Case Report: Paralytic Ileus: A Potential Extrapulmonary Manifestation of Severe COVID-19

Abstract

The COVID-19 pandemic has recently spread worldwide, presenting primarily in the form of pneumonia or other respiratory disease. In addition, gastrointestinal manifestations have increasingly been reported as one of the extrapulmonary features of the virus. We report two cases of SARS-CoV-2 infection complicated by paralytic ileus. The first patient was a 33-year-old man who was hospitalized with severe COVID-19 pneumonia requiring ventilator support and intensive care. He developed large bowel dilatation and perforation of the mid-transverse colon, and underwent laparotomy and colonic resection. Histopathology of the resected bowel specimen showed acute inflammation, necrosis, and hemorrhage, supporting a role for COVID-19-induced micro-thrombosis leading to perforation. The second patient was a 33-year-old man who had severe COVID-19 pneumonia, renal failure, and acute pancreatitis. His hospital course was complicated with paralytic ileus, and he improved with conservative management. Both cases were observed to have elevated liver transaminases, which is consistent with other studies. Several authors have postulated that the angiotensin-converting enzyme 2 receptors, the host receptors for COVID-19, that are present on enterocytes in both the small and large bowel might mediate viral entry and resultant inflammation. This is a potential mechanism of paralytic ileus in cases of severe COVID-19 infection. Recognizing paralytic ileus as a possible complication necessitates timely diagnosis and management.

Acute abdomen in a 54-year-old COVID-19 patient: a case report

“…The ACE2 protein serves as the primary receptor for virus entry into the gastric, duodenal and rectal epithelium. These receptors are most prominent in the small and large intestine [ 2 ]. It has been hypothesized that the ACE2 receptors allow initial entry of COVID-19 to mediate inflammation of the large and small bowel [ 1 ].…”

Colonic Ileus, Distension, and Ischemia Due to COVID-19-Related Colitis: A Case Report and Literature Review

“…One of these, a 33-year old man with colonic dilatation underwent emergency laparotomy, which revealed a perforation in the transverse colon. This patient had received treatment with tocilizumab prior to surgery [ 14 ]. Other isolated reports have also identified acute ischemic colitis secondary to COVID-19 as a possible etiology of colonic ileus [ 15 ].…”

A challenging case of COVID-19 infection presented with isolated acute abdominal pain: A case report and literature review

“… 12 Furthermore, ACE2 expression on small intestinal enterocytes may mediate the invasion of the virus and activation of gastrointestinal inflammation. 13 This could be, therefore, a potential mechanism of abdominal in patients with severe COVID-19. Two cases were published recently mentioned COVID-19 that complicated by paralytic ileus [R5].…”

“…The histopathology of resected bowel specimen in these cases suggests a role for COVID-19-induced microthrombosis leading to gastrointestinal perforation. 13 In a recent systematic review and meta-analysis of 47 studies including 10,890 patients with COVID-19, the pooled prevalence of gastrointestinal symptoms was as follows: diarrhea 7.7%, nausea/vomiting 7.8%, and abdominal pain 2.7%. 6 Isolated gastrointestinal symptoms, including abdominal pain, were reported rarely.…”