Patient
GI Manifestation in COVID 19 PatientKhushboo Priya
 
COVID-19: More Than A Lung Infection
COVID-19: More Than A Lung InfectionCOVID-19: More Than A Lung Infection
COVID-19: More Than A Lung InfectionJohnJulie1
 
COVID-19: More Than A Lung Infection
COVID-19: More Than A Lung InfectionCOVID-19: More Than A Lung Infection
COVID-19: More Than A Lung InfectionJohnJulie1
 
COVID-19: More Than A Lung Infection
COVID-19: More Than A Lung InfectionCOVID-19: More Than A Lung Infection
COVID-19: More Than A Lung InfectionAnonIshanvi
 
COVID-19: More Than A Lung Infection
COVID-19: More Than A Lung InfectionCOVID-19: More Than A Lung Infection
COVID-19: More Than A Lung Infectionsemualkaira
 
COVID-19: More Than A Lung Infection
COVID-19: More Than A Lung InfectionCOVID-19: More Than A Lung Infection
COVID-19: More Than A Lung InfectionEditorSara
 
COVID-19: More Than A Lung Infection
COVID-19: More Than A Lung InfectionCOVID-19: More Than A Lung Infection
COVID-19: More Than A Lung Infectionsemualkaira
 
COVID-19: More Than A Lung Infection
COVID-19: More Than A Lung InfectionCOVID-19: More Than A Lung Infection
COVID-19: More Than A Lung InfectionNainaAnon
 
COVID-19 is a new strain of Coronaviruses virus declared by the World Health ...
COVID-19 is a new strain of Coronaviruses virus declared by the World Health ...COVID-19 is a new strain of Coronaviruses virus declared by the World Health ...
COVID-19 is a new strain of Coronaviruses virus declared by the World Health ...semualkaira
 
COVID-19: More Than A Lung Infection
COVID-19: More Than A Lung InfectionCOVID-19: More Than A Lung Infection
COVID-19: More Than A Lung Infectiondaranisaha
 
COVID 19 radiology.ppt human education system
COVID 19 radiology.ppt human education systemCOVID 19 radiology.ppt human education system
COVID 19 radiology.ppt human education systemssuserb52e6c
 
Gastrointestinal Manifestations of Covid 19 piyush
Gastrointestinal Manifestations of  Covid 19 piyushGastrointestinal Manifestations of  Covid 19 piyush
Gastrointestinal Manifestations of Covid 19 piyushpiyushpatwa
 
Covid 19 aka mers cov2 update and perinatal covid
Covid 19 aka mers cov2 update and perinatal covidCovid 19 aka mers cov2 update and perinatal covid
Covid 19 aka mers cov2 update and perinatal covidSri ChowdarRy
 
Bowel Perforation in COVID-19 Patient Treated With Dexamethasone
Bowel Perforation in COVID-19 Patient Treated With DexamethasoneBowel Perforation in COVID-19 Patient Treated With Dexamethasone
Bowel Perforation in COVID-19 Patient Treated With Dexamethasonesuppubs1pubs1
 
Tuberculous Ileal Perforation in Post-Appendicectomy PeriOperative Period: A ...
Tuberculous Ileal Perforation in Post-Appendicectomy PeriOperative Period: A ...Tuberculous Ileal Perforation in Post-Appendicectomy PeriOperative Period: A ...
Tuberculous Ileal Perforation in Post-Appendicectomy PeriOperative Period: A ...iosrjce
 

Ähnlich wie Gastrointestinal perforation in covid 19 patients – case series and review of the literature (20)

Digestive Manifestations During Infection with COVID-19: Experience of A Moro...
Digestive Manifestations During Infection with COVID-19: Experience of A Moro...Digestive Manifestations During Infection with COVID-19: Experience of A Moro...
Digestive Manifestations During Infection with COVID-19: Experience of A Moro...
 
Digestive Manifestations During Infection with COVID-19: Experience of A Moro...
Digestive Manifestations During Infection with COVID-19: Experience of A Moro...Digestive Manifestations During Infection with COVID-19: Experience of A Moro...
Digestive Manifestations During Infection with COVID-19: Experience of A Moro...
 
