Bowel ischemia in COVID-19 infection: one-year surgical experience
Open accessAbstract
BACKGROUND: COVID-19 is a deadly multisystemic disease, and bowel ischemia, the most consequential gastrointestinal manifestation, remains poorly described. Our goal is to describe our institution's surgical experience with management of bowel ischemia due to COVID-19 infection over a one-year period. METHODS: All patients admitted to our institution between March 2020 and March 2021 for treatment of COVID-19 infection and who underwent exploratory laparotomy with intra-operative confirmation of bowel ischemia were included. Data from the medical records were analyzed. RESULTS: Twenty patients were included. Eighty percent had a new or increasing vasopressor requirement, 70% had abdominal distension, and 50% had increased gastric residuals. Intra-operatively, ischemia affected the large bowel in 80% of cases, the small bowel in 60%, and both in 40%. Sixty five percent had an initial damage control laparotomy. Most of the resected bowel specimens had a characteristic appearance at the time of surgery, with a yellow discoloration, small areas of antimesenteric necrosis, and very sharp borders. Histologically, the bowel specimens frequently have fibrin thrombi in the small submucosal and mucosal blood vessels in areas of mucosal necrosis. Overall mortality in this cohort was 33%. Forty percent of patients had a thromboembolic complication overall with 88% of these developing a thromboembolic phenomenon despite being on prophylactic pre-operative anticoagulation. CONCLUSION: Bowel ischemia is a potentially lethal complication of COVID-19 infection with typical gross and histologic characteristics. Suspicious clinical features that should trigger surgical evaluation include a new or increasing vasopressor requirement, abdominal distension, and intolerance of gastric feeds.
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Acute mesenteric ischemia is a rare yet severe complication of COVID-19, presenting a poor prognosis despite medical and surgical interventions.
“AMI is a rare, yet severe, complication of COVID-19, presenting a poor prognosis despite medical and surgical interventions [8,9].”
From Outcomes of Acute Mesenteric Ischemia in Patients With COVID-19: A Nationwide Database Study (2023) · cites this paper as [8]
Among the 36 articles, 6 retrospective studies documented intestinal ischemia in 55 patients admitted to intensive care units with COVID-19 pneumonia for whom surgical consult was necessary.
“Among these, we identified 6 retrospective studies [16,17,18,19,20,21], documenting intestinal ischemia in 55 patients admitted to intensive care units (ICU) with COVID-19 pneumonia for whom surgical consult was necessary (Table 1).”
From Acute mesenteric ischemia in COVID-19 patients (2021) · cites this paper as [19]
Prolonged stay in intensive care, intubation, and the need for vasopressor medication was associated with increased risk of acute bowel ischemia.
“Prolonged stay in intensive care, intubation, and the need for vasopressor medication was associated with increased risk of acute bowel ischemia [8,18,19].”
From Acute mesenteric ischemia in COVID-19 patients (2021) · cites this paper as [19]
Several authors described in acute bowel ischemia encountered in ICU patients with COVID-19 a distinct yellowish color, rather than the typical purple or black color of ischemic bowel, predominantly located at the antimesenteric side or circumferentially with affected areas well delineated from the adjacent healthy areas.
“Several authors described in acute bowel ischemia encountered in ICU patients with COVID-19, a distinct yellowish color, rather than the typical purple or black color of ischemic bowel, predominantly located at the antimesenteric side or circumferentially with affected areas well delineated from the adjacent healthy areas [18,19].”
From Acute mesenteric ischemia in COVID-19 patients (2021) · cites this paper as [19]
Obesity might be considered a possible risk factor, with a reported mean BMI of 31.2-32.5 in hospitalized patients.
“Obesity might be considered a possible risk factor, with a reported mean BMI of 31.2–32.5 in hospitalized patients [16,18,19].”
From Acute mesenteric ischemia in COVID-19 patients (2021) · cites this paper as [19]
Despite early surgery, the outcome is severe in these cases, with an overall mortality of 45-50% in reported studies and up to 100% in patients over 65 years of age according to Hwabejira et al.
“Despite early surgery, the outcome is severe in these cases, with an overall mortality of 45–50% in reported studies and up to 100% in patients over 65 years of age according to Hwabejira et al. [19].”
From Acute mesenteric ischemia in COVID-19 patients (2021) · cites this paper as [19]
Non-occlusive mesenteric ischemia in patients hospitalized in intensive care units for SARS-CoV-2 pneumonia requiring vasopressor medication may be caused by vasospastic constriction.
“Non-occlusive mesenteric ischemia in patients hospitalized in intensive care units for SARS-CoV-2 pneumonia requiring vasopressor medication may be caused vasospastic constriction [19,64,65].”
From Acute mesenteric ischemia in COVID-19 patients (2021) · cites this paper as [19]
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- Authors
- Hwabejire, J. O., Kaafarani, H. M. A., Mashbari, H., Misdraji, J., Fagenholz, P. J., Gartland, R. M., Abraczinskas, D. R., Mehta, R. S., Paranjape, C. N., Eng, G., Saillant, N. N., Parks, J., Fawley, J. A., Lee, J., King, D. R., Mendoza, A. E., & Velmahos, G. C.
- Affiliations
- Harvard University (US)
- Massachusetts General Hospital (US)
- Corresponding author
- Hwabejire, John O.
- ORCID
- Venue
- The American Surgeon™
- Publisher
- SAGE Publications
- Published
- 2021-11-12
- Volume
- 87
- Issue
- 12
- Pages
- 1893-1900
- ISSN
- 0003-1348 (ISSN-L)
- 1555-9823
- OpenAlex
- W3214620278
- Cited by
- 15
- References
- 11
- Citations by year
- 2025: 1 · 2024: 2 · 2023: 4 · 2022: 6 · 2021: 1 · 2012: 1
- FWCI
- 3.08
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- The American Surgeon (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Funders
- National Heart, Lung, and Blood Institute (R01HL119248)
- Topics
- Health Sciences › Medicine › Surgery › Abdominal vascular conditions and treatments
- Health Sciences › Medicine › Infectious Diseases › COVID-19 Clinical Research Studies
- Health Sciences › Medicine › Oncology › COVID-19 and healthcare impacts
- Keywords
- COVID-19 pandemic, intestinal ischemia, mesenteric ischemia, damage control laparotomy, bowel resection, fibrin thrombi, mucosal necrosis, thromboembolic events, thromboprophylaxis, vasopressor requirement, mortality
- MeSH terms
- COVID-19, SARS-CoV-2, Female, Humans, Intestinal Diseases, Ischemia, Laparotomy, Male, Massachusetts, Middle Aged
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