S2946 A Rare Case of COVID-19 Infection Presenting With Devastating Intestinal Perforation Requiring Emergent Surgical Intervention: A Case Report

Abstract

Introduction: COVID-19 pandemic is believed to be a systemic disease that affects not only the lungs but also other vital organs however, current available literature mainly focuses on acute respiratory symptoms. Symptoms include fever, myalgia and dyspnea. However gastrointestinal (GI) symptoms were reported in 3-50% of cases, including nausea, vomiting, abdominal pain, and diarrhea. Here we report a case of COVID-19 presenting with intestinal perforation. Case Description/Methods: 52-year-old female with a remote history of Roux-en-Y gastric bypass surgery who was diagnosed with COVID-19 three days prior to admission presented with epigastric pain, nausea, vomiting, and constipation for 2 days. Vital signs were normal. Laboratory workup was remarkable for non-anion gap metabolic acidosis and elevated inflammatory markers. Chest X-Ray showed air under the diaphragm. Abdominal CT scan showed pneumoperitoneum in the right subdiaphragmatic and mid abdomen/pelvis. Surgery was consulted and patient underwent emergent diagnostic laparoscopy and subsequent exploratory laparotomy with findings of large perforation at gastrojejunostomy, Intra-abdominal abscess. Patient underwent revision of gastrojejunostomy, drainage of intra-abdominal abscess with perotinel lavage. Intraabdominal cultures isolated Klebsiella pneumonia, Citrobacter freundii, Prevotella melaninogenica,Enterococcus faecalis and several Candida. Blood cultures isolated Clostridium subterminale bacteremia. Patient was started on IV antibiotics. The patient was discharged to be followed by surgery for resolution of symptoms and drainage removal. Discussion: Gastrointestinal symptoms of COVID-19 disease were reported in accumulated literature. Moreover, COVID-19 virus has been isolated in stool specimens. The question becomes, are those GI manifestations considered part of systemic symptoms of an airborne infection, or COVID-19 itself can potentially be transmitted feco-orally. Pathophysiology is yet unclear, suggested hypothesis includes direct invasion of intestinal cells by the SARS-CoV-2 RNA, as GI cells express ACE2. Another theory is imbalance of autonomic innervation of GI tract given the neuroinvasive tendency of COVID-19. It is not clear whether patients with past GI diseases like inflammatory bowel disease, peptic ulcers, and prior GI surgery are more prone to GI complications. This case highlights GI complications in Covid-19-positive patients especially those with GI history for early diagnosis and prevention of possible complications.Figure 1.: Figure (A): CT shows free air, Figure (B): CT abdomen shows air-fluid level, Figure (C): Abdominal X-ray shows air under the diaphragm.