key: cord-0690093-ohj3h2xi
authors: Kaafarani, Haytham M. A.; El Moheb, Mohamad; Hwabejire, John O.; Naar, Leon; Christensen, Mathias A.; Breen, Kerry; Gaitanidis, Apostolos; Alser, Osaid; Mashbari, Hassan; Bankhead-Kendall, Brittany; Mokhtari, Ava; Maurer, Lydia; Kapoen, Carolijn; Langeveld, Kimberly; El Hechi, Majed W.; Lee, Jarone; Mendoza, April E.; Saillant, Noelle N.; Parks, Jonathan; Fawley, Jason; King, David R.; Fagenholz, Peter J.; Velmahos, George C.
title: Gastrointestinal Complications in Critically Ill Patients With COVID-19
date: 2020-05-01
journal: Ann Surg
DOI: 10.1097/sla.0000000000004004
sha: 39b7a28b75b937397bd76dbe93afd031c4c48cd9
doc_id: 690093
cord_uid: ohj3h2xi

Supplemental Digital Content is available in the text

Extra-pulmonary disease has been observed in patients with Coronavirus Disease 2019 (COVID-19) (1) (2) (3) . We describe here the gastrointestinal (GI) complications of patients with severe COVID-19 admitted to the intensive care unit (ICU) at the Massachusetts General Hospital between March 13 th and April 12 th , 2020.

During this time period, 141 patients were admitted to the ICU with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection confirmed by reverse-transcriptasepolymerase-chain-reaction (RT-PCR) testing. The median (interquartile range [IQR]) age was 57 (47, 70) years, 65% of them were males, and 45% had GI symptoms (e.g. abdominal pain, diarrhea, vomiting) on hospital presentation ( Table 1 ). The median (IQR) Sequential Organ Failure Assessment (SOFA) Score upon admission to the ICU was 5 (4, 7.5), and 128 (91%) required mechanical ventilation. A total of 104 patients (74%) developed at least one GI complication.

We stratified the GI complications into four categories: hepatobiliary, hypomotility, bowel ischemia, and other. Among the hepatobiliary complications, transaminitis was the most common (67%). The mean highest values recorded for aspartate aminotransferase (AST) and

Alanine Aminotransferase (ALT) were 420.7 U/L and 479.0 U/L respectively, representing a 7.5-and 12-fold increase from the physiological values. Four patients (4%) developed acute acalculous cholecystitis and one patient (1%) developed acute pancreatitis during their ICU stay.

Half of the patients developed hypomotility-related complications of variable severity.

Almost all patients with GI complications required nasogastric or orogastric tubes. Forty-six percent of patients had gastric feeding held for at least 24 hours due to high gastric residuals, and 58 (56%) developed an ileus diagnosed clinically and/or radiologically. Four of the patients with severe ileus had clinical and radiologic findings concerning for bowel ischemia Copyright © 2020 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited. and were taken to the operating room on days 11, 14, 15, and 22 of hospitalization, respectively, for an exploratory laparotomy. Two patients were found to have extensive patchy bowel necrosis involving half to two thirds of the total bowel length, despite patent proximal mesenteric vessels on the computed imaging (CT) scan, perhaps suggesting microvessel thrombosis. Intraoperatively, the necrotic bowel had a distinct bright yellow color in contrast to the common finding of purple-black color ( Figure 1 Two additional patients were diagnosed with a colonic paralytic ileus, clinically identical to colonic pseudoobstruction (Ogilvie's syndrome) on days 6 and 14 of hospitalization. Figure 2 in the Supplementary Appendix, http://links.lww.com/SLA/C198 shows an abdominal x-ray of one of these two patients demonstrating significant colonic dilation with cecal wall pneumatosis. On exploratory laparotomy, patchy areas of necrosis of the entire colon were noted; a total colectomy and an end ileostomy were performed. The pathology of the resected bowel showed focal transmural areas of necrosis with acute fibrinopurulent serositis. The overall 14-day patient mortality was 15%. The mortality rate of the subset of patients who required abdominal surgery was as high as 40%.

In this series of critically ill patients with COVID-19, we report a high incidence of hepatobiliary, hypomotility, and ischemic GI complications. Of 141 patients, 58 had ileus, two had an Ogilvie-like syndrome, one had extensive hepatic necrosis, and four had bowel ischemia necessitating emergent surgery and bowel resection. Although these GI complications could be attributed to pharmacologic adverse events and metabolic and

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