Pneumatosis Intestinalis in COVID-19: Case Series

Abstract

Objective: To describe the clinical characteristics and outcomes of patients with coronavirus disease 2019 (COVID-19) who developed pneumatosis intestinalis (PI). Methods: This case series was conducted in intensive care units at two large tertiary care centers within the Northwell Health System, located in New York State. Patients were included if they were identified as having confirmed COVID-19 as well as pneumatosis intestinalis from March 16, 2020 to July 31, 2020. Patient demographics, clinical characteristics, vasopressor use, anticoagulation use, opiate use, paralytic use, COVID-19 treatment regimen, serum lactate, arterial pH, serum bicarbonate, subsequent intervention, and outcomes during hospitalization were collected. Results: A total of nine patients were identified. Average serum lactate was 4.33 mmol/L at time of diagnosis. Portal venous gas (56%) and bowel dilation (56%) were common radiographic findings. Subsequent morbidity (increased vasopressor requirements-67%, acute kidney injury-67%, increased oxygen requirements-44%) and mortality (78%) were high. PI occurred despite a majority of patients being on anticoagulation (78%). Interleukin-6 (IL-6) inhibitors were commonly administered (56%) prior to development of PI. Conclusion: Pneumatosis intestinalis in COVID-19 is clinically significant, with high morbidity and mortality, and is also likely underdiagnosed.

COVID-19 Imaging: What We Know Now and What Remains Unknown

“…admitted to the ICU (92).Common findings observed on abdominal CT scans include colorectal and small bowel wall thickening, fluid-filled colon, and infarction of the kidney, spleen, or liver. Pneumatosis and portal I n p r e s s venous gas without vascular involvement may be associated with ischemic enteritis and necrosis or pneumatosis cystoides intestinalis(98). Direct viral infection, small vessel thrombosis, and nonocclusive mesenteric ischemia have been proposed as causes for the spectrum of bowel findings in COVID-19 (92).Right upper abdominal US most commonly reveals signs of cholestasis, particularly gallbladder distension and sludge, and fatty liver (92).…”

The Role of Hyperbaric Oxygen Therapy in Pneumatosis Cystoides Intestinalis—A Scoping Review

“…PCI can be secondary to a wide of underlying conditions or predisposing factors: pulmonary disorders, mucosal disruption, gastrointestinal motility disorders, malignancies, infectious, immunological disturbances, iatrogenic causes and intraabdominal complications. Secondary PCI is traditionally divided into two categories: benign or non-urgent and life-threatening causes ( Table 2 ) ( 4 , 5 , 8 – 11 , 14 – 27 , 29 , 34 – 82 ).…”

Pneumatosis Intestinalis Due to COVID-19 Infection in Kidney Transplant Recipient: A Case Report

“…Despite having been described for the first time in 1730 by DuVernoi in an autopsy report, there are no conclusive guidelines for diagnosing and treating PI [ 1 , 4 ]. In most cases it is asymptomatic and diagnosed accidentally during imaging studies such as a computed tomography scan [5] , [6] , [7] , [8] . The symptoms can vary from mild abdominal pain, nausea, and vomiting to features of peritonitis due to bowel perforation [ [1] , [2] , [3] , [4] , 7 , 9 , 10 , 11 , 13 , 14 ].…”

“…The most common treatment is conservative: nihil per os, total parenteral nutrition, empirical antibiotics, and hyperbaric oxygen. In a few reported cases the treatment of choice was surgical because of peritonitis symptoms [ 3 , 7 , 10 , 12 , 15 ].…”

“…Due to high ACE2 expression in respiratory, myocardial, and gastrointestinal epithelial cells, the virus can give rise to a variety of symptoms at these sites [ 5 , 11 , 12 , 15 ]. The most common gastrointestinal (GI) tract symptoms include mild abdominal pain and diarrhea [ 7 , 11 , 13 ]. Additionally, COVID-19 viral RNA has been detected for a longer duration of time in the feces of patients taking glucocorticoids compared with patients that are not, suggesting these drugs prolong the virus's presence in the GI tract, potentially increasing the risk of local complications.…”