INTRODUCTION: N/a. CASE DESCRIPTION/METHODS: A 30-year-old male with no past medical history or family history of GI disease presented to an outside hospital with two weeks of cough and dyspnea. He was found to be positive for COVID-19, and shortly after admission developed respiratory failure requiring intubation. His hospitalization was complicated by septic shock and renal failure. He also developed intracerebral hemorrhage while on prophylactic heparin infusion. The patient was transferred to our facility for neurosurgical evaluation though no intervention was needed. One week after arrival he developed melena and anemia. He underwent upper endoscopy, which was only notable for a small GE junction ulcer treated with band ligation. Due to continued melena, he underwent colonoscopy, but no blood was noted in colon or terminal ileum. Capsule endoscopy subsequently revealed clean based and actively bleeding ulcers at the jejunum and proximal ileum concerning for COVID-19-related small bowel disease. He improved with supportive care with no further overt bleeding. He is planned for repeat capsule endoscopy. DISCUSSION: COVID-19 is commonly thought of as a pulmonary disorder. However, studies report frequent GI symptoms of diarrhea, nausea/vomiting and abdominal pain. Prevalence ranges widely from 2-40%, may occur in absence of other features, and often portends worse prognosis. SARS-CoV-2 has been recovered from feces and may persist even after clearance from the respiratory tract. SARS-CoV-2 is also thought to have direct pathologic effects on the GI tract from cytotoxicity and systemic inflammation. The virus has a tropism for the GI tract mediated by the ACE2 receptor, which it uses to internalize into human cells. ACE2 is expressed throughout the GI tract, particularly in the small bowel. Histology of infected small bowel has shown evidence of enterocyte desquamation, edema and lymphocytic infiltration. Despite this, there are few reports of COVID-related GI tract disease. In one case, a patient presented with bloody diarrhea after returning from travel to Egypt. Endoscopy revealed patchy erythema throughout the left colon, though with normal pathology, consistent with a diagnosis of COVID-related hemorrhagic colitis. In a similar case from Italy, a young woman with diarrhea was found to have ulcerative lesions on ileocecal valve with presence of viral particles on pathology. To the best of our knowledge, this is the first case of a patient with COVID-19 with isolated small bowel involvement.Figure 1.: EGD, colonoscopy. A. GE junction ulcer with overlying clot (arrow), B. GE junction ulcer after banding, C. Cecum, with normal appearing mucosa, D. Terminal ileum, with normal appearing mucosa.Fig: 2Capsule endoscopy. A. Ulcer in proximal jejunum, B.-C. Ulcerated jejunal mucosa, D. Ulcerated ileal mucosa with active oozing.
Read full abstract