TRombosis metadica
TRombosis metadica TRombosis metadica
TRombosis metadica
 
COVID-19 Testing Centers PowerPoint Templates.pptx
COVID-19 Testing Centers PowerPoint Templates.pptxCOVID-19 Testing Centers PowerPoint Templates.pptx
COVID-19 Testing Centers PowerPoint Templates.pptx
 
Case report :systemic torulopsis after gastric bypass operation
Case report :systemic torulopsis after gastric bypass operationCase report :systemic torulopsis after gastric bypass operation
Case report :systemic torulopsis after gastric bypass operation
 
GI Manifestation in COVID 19 Patient
GI Manifestation in COVID 19 PatientGI Manifestation in COVID 19 Patient
GI Manifestation in COVID 19 Patient
 
COVID-19: More Than A Lung Infection
COVID-19: More Than A Lung InfectionCOVID-19: More Than A Lung Infection
COVID-19: More Than A Lung Infection
 
COVID-19: More Than A Lung Infection
COVID-19: More Than A Lung InfectionCOVID-19: More Than A Lung Infection
COVID-19: More Than A Lung Infection
 
COVID-19: More Than A Lung Infection
COVID-19: More Than A Lung InfectionCOVID-19: More Than A Lung Infection
COVID-19: More Than A Lung Infection
 
COVID-19: More Than A Lung Infection
COVID-19: More Than A Lung InfectionCOVID-19: More Than A Lung Infection
COVID-19: More Than A Lung Infection
 
COVID-19: More Than A Lung Infection
COVID-19: More Than A Lung InfectionCOVID-19: More Than A Lung Infection
COVID-19: More Than A Lung Infection
 
COVID-19: More Than A Lung Infection
COVID-19: More Than A Lung InfectionCOVID-19: More Than A Lung Infection
COVID-19: More Than A Lung Infection
 
COVID-19: More Than A Lung Infection
COVID-19: More Than A Lung InfectionCOVID-19: More Than A Lung Infection
COVID-19: More Than A Lung Infection
 
COVID-19 is a new strain of Coronaviruses virus declared by the World Health ...
COVID-19 is a new strain of Coronaviruses virus declared by the World Health ...COVID-19 is a new strain of Coronaviruses virus declared by the World Health ...
COVID-19 is a new strain of Coronaviruses virus declared by the World Health ...
 
COVID-19: More Than A Lung Infection
COVID-19: More Than A Lung InfectionCOVID-19: More Than A Lung Infection
COVID-19: More Than A Lung Infection
 
COVID 19 radiology.ppt human education system
COVID 19 radiology.ppt human education systemCOVID 19 radiology.ppt human education system
COVID 19 radiology.ppt human education system
 
Gastrointestinal Manifestations of Covid 19 piyush
Gastrointestinal Manifestations of  Covid 19 piyushGastrointestinal Manifestations of  Covid 19 piyush
Gastrointestinal Manifestations of Covid 19 piyush
 
Covid 19 aka mers cov2 update and perinatal covid
Covid 19 aka mers cov2 update and perinatal covidCovid 19 aka mers cov2 update and perinatal covid
Covid 19 aka mers cov2 update and perinatal covid
 
Bowel Perforation in COVID-19 Patient Treated With Dexamethasone
Bowel Perforation in COVID-19 Patient Treated With DexamethasoneBowel Perforation in COVID-19 Patient Treated With Dexamethasone
Bowel Perforation in COVID-19 Patient Treated With Dexamethasone
 
Tuberculous Ileal Perforation in Post-Appendicectomy PeriOperative Period: A ...
Tuberculous Ileal Perforation in Post-Appendicectomy PeriOperative Period: A ...Tuberculous Ileal Perforation in Post-Appendicectomy PeriOperative Period: A ...
Tuberculous Ileal Perforation in Post-Appendicectomy PeriOperative Period: A ...
 

Mehr von Clinical Surgery Research Communications

Two treatment methods for spiral fracture of the lower third of the tibia sha...
Two treatment methods for spiral fracture of the lower third of the tibia sha...Two treatment methods for spiral fracture of the lower third of the tibia sha...
Two treatment methods for spiral fracture of the lower third of the tibia sha...Clinical Surgery Research Communications
 
Preoperative hematological parameters predicting mortality in stanford type a...
Preoperative hematological parameters predicting mortality in stanford type a...Preoperative hematological parameters predicting mortality in stanford type a...
Preoperative hematological parameters predicting mortality in stanford type a...Clinical Surgery Research Communications
 
