S2845 A Rare Pandemic Presentation: Acute Perforated Duodenal Ulcer in a COVID-19 Case With Acute Abdominal Pain

Abstract

INTRODUCTION: Gastrointestinal presentations in the novel Covid-19 pandemic include nausea, diarrhea, ischemic colitis, elevated liver enzymes and abdominal pain in 3-4% of cases. Excluding abnormal liver functions at initial presentation, most gastrointestinal symptoms generally portray a favorable prognostic outcome. Ischemic phenomena ostensibly comprise a third of ICU patients with systemic inflammatory response and coagulopathy. Neither serious upper gastrointestinal manifestation [at initial presentation] nor acute peptic ulcer symptoms with associated perforations, with respect to Covid-19, have been noted worldwide. We report such a case. Managed successfully and treated in a conventional manner, with accepted FDA approved therapy for Covid-19. CASE DESCRIPTION/METHODS: A 72 year old female presented to the ED with left upper quadrant pain and chest pain and subsequently discharged after an initial negative CT. 2 days later, at the height of the covid pandemic surge in the NYC area, she presented with worsening of symptoms. Repeat CT revealed free air under her diaphragm and resulted in an emergency laparotomy with an omental patch repair/suturing of acutely perforated duodenal ulcer. Acute febrile status on post op day 4 with myalgias led to a diagnosis of Covid-19 with appropriate PCR testing. Adhering to conventional treatment in the early pandemic wave, she underwent immediate additional therapy with HCQ and Zithromax for 5 days and discarded home on PPIs after full recovery. Her subsequent Covid testing was negative with both IgG and IgM antibody response. Similarly, her stool H.Pylori PCR and her stool Covid PCR were also negative. DISCUSSION: Perforated peptic ulceration, warranting emergent surgery, has not been detailed as an etiology of abdominal pain in Covid-19 patients in the novel Coronavirus pandemic literature. Our case underwent an emergency surgery at the height of the pandemic at a NJ epicenter hospital. Covid-19 positive status was not discovered until post op day 4 as the outcomes for the patient may not have been as fortuitous with known prior diagnosis of Covid-19 in the early pandemic panic atmosphere. Contrasting with respect to other initial gastrointestinal manifestations in Covid, our patient had a favorable outcome while managed successfully and treated conventionally. In future waves of the pandemic, the gastrointestinal community should have a heightened suspicion for complicated acute peptic ulcer disease in Covid-19 patients presenting with acute upper abdominal pain.Figure 1.: Large free intraperitoneal air in the right greater left sub-diaphragmatic area.Figure 2.: Perforated duodenal ulcer with large amount free intraperitoneal air as seen on sagittal plane.