key: cord-1018611-94vkfrtw authors: Handaya, Adeodatus Yuda; Andrew, Joshua; Hanif, Ahmad Shafa; Fauzi, Aditya Rifqi title: Covid-19 mimicking symptoms in emergency gastrointestinal surgery cases during pandemic: a case series date: 2020-10-24 journal: Int J Surg Case Rep DOI: 10.1016/j.ijscr.2020.10.064 sha: 271c1b409bf2b810b94ecf63a61782f22bab8066 doc_id: 1018611 cord_uid: 94vkfrtw BACKGROUND: The COVID-19 pandemic has changed patient management in all sectors. All patients need to be examined for COVID-19, including in digestive surgery emergency cases. In this paper, we report four digestive surgery emergency cases with clinical and radiological findings similar to COVID-19. CASE PRESENTATION: We report four digestive surgery emergency cases admitted with fever and cough symptoms. Case 1 is a 75-year-old male with gastric perforation and pneumonia, case 2 is a 32-year-old female with intestinal and pulmonal tuberculosis, case 3 is a 30-year-old female with acute pancreatitis with pleuritis and pleural effusion, and the last case is a 56-year-old female with rectosigmoid cancer with pulmonal metastases. All the patients underwent emergency laparotomy, were hospitalized for therapy, and discharged from the hospital. After 1-month follow-up after surgery, 1 patient had no complaints, 2 patients had surgical site infection, and 1 patient died because of ARDS due to lung metastases. DISCUSSION: For all four cases, the surgeries were done with strict COVID-19 protocol which included patient screening, examination, laboratory assessment, rapid test screening, and RT-PCR testing. There were no intrahospital mortalities and all the patients were discharged from the hospital. Three patients were followed-up and recovered well with 2 patients having surgical site infection which recovered within a week. However, 1 patient did not show up for the scheduled follow-up and was reported dead 2 weeks after surgery because of ARDS due to lung metastases. CONCLUSIONS: Emergency surgery, especially digestive surgery cases, can be done in the COVID-19 pandemic era with strict prior screening and examination, and safety protocol. COVID-19 belongs to the coronavirus family which infect the respiratory system and cause symptoms such as fever, breathing difficulty, and even respiratory failure [1] . COVID-19 is spread through droplets and enters the host through mouth, nose, and eyes and mostly infects adults and older population with nearly half of all cases having comorbid medical conditions, for whom case fatality rates are elevated in these patients with co-existing diseases [2, 3] . Until July, 27 th 2020, COVID-19 had infected more than 16 million people worldwide and more than 100,000 people in Indonesia [4] . Patients undergoing emergency surgery have higher mortality and morbidity rates than elective surgery patients. Data from the American College of Surgeons (ACS) and National Surgical Quality Improvement Program (NSQIP) showed a mortality of 14% at 30 days for emergency laparotomy patients in the US. Emergency status was a significant predictor for morbidity, serious morbidity, and mortality compared to elective surgery, adjusting for patient-related and operation-related risk factors, in hospital performance [5] . The COVID-19 pandemic has changed the ways patients are admitted and treated, including in emergency digestive surgery cases. In this paper, we aimed to report four digestive surgery emergency cases admitted with fever and cough symptoms, mimicking COVID-19. This work has been reported in line with PROCESS criteria [6] . A 75-year-old man was admitted to our emergency department with fever, cough, and abdominal pain. The patient had history of diabetes and gastritis diagnosed and treated by gastroenterologist, smoking history, and routinely used analgesics in a recent three consecutive years span. Ronchi and peritoneal signs were found in his physical examination. Laboratory results showed haemoglobin level of 12.5 g/dL, leucocyte count 11.6 x10 9 /L, neutrophils 79.3%, lymphocytes 14.0%, and Neutrophils-Lymphocytes Ratio (NLR) 5.66. Both Anti-SARS-CoV-2 IgG and IgM Rapid Test showed non-reactive results. Chest X-Rays showed bronchopneumonia (Fig.1a) and chest computed tomography (CT)-scan showed emphysematous lungs (Fig.1b) . Abdominal X-Ray The patient underwent exploratory laparotomy with level 3 personal protective equipment. Intraoperative findings were pancreatic necrosis, cholelithiasis, and appendicitis. Pancreatic debridement, cholecystectomy, and appendectomy were done (Fig.3d) . The surgery was followed by intraabdominal irrigation for 3 days and 5 days ward treatment. The COVID-19 PCR test with