Percutaneous transforaminal endoscopic discectomy in the treatment of lumbar ...
Percutaneous transforaminal endoscopic discectomy in the treatment of lumbar ...Percutaneous transforaminal endoscopic discectomy in the treatment of lumbar ...
Percutaneous transforaminal endoscopic discectomy in the treatment of lumbar ...Clinical Surgery Research Communications
 
Lnc rna meg3 promotes glaucomatous retinal ganglion cell apoptosis via upregu...
Lnc rna meg3 promotes glaucomatous retinal ganglion cell apoptosis via upregu...Lnc rna meg3 promotes glaucomatous retinal ganglion cell apoptosis via upregu...
Lnc rna meg3 promotes glaucomatous retinal ganglion cell apoptosis via upregu...Clinical Surgery Research Communications
 
Evaluation of subclavian, thoracic aorta and innominate artery injuries in bl...
Evaluation of subclavian, thoracic aorta and innominate artery injuries in bl...Evaluation of subclavian, thoracic aorta and innominate artery injuries in bl...
Evaluation of subclavian, thoracic aorta and innominate artery injuries in bl...Clinical Surgery Research Communications
 
Clinical application and efficacy analysis of 3 d navigation module in the tr...
Clinical application and efficacy analysis of 3 d navigation module in the tr...Clinical application and efficacy analysis of 3 d navigation module in the tr...
Clinical application and efficacy analysis of 3 d navigation module in the tr...Clinical Surgery Research Communications
 
Circ ldlrad3 regulates cell proliferation, migration and invasion of pancreat...
Circ ldlrad3 regulates cell proliferation, migration and invasion of pancreat...Circ ldlrad3 regulates cell proliferation, migration and invasion of pancreat...
Circ ldlrad3 regulates cell proliferation, migration and invasion of pancreat...Clinical Surgery Research Communications
 
Casc15 promotes lens epithelial cell apoptosis in age related cataracts by re...
Casc15 promotes lens epithelial cell apoptosis in age related cataracts by re...Casc15 promotes lens epithelial cell apoptosis in age related cataracts by re...
Casc15 promotes lens epithelial cell apoptosis in age related cataracts by re...Clinical Surgery Research Communications
 
Application of piezosurgery osteotomy in cervical laminoplasty prospective,...
Application of piezosurgery osteotomy in cervical laminoplasty   prospective,...Application of piezosurgery osteotomy in cervical laminoplasty   prospective,...
Application of piezosurgery osteotomy in cervical laminoplasty prospective,...Clinical Surgery Research Communications
 
Aneurysmal bone cyst arising in iliopubic chondromyxoid fibroma – a case report
Aneurysmal bone cyst arising in iliopubic chondromyxoid fibroma – a case reportAneurysmal bone cyst arising in iliopubic chondromyxoid fibroma – a case report
Aneurysmal bone cyst arising in iliopubic chondromyxoid fibroma – a case reportClinical Surgery Research Communications
 
A laparoscopic complete mesocolic excision for the surgical treatment of righ...
A laparoscopic complete mesocolic excision for the surgical treatment of righ...A laparoscopic complete mesocolic excision for the surgical treatment of righ...
A laparoscopic complete mesocolic excision for the surgical treatment of righ...Clinical Surgery Research Communications
 
A comparison of health related quality of life among knee osteoarthritis pati...
A comparison of health related quality of life among knee osteoarthritis pati...A comparison of health related quality of life among knee osteoarthritis pati...
A comparison of health related quality of life among knee osteoarthritis pati...Clinical Surgery Research Communications
 
Double j stent migration in the contralateral ureter during robotassisted pye...
Double j stent migration in the contralateral ureter during robotassisted pye...Double j stent migration in the contralateral ureter during robotassisted pye...
Double j stent migration in the contralateral ureter during robotassisted pye...Clinical Surgery Research Communications
 

Mehr von Clinical Surgery Research Communications (20)

X ray measurement and analysis on parameters of intervertebral foramen
X ray measurement and analysis on parameters of intervertebral foramenX ray measurement and analysis on parameters of intervertebral foramen
X ray measurement and analysis on parameters of intervertebral foramen
 
Two treatment methods for spiral fracture of the lower third of the tibia sha...
Two treatment methods for spiral fracture of the lower third of the tibia sha...Two treatment methods for spiral fracture of the lower third of the tibia sha...
Two treatment methods for spiral fracture of the lower third of the tibia sha...
 
