key: cord-0744743-dkj5mbea
authors: Parry, Arshed Hussain; Wani, Abdul Haseeb; Yaseen, Mudasira
title: Acute mesenteric ischemia in severe coronavirus-19 (COVID-19): possible mechanisms and diagnostic pathway
date: 2020-05-23
journal: Acad Radiol
DOI: 10.1016/j.acra.2020.05.016
sha: 65ed565f2ea1639f021a31001588ac8421187940
doc_id: 744743
cord_uid: dkj5mbea

nan

acute mesenteric ischemia (AMI) has been reported in severe COVID-19 patients (2) . AMI is a devastating complication with high mortality rate, so high suspicion, early recognition and timely treatment is essential to avoid morbidity and mortality associated with this disorder.

The exact pathological mechanism underpinning the complication of AMI in COVID-19 is not known at present. Putatively, four mechanisms, in isolation or in varying combinations could account for this fulminant complication in severe COVID-19. First, a coagulation disorder Lastly, shock or hemodynamic compromise which is commonly associated with severe COVID-19 pneumonia may lead to a non-occlusive mesenteric ischemia.

A vigilant and systematic approach is needed to suspect, diagnose and manage this otherwise fatal complication of severe COVID-19.

Patients with severe COVID-19 complicated by AMI may present with abdominal pain, nausea/vomiting, diarrhea, abdominal distention or worsening systemic status (sepsis).

Blood tests may reveal elevated lactate levels and fibrin degradation products (D-dimer).

However, both these tests are non-specific and may be elevated in severe COVID-19 without AMI.

Imaging has a vital role to play in timely detection of AMI and is the mainstay of diagnosis.

Although readily available, abdominal radiographs lack sensitivity and specificity. Ultrasound avoids the use of ionizing radiation but is also non-specific. CT angiography (CTA) is the imaging study of choice to diagnose AMI. CTA is usually performed to detect PE in severe COVID-19 patients. CTA done for detection of PE may need to be extended to cover the abdomen so that both the chest and abdomen are scanned in the same examination. This might come at the cost of higher radiation dose but given the seriousness of AMI the trade-off is worth it.

On CT, thick walled, edematous and dilated bowel (>3cm) should raise the suspicion of AMI.

Presence of pneumatosis intestinalis or portal venous gas suggests bowel ischemia. But presence of pneumatosis must be interpreted with caution as it may be present secondary to mechanical ventilation in patients of severe COVID-19. Non-enhancing thick bowel suggests bowel infarction. Frank perforation presents as discontinuity of bowel wall with localized air containing collection.

In conclusion, precise knowledge of the occurrence of AMI in COVID-19 patients is essential for ordering appropriate diagnostic testing at a low threshold level and quick decision making with regard to intensity of thromboprophylaxis to reduce the morbidity and mortality associated with this disorder.

Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in

Abdominal Imaging Findings in COVID-19: Preliminary Observations. Radiology

Severe COVID-19 infection associated with endothelial activation

Incidence of thrombotic complications in critically ill ICU patients with COVID-19

Pitfalls, and Conditions that Mimic Mesenteric Ischemia at CT