nasopharyngeal swab sample showed negative results and the pathologic finding showed pancreatitis necroticans. The patient was discharged and had no complaints in weekly follow-ups for 3 consecutive weeks. (Insert Figure 3 here) A 56-year-old woman was admitted to our emergency department with fever, cough, abdominal pain, bloating, and inability to defecate. The patient had history of gastritis, haemorrhoids, and previous endoscopy examination showed a rectal tumor. Abdominal distention was found in her physical examination. Laboratory results showed Hemoglobin level of 10.6 g/dL, Leucocyte count 8.4 x10 9 /L, Neutrophils 63.6%, Lymphocytes 25.1%, Neutrophils-Lymphocytes Ratio (NLR) 2.53, and carcinoembryonic antigen (CEA) >2200 ng/mL. Both Anti-SARS-CoV-2 IgG and IgM rapid tests showed non-reactive results. Chest X-Ray (Fig.4a) and CT scan (Fig.4b) showed multiple metastatic nodules in both lungs without signs of bronchopneumonia or pleural effusion. Abdominal CT scan showed (Fig.4c) 9x3.5cm sigmoid tumor, posterior sigmoid lymph node enlargement, and liver metastases. The patient was diagnosed with large bowel obstruction in rectal cancer. The patient underwent exploratory laparotomy J o u r n a l P r e -p r o o f with level 3 personal protective equipment. Intraoperative finding was rectosigmoid tumor. Tumor resection and Hartmann's procedure were done (Fig.4d) . The patient was treated 3 days in the intensive care unit after the surgery and moved to the general ward with stable condition. The COVID-19 PCR test with nasopharyngeal swab sample showed negative results and the pathologic finding showed adenocarcinoma mucoides. The patient was discharged after 10 days ward care scheduled for weekly follow-up. The patient did not show up for the scheduled follow-up and was reported dead after returning to the emergency room with ARDS due to lung metastases two weeks after discharged. (Insert Figure 4 here) The indications of emergency surgery are the same in this COVID-19 pandemic setting compared to non-pandemic settings. COVID-19 examination must be done as soon as possible, but the decision of surgery must be timely done in emergency cases, whether the COVID-19 test result is available or not [7] . [8, 9, 11] . We report four cases of emergency digestive surgery cases with COVID-19 symptoms of cough and fever. Case 1 was a 75-year-old male with gastric perforation, case 2 was a 32-year-old woman with abdominal and pulmonary tuberculosis, case 3 was a 30-year-old woman with acute pancreatitis and minimal pleural effusion, and case 4 was a 56-year-old female rectosigmoid cancer patient with lung metastasis. All patients underwent laparotomy procedure and COVID-19 screenings were done prior to surgeries. All patients received definitive therapies according to their diseases and were examined for COVID-19 with RT-PCR test with negative results. Emergency surgery in digestive surgery cases with COVID-19 signs and symptoms can be done with strict examination, assessment, and protocol. Recommendations for operating room personnel to minimize infection risk in COVID-19 confirmed or suspected cases are as follows [12] : (1) Use of personal protective Epidemiology, causes, clinical manifestation and diagnosis, prevention and control of coronavirus disease (COVID-19) during the early outbreak period: a scoping review COVID-19: Disease, management, treatment, and social impact Cancer care in the time of COVID-19 COVID-19) Dashboard Anesthesia for emergency abdominal surgery The PROCESS 2018 Statement: Updating Consensus Preferred Reporting Of CasE Series in Surgery (PROCESS) Guidelines Emergency surgery in suspected COVID-19 patients with acute abdomen: case series and perspectives Surgical practice in the current COVID-19 pandemic: a rapid systematic review Surgical management of patients with COVID-19 infection. recommendations of the Spanish association of surgeons Surgery in times of COVID-19: recommendations for hospital and patient management COVID-19: Good Practice for Surgeons and Surgical Teams Considerations for Optimum Surgeon Protection Before, During, and After Operation Coronavirus disease 2019: what we know? The effects of COVID-19 pandemic on the provision of urgent surgery: a perspective from the USA Characteristics of and public health responses to the coronavirus disease 2019 outbreak in China Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine Covid-19: the new threat Covid-19 and the digestive system Updating the diagnostic criteria of COVID-19 "suspected case" and "confirmed case" is necessary We thank patient family, the surgical team and the nursing staff who were involved in the surgery and patients care.