Suppress lung cancer progression via up regulation of linc rna-p21
Suppress lung cancer progression via up regulation of linc rna-p21Suppress lung cancer progression via up regulation of linc rna-p21
Suppress lung cancer progression via up regulation of linc rna-p21
 
Preoperative hematological parameters predicting mortality in stanford type a...
Preoperative hematological parameters predicting mortality in stanford type a...Preoperative hematological parameters predicting mortality in stanford type a...
Preoperative hematological parameters predicting mortality in stanford type a...
 
Percutaneous transforaminal endoscopic discectomy in the treatment of lumbar ...
Percutaneous transforaminal endoscopic discectomy in the treatment of lumbar ...Percutaneous transforaminal endoscopic discectomy in the treatment of lumbar ...
Percutaneous transforaminal endoscopic discectomy in the treatment of lumbar ...
 
Lnc rna meg3 promotes glaucomatous retinal ganglion cell apoptosis via upregu...
Lnc rna meg3 promotes glaucomatous retinal ganglion cell apoptosis via upregu...Lnc rna meg3 promotes glaucomatous retinal ganglion cell apoptosis via upregu...
Lnc rna meg3 promotes glaucomatous retinal ganglion cell apoptosis via upregu...
 
Genital auto mutilation, the second attempt was dramatic
Genital auto mutilation, the second attempt was dramaticGenital auto mutilation, the second attempt was dramatic
Genital auto mutilation, the second attempt was dramatic
 
Evaluation of subclavian, thoracic aorta and innominate artery injuries in bl...
Evaluation of subclavian, thoracic aorta and innominate artery injuries in bl...Evaluation of subclavian, thoracic aorta and innominate artery injuries in bl...
Evaluation of subclavian, thoracic aorta and innominate artery injuries in bl...
 
Clinical application and efficacy analysis of 3 d navigation module in the tr...
Clinical application and efficacy analysis of 3 d navigation module in the tr...Clinical application and efficacy analysis of 3 d navigation module in the tr...
Clinical application and efficacy analysis of 3 d navigation module in the tr...
 
Circ ldlrad3 regulates cell proliferation, migration and invasion of pancreat...
Circ ldlrad3 regulates cell proliferation, migration and invasion of pancreat...Circ ldlrad3 regulates cell proliferation, migration and invasion of pancreat...
Circ ldlrad3 regulates cell proliferation, migration and invasion of pancreat...
 
Caustic esophageal stricture from diagnosis untill cure
Caustic esophageal stricture from diagnosis untill cureCaustic esophageal stricture from diagnosis untill cure
Caustic esophageal stricture from diagnosis untill cure
 
Casc15 promotes lens epithelial cell apoptosis in age related cataracts by re...
Casc15 promotes lens epithelial cell apoptosis in age related cataracts by re...Casc15 promotes lens epithelial cell apoptosis in age related cataracts by re...
Casc15 promotes lens epithelial cell apoptosis in age related cataracts by re...
 
Application of piezosurgery osteotomy in cervical laminoplasty prospective,...
Application of piezosurgery osteotomy in cervical laminoplasty   prospective,...Application of piezosurgery osteotomy in cervical laminoplasty   prospective,...
Application of piezosurgery osteotomy in cervical laminoplasty prospective,...
 
Aneurysmal bone cyst arising in iliopubic chondromyxoid fibroma – a case report
Aneurysmal bone cyst arising in iliopubic chondromyxoid fibroma – a case reportAneurysmal bone cyst arising in iliopubic chondromyxoid fibroma – a case report
Aneurysmal bone cyst arising in iliopubic chondromyxoid fibroma – a case report
 
Acute massive gastric dilatation a surgical emergency
Acute massive gastric dilatation   a surgical emergencyAcute massive gastric dilatation   a surgical emergency
Acute massive gastric dilatation a surgical emergency
 
A laparoscopic complete mesocolic excision for the surgical treatment of righ...
A laparoscopic complete mesocolic excision for the surgical treatment of righ...A laparoscopic complete mesocolic excision for the surgical treatment of righ...
A laparoscopic complete mesocolic excision for the surgical treatment of righ...
 
A comparison of health related quality of life among knee osteoarthritis pati...
A comparison of health related quality of life among knee osteoarthritis pati...A comparison of health related quality of life among knee osteoarthritis pati...
A comparison of health related quality of life among knee osteoarthritis pati...
 
A case of perinatal cardiomyopathy
A case of perinatal cardiomyopathyA case of perinatal cardiomyopathy
A case of perinatal cardiomyopathy
 
Double j stent migration in the contralateral ureter during robotassisted pye...
Double j stent migration in the contralateral ureter during robotassisted pye...Double j stent migration in the contralateral ureter during robotassisted pye...
Double j stent migration in the contralateral ureter during robotassisted pye...
 
Complicated tracheo bronchial papillomatosis
Complicated tracheo bronchial papillomatosisComplicated tracheo bronchial papillomatosis
Complicated tracheo bronchial papillomatosis
 

Kürzlich hochgeladen

ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptxORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptxNIKITA BHUTE
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaSujoy Dasgupta
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxNaveenkumar267201
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.pptRamDBawankar1
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyZurück zum Ursprung
 
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfPAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfDolisha Warbi
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu Medical University
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu Medical University
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Peter Embi
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsMedicoseAcademics
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdfHongBiThi1
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisSujoy Dasgupta
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdfHongBiThi1
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communicationskatiequigley33
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondSujoy Dasgupta
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfMedicoseAcademics
 

Kürzlich hochgeladen (20)

ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptxORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
 
American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturally
 
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfPAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
 
Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu
 
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functions
 
Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosis
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communications
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and Beyond
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdf
 

Gastrointestinal perforation in covid 19 patients – case series and review of the literature

  • 1. Creative Commons 4.0 Gastrointestinal perforation in COVID-19 patients – case series and review of the literature Deepak Vermaa, * , Sarthak Sharmaa , Lalit Kishore Garga , Aishwarya Tinaikara a Department of Surgery, Dr. Sampurnanand Medical College, Jodhpur 342001, Rajasthan, India. * Corresponding author: Deepak Verma Mailing address: Department of Surgery, Dr. Sampurnanand Medical College, Jodhpur 342001, Rajasthan, India. E-mail: drdeepakv3@gmail.com Received: 11 December 2020 / Accepted: 24 December 2020 INTRODUCTION Severe acute respiratory syndrome coronavirus-2 (SARS-CoV 2) caused coronavirus disease and it had af- fected 5 crore world’s population with 14 lakh deaths. Since the virus primarily affected respiratory systems, the initial phase of symptomatology revolved around respiratory symptoms like dry cough, fever, etc. due to the involvement of the lungs [1] . But as time passed, varied symptoms were increasingly noted either in ad- dition to respiratory symptoms or in isolation like loss of smell and taste, myalgia, pain abdomen, diarrhea [2, 3] . Lately, gastrointestinal symptoms with acute abdo- men were observed in a few patients, and a diagnosis of gastrointestinal perforation was made. As more and more studies poured in regarding the nature of Severe acute respiratory syndrome coro- navirus -2 (SARS-CoV 2), theories were postulated Case Report regarding the pathogenesis of perforation. Presence of Angiotension-converting Enzyme (ACE 2) receptors in the stomach, duodenum, and rectum, thromboembolic phenomenon leading to ischemia of gut, neuroinvasive propensity of virus causing dilatation of gut, increase intraluminal pressure due to constipation and finally the rare side effect of Tocilizumab used for COVID-19 cases treatment were considered as causes for gastro- intestinal tract perforation. We are presenting a case report of three cases pre- senting as perforation during the course of COVID-19 disease along with a review of the literature regarding causes of such perforation. CASE REPORT Case 1 A 60 years old female was admitted with symptoms of dry cough, fever, and myalgia and tested positive for COVID-19 RT-PCR. She was a known case of hypo- thyroidism (on 75 microgram thyroxine per day). She was treated with steroids and Rivaroxaban and sent for home isolation after 7 days. On the 4th day of her discharge, she complained of pain abdomen and dis- tension. Examination revealed distension with guard- Abstract Severe acute respiratory syndrome coronavirus-2 (SARS-CoV 2) involving the respiratory tract started in 2019 in Wuhan, China but spread to almost all parts of the world to the extent that it was declared a pandemic by WHO. As more and more cases are detected, the involvement of systems other than respiratory was observed and nearly 5 to 50 % of patients have abdominal symptoms like pain and diarrhea. During the course of treat- ment, few patients developed a rare complication of gastrointestinal perforation. Three cases (two with colonic perforation and one with gastric perforation) of gastrointestinal perforation in COVID-19 positive patient are reported in the article with a review of the literature regarding the various hypothesis of intestinal perforation in these patients. Keywords: COVID-19; gastrointestinal perforation; severe acute respiratory syndrome coronavirus-2 (SARS-CoV 2); Tocilizumab Clin Surg Res Commun 2020; 4(4): 13-17 DOI: 10.31491/CSRC.2020.12.064 Metin Onur Beyaz et al 13
  • 2. ing and rigidity all over the abdomen. Besides other investigations, COVID-19 RT-PCR was repeated which was positive. D-Dimer was 953 ng/ml, LDH- 735 U/L, PT was 30.6 seconds with 2.56 INR. IL-6, Ferritin, and other investigations were within normal limits. CT tho- rax was suggestive of multifocal areas of consolidation in bilateral peripheral lung fields – typical of COVID-19 with a severity score of 17/25 (Figure 1). X-Ray chest ANT PUBLISHING CORPORATION Published online: 30 December 2020 showed bilateral consolidation with gas under the dia- phragm (Figure 2). Exploratory laparotomy revealed a fecal-purulent col- lection of 2 liters with dense adhesion and 1 cm size perforation over the anterior wall of the upper one- third of the rectum. The surrounding rectal wall was oedematous. Repair of perforation with decompressing transverse loop colostomy was done. The patient was treated in ICU with antibiotics, fluconazole, low mo- lecular weight heparin. Repeated RT-PCR for COVID-19 was negative on the 6th post-operative day. She was discharged from the hospital on the 11th post-operative day. Case 2 A 24-year female was admitted to the Department of Obstetric with full-term pregnancy and labor pains. She was subjected to emergency Lower segment ce- sarean section. On the fifth postoperative day, she complained of severe pain abdomen, vomiting, and distension of the abdomen. The patient had tachy- cardia with abdominal distension and obliteration of liver dullness. Being immediate post-partum period, guarding and rigidity were not appreciated due to the lax abdominal wall. CT chest revealed atypical viral pneumonitis (Figure 3). X-Ray was showing a massive pneumoperitoneum (Figure 4) and COVID-19 RT-PCR was positive. D-Dimer was 3000 ng/ml, IL6 – 127 pg/ ml and LDH was 800 U/L. Patient was subjected to emergency exploratory laparotomy. There was 1.5 L of fecal-purulent fluid in the peritoneal cavity with adhe- sion and a 1.5 cm size perforation on the anterior wall of the caecum and edema of the caecal wall. Primary closure with decompressing loop ileostomy was done. Oxygenation supplementation, Meropenam antibiotics with low molecular weight heparin, and steroid were given. The patient recovered and was discharged with an ileostomy. Deepak Verma et al 14 Figure 1: Chest CT scan of case 1 showing patchy consolidation of COVID-19 (Score 17/25). Figure 2: X-Ray Flat plate abdomen in erect posture showing gas under the diaphragm (Case 1). Figure 3: CT scan chest showing atypical viral pneumonitis (COVID-19) of case 2.
  • 3. spread to all other parts of the world becoming a pan- demic. India is the second most affected country across the world (nearly one billion cases) with a mortality of about 1.5 %. Since it primarily affects the respiratory system, symptoms such a fever, dry cough, dyspnea, and respiratory illness represent the most common manifestation [1] . Since the virus and illness are relatively new, symptom- atology is not very well understood and as the number of cases is increasing, various new symptoms like loss of smell and taste, etc. have also been reported. Ap- proximately 5 to 50% of the cases have gastrointestinal symptoms [2] like pain abdomen, diarrhea, and vomiting [3] . Detection of COVID-19 virus in stool [4] and a poten- tial fecal-oral transmission route has been suggested [5] . The various mechanism by which the gastrointestinal tract is affected in COVID-19 has been postulated. High expression of the angiotensin-converting enzyme (ACE) 2 receptor in the epithelium of the stomach, duodenum, and rectum [6] with SARS-CoV 2 binding to these recep- tors to gain entrance to host cell [7] is the key mecha- nism of involvement of gastrointestinal tract. Studies have stated that critically ill patients with CO- VID-19 are more likely to have a hypercoagulable state, with the manifestation of intravascular coagulation due to local damage [8, 9] . This may lead to ischemia of the entire gut with colonic perforation as a part of the septic and thromboembolic phenomenon caused by viral infection directly and indirectly. SARS-CoV 2 RNA was mainly detected in the cytoplasm of gastrointestinal epithelial cells indicating infection and replication of the virus in these cells leading to lo- cal damage [10] . Since the neuroinvasive propensity has been demon- strated as a common feature of coronavirus, a neuronal injury should be regarded as a possible pathogenetic mechanism [11] . This causes an imbalance of the auto- nomic innervation of the colon, altered colonic motil- ity, and dilatation of the colon. Critically ill ICU patients due to COVID-19 are mostly kept nil orally and can also have stress-related muco- sal damage with ulceration. These patients become significantly constipated contributing to increased in- traluminal pressure [12] . Colonic dilatation and increase intraluminal pressure can precipitate perforation of the gastrointestinal tract particularly the stomach, duodenum, and colon. Studies have demonstrated the detectable presence of coronavirus RNA in stools of in- fected patients [10, 13] . Perforation in COVID-19 patients has been reported in various studies [2,14] . A combina- Clin Surg Res Commun 2020; 4(4): 13-17 DOI: 10.31491/CSRC.2020.12.064 Deepak Verma et al 15 Case 3 A 21-year-old male patient presented in a surgical emergency with a history of pain, fever, cough, vomit- ing, and distension of the abdomen. Clinical examina- tion revealed a distended abdomen with guarding and rigidity along with pyrexia. No previous history of drug intake or acid peptic disease was present. X-Ray flat plate abdomen revealed gas under the diaphragm. CO- VID-19 RT-PCR was positive. Other routine investiga- tions were normal except for an INR of 2.14. D-Dimer, IL-6, and LDH were marginally raised. Emergency exploratory laparotomy was done and there was in- flamed thick omentum with 2 L of bile stained purulent fluid. 0.5 cm size perforation was seen on the anterior wall of the stomach at the pre-pyloric region. Closure of perforation with Graham’s patch and LMWH, anti- biotics, corticosteroids, and oxygen supplementation were administered. The patient was discharged on the 11th post-operative day. DISCUSSION Severe acute respiratory syndrome coronavirus-2 (SARS-CoV 2) cause novel coronavirus disease. Al- though it started in Wuhan, China in 2019, now it had Figure 4: Presence of gas under diaphragm case 2.
  • 4. ANT PUBLISHING CORPORATION Published online: 30 December 2020 Consent for publication Written consent was obtained from the individual case for publication of images used in this paper. REFERENCES 1. Zhu, N., Zhang, D., Wang, W., Li, X., Yang, B., Song, J., ... & Niu, P. (2020). A novel coronavirus from patients with pneumonia in China, 2019. New England Journal of Med- icine. 2. Neto, I. J. F. C., Viana, K. F., da Silva, M. B. S., da Silva, L. M., de Oliveira, G., da Silva Cecchini, A. R., ... & Robles, L. (2020). Perforated acute abdomen in a patient with CO- VID-19: an atypical manifestation of the disease. Journal of Coloproctology. 3. Kotfis, K., & Skonieczna-Żydecka, K. (2020). COVID-19: gastrointestinal symptoms and potential sources of 2019-nCoV transmission. Anaesthesiol Intensive Ther 2020; 52 (1). 4. Jin, X., Lian, J. S., Hu, J. H., Gao, J., Zheng, L., Zhang, Y. M., ... & Yu, G. D. (2020). Epidemiological, clinical and virologi- cal characteristics of 74 cases of coronavirus-infected disease 2019 (COVID-19) with gastrointestinal symp- toms. Gut, 69(6), 1002-1009. 5. Gu, J., Han, B., & Wang, J. (2020). COVID-19: gastrointes- tinal manifestations and potential fecal–oral transmis- sion. Gastroenterology, 158(6), 1518-1519. 6. Zhao, D., Yao, F., Wang, L., Zheng, L., Gao, Y., Ye, J., ... & Gao, R. (2020). A comparative study on the clinical features of COVID-19 pneumonia to other pneumonias. Clinical Infectious Diseases. 7. Wong, S. H., Lui, R. N., & Sung, J. J. (2020). Covid‐19 and the digestive system. Journal of gastroenterology and hepatology, 35(5), 744-748. 8. Song, Y., Liu, P., Shi, X. L., Chu, Y. L., Zhang, J., Xia, J., ... & Wang, M. Y. (2020). SARS-CoV-2 induced diarrhoea as onset symptom in patient with COVID-19. Gut, 69(6), 1143-1144. 9. Wang, W., Gao, R., Zheng, Y., & Jiang, L. (2020). COVID-19 with spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema. Journal of travel medi- cine, 27(5), taaa062. 10. Tian, Y., Rong, L., Nian, W., & He, Y. (2020). gastrointes- tinal features in COVID‐19 and the possibility of faecal transmission. Alimentary pharmacology & therapeutics, 51(9), 843-851. 11. Conde, G., Pájaro, L. D. Q., Marzola, I. D. Q., Villegas, Y. R., & Salazar, L. R. M. (2020). Neurotropism of SARS-CoV 2: Mechanisms and manifestations. Journal of the neuro- logical sciences. 12. Kangas-Dick, A., Prien, C., Rojas, K., Pu, Q., Hamshow, M., Wan, E., ... & Wiesel, O. (2020). Gastrointestinal perfora- tion in a critically ill patient with COVID-19 pneumonia. tion of factors like mucosal damage, ulceration, over- distension of the bowel, and increased intraluminal pressure contribute to the perforation of the bowel. Tocilizumab, a monoclonal IL-6 receptor antibody, is used in rheumatoid arthritis and its use was identi- fied as a risk factor associated with lower intestinal perforation, which had been reported as a rare but serious complication in a clinical trial of this drug [15] . The mechanism of intestinal perforation in patients receiving Tocilizumab is not fully understood, but prior diverticulitis has been noted as a risk factor [15] . Since there is no elevation of C-Reactive protein in these patients there is some delay in the diagnosis of per- foration. Tocilizumab is also used in the treatment of cytokine release syndrome associated with severe CO- VID-19 [16] . Other authors have also warned about the possibility of the risk of intestinal perforation while using Tocilizumab in COVID-19 patients [17] . However, in the cases reported in this study, Tocilizumab was not used in any patient for COVID-19 treatment. Diagnosis of gastrointestinal perforation can easily be made by history of pain, distension of abdomen, guarding and rigidity, and radiographic evidence of pneumoperitoneum. In a clinically stable patient, CT abdomen is more sensitive investigation along with CT chest to predict outcome post-surgery. Early operative intervention carries a better prognosis. Delay in the diagnosis of gastrointestinal perforation is associated with a poor prognosis due to compromised respiratory status, septicemia, edema of gut precluding optimum closure of gut, and high incidence of the thromboem- bolic phenomenon. However, in cases diagnosed later with the poor general condition, drainage of the peri- toneal cavity at the bedside with non-operative conser- vative management can be attempted although with a guarded prognosis. DECLARATIONS Authors’ contributions Deepak Verma participated in surgical treatment and wrote the article. Sarthak Sharma carried out treat- ment and recordkeeping and data acquisition. Lalit Kishore Garg checked the article and supervised the patient’s care. Aishwarya Tinaikar followed the patient in outcome point. Conflict of interest The authors declared that there are no conflicts of in- terest to disclose. Deepak Verma et al 16
  • 5. Clin Surg Res Commun 2020; 4(4): 13-17 DOI: 10.31491/CSRC.2020.12.064 Deepak Verma et al 17 SAGE open medical case reports, 8, 2050313X20940570. 13. Zhang, W., Du, R. H., Li, B., Zheng, X. S., Yang, X. L., Hu, B., ... & Zhou, P. (2020). Molecular and serological investiga- tion of 2019-nCoV infected patients: implication of mul- tiple shedding routes. Emerging microbes & infections, 9(1), 386-389. 14. De Nardi, P., Parolini, D. C., Ripa, M., Racca, S., & Rosati, R. (2020). Bowel perforation in a Covid-19 patient: case report. International Journal of Colorectal Disease, 1. 15. Strangfeld, A., Richter, A., Siegmund, B., Herzer, P., Rock- witz, K., Demary, W., ... & Listing, J. (2017). Risk for lower intestinal perforations in patients with rheumatoid arthritis treated with tocilizumab in comparison to treatment with other biologic or conventional synthetic DMARDs. Annals of the rheumatic diseases, 76(3), 504- 510. 16. Zhang, C., Wu, Z., Li, J. W., Zhao, H., & Wang, G. Q. (2020). The cytokine release syndrome (CRS) of severe CO- VID-19 and Interleukin-6 receptor (IL-6R) antagonist Tocilizumab may be the key to reduce the mortality. In- ternational journal of antimicrobial agents, 105954. 17. Vikse, J., & Henry, B. M. (2020). Tocilizumab in COVID-19: beware of risk of intestinal perforation. International Journal of Antimicrobial Agents.