*Corresponding author:Syed Muhammad Ali, Department of Acute Care Surgery, Hamad Medical Corporation, Doha 3050, Qatar
How to cite this article:Fakhar S, Syed Muhammad A, Sana S, Umair S, Nadia K. Acute Mesenteric Ischemia Due to COVID-19: A Case Report.
002 Open Access J Surg. 2020; 12(2): 555831. DOI: 10.19080/OAJS.2020.12.555832.
Introduction: Recent evidence has shown that a key feature of severe COVID –19 is that it may predispose to both venous and arterial thromboembolic diseases leading to adverse outcomes.
Case Presentation: We report a case of an elderly lady who presented with acute abdomen and diagnosed to have acute mesenteric ischemia (AMI). She was tested positive for COVID – 19 and underwent surgical intervention but could not survive her post-operative course.
Conclusion: There remains much interest, and an urgent clinical need, to precisely delineate the mechanisms by which SARS CoV-2 infection causes thrombotic complications in the hope that new insights into this process will yield novel therapeutic approaches where early diagnosis and prompt effective treatment could have improved the clinical outcome.
Since the disclosure of the SARS-CoV-2, emerging in Wuhan China, which causes COVID-19, a huge number of cases have been analyzed overall bringing about countless deaths. In the United States, there are approximately 2.9 million reported cases with over 100,000 deaths as of 1st week of July 2020 . Although the unfavorable impacts of COVID-19 were at first considered to influence the respiratory tract by causing pneumonia and respiratory distress syndrome (ARDS), it has now become clear that COVID-19 may be related to thromboembolic complications . Apart from deep venous thrombosis and pulmonary embolism (PE), acute mesenteric ischemia (AMI) has also been reported in severe COVID-19 patients . Acute mesenteric ischemia is a potentially fatal vascular emergency, with an overall mortality of 60-80%  requiring prompt diagnosis and treatment. This report will detail the clinical findings of the prothrombotic status of a patient experiencing AMI while testing positive for COVID-19.
71-year-old female known to have diabetes mellitus type 2, hypertension, atrial fibrillation on warfarin, presented to the
emergency department with epigastric pain of one-day duration, sudden onset, severe in nature, postprandial, non- radiating associated with vomiting containing food particles and with a sense of impending doom. She was uncomfortable, afebrile with tachycardia (136) and blood pressure of 169/82 and maintaining 95% O2 saturation on room air. Her abdominal examination showed out of proportion tenderness in the periumbilical region without rigidity but guarding. Her WBC count was high (23.7 x 103/ ul) with an increased neutrophil count and increased inflammatory markers, CRP was 5.2mg/dl and lactic acid = 6.9 mmol/L and also had high Troponin T levels (23-24 ng/L) (Table 1).
The patient initially underwent an abdominal XR (Figure 1) which displayed non-specific bowel pattern, and no abnormal air-fluid levels. Her CT Abdomen (Figure 2) revealed complete occlusion of the superior mesenteric artery, with mild dilatation of the proximal small intestinal loops showing suspicious pneumatosis intestinalis and poor post-contrast enhancement of the distal ileal loops features concerning for bowel ischemia. The patient was immediately shifted to operating theatre for midline
laparotomy. There was foul-smelling serosanguinous peritoneal
fluid along with complete gangrene of the small bowel, colon was
healthy and other organs were unremarkable. Damage control
surgery with resection of the gangrenous bowel was carried out
except 30 cm distal to the duodeno-jejunal junction and 15 cm
proximal to the ileocaecal valve (Figures 3 and 4).
The patient was transferred to surgical ICU post-operatively
for ventilator and hemodynamic support. She was confirmed to
be infected with COVID-19 by PCR nasal swab. She was unstable
during her recovery and developed metabolic acidosis with
respiratory acidosis resulting in increasing difficulty to maintain
her oxygenation despite full mechanical ventilator support and
100% Fio2. On second day hemodialysis was started despite
which patient continued to deteriorate and developed mixed
acidosis, multiple organ failure, and refractory septic shock
secondary to abdominal sepsis and viral infection (COVID19) all
that led to increasing lactic acid level and liver failure. On 3rd
post-operative day, the patient developed cardiac arrest with
asystole and expired.
The novel coronavirus belongs to a group of severe acute
respiratory syndrome-related corona viruses . It originated in
Wuhan, Hubei Province, China, in December 2019 and was declared
a pandemic by WHO on 11 March 2020 . Severe SARS-CoV-2
infection is more commonly observed in patients with specific
comorbidities, yet the mechanism of this relationship is unclear.
Advanced age, hypertension, diabetes, smoking, and coronary
artery disease are risk factors for severe COVID-19, conditions
which are all associated with vascular endothelial dysfunction.
Vascular complications are increasingly being reported  in
COVID patients. Apart from venous thromboembolism, acute
mesenteric ischemia (AMI) has been reported in severe COVID-19
patients. Acute mesenteric ischemia is a life-threatening
emergency; the delay in diagnosis of which contributes to the
continued high mortality rate.
The exact mechanism underlying the complication of AMI
in COVID-19 patients is still unknown at present. However,
a few mechanisms, independently or in combination could
be responsible for this complication. Firstly, the SARS-CoV-2
enters the cell via the angiotensin-converting enzyme 2 (ACE2)
receptor present in the alveoli. The severe form of the infection
is characterized by an intense immune-inflammatory response,
evidenced by the presence of neutrophils, lymphocytes,
monocytes, and macrophage . High serum levels of proinflammatory
cytokines (interleukins 1 and 6, tumor necrosis
factor and interferon-g), known as “cytokine storm”, have been
reported in those patients . Evidence has shown a bidirectional
relationship between inflammation and coagulation, in which
inflammation activates coagulation, and coagulation heightens
inflammatory activity . However, the evidence available at
present has not conclusively demonstrated large mesenteric
vessel (arterial or venous) thrombosis. Preliminary pathological
evidence has shown bowel necrosis with small vessel thrombosis
involving the submucosal arterioles, thereby pointing to an in-situ
thrombosis of small mesenteric vessels rather than an embolic
The expression of angiotensin-converting enzyme (ACE 2) on
enterocytes of the small bowel, the target site for SARS-COV 2 also
may point to damage leading to cause mesenteric ischemia which
seems more plausible cause in our patient as her atrial fibrillation
was well controlled. However, there may be a possibility that
thrombus originated from heart and aggravated by the concurrent
COVID-19 infection. Lastly, the hemodynamic instability in the
form of hypotension, associated with COVID-19 pneumonia might
also play a role in causing nonocclusive mesenteric ischemia .
Understanding the relationship between COVID-19 and
the occurrence of AMI needs to be further studied as it will be
imperative in setting appropriate diagnostic testing as well as
developing new therapeutic targets. The growing awareness
and understanding of thrombotic complications in patients with
SARS-CoV-2 infection will contribute to a more rigorous approach
resulting in the earlier detection of such events and reducing the
mortality rate associated with the disorder.
Waiver of Consent was received as the Patient expired and no
Relatives or Next of Kin were found for Consent. Approval received
by Medical Research committee of Hamad Medical Corporation
reference number (MRC-04-20-664).