Acute Abdomen in Corona

Dr. Dhaval Mangukiya

GI HPB & Cancer Surgeon
SIDS Hospital & Research Center
Hypotheses

 small vessel thrombosis

or
 viral enteroneuropathy

Gastrointestinal manifestations

Liver injury
 Gastrointestinal manifestations
cohorts have reported frequencies
 Diarrhea 2.0–10.1%

 Vomiting 1.0– 10.1%

 Abdominal pain 2.2–5.8%

Studies have identified the SARS-CoV-2 RNA in anal/rectal swabs

• Zhang W, Du RH, Li B et al. Molecular and serological investigation of 2019-nCoV infected

patients: implication of multiple shedding routes. Emerg. Microbes. Infect. 2020; 9: 386–9.
• Xu Y, Li X, Zhu B et al. Characteristics of pediatric SARS-CoV-2 infection and potential
evidence for persistent fecal viral shedding. Nat. Med. 2020
 Liver injury in Covid-19 patients

 14.8–53.1% of Covid-19 patients had abnormal levels of alanine aminotransferase (ALT)

and aspartate aminotransferase (AST)
 Most of the liver injuries are mild and transient
 Mechanism
 Direct viral infection of hepatocytes
 Immune-related injury
 Drug hepatotoxicity

Xu L, Liu J, Lu M, Yang D, Zheng X. Liver injury during highly pathogenic human

coronavirus infections. Liver Int. 2020.
Critically ill patients with COVID-19

 Bowel ischemia
 Transaminitis
 Gastrointestinal bleeding
 Pancreatitis
 Ogilvie syndrome
 Severe ileus

Kaafarani HMA, El Moheb M, Hwabejire JO, et al. Gastrointestinal complications in critically ill
patients with COVID-19. Ann Surg. 2020;272(2)
Critically ill patients with COVID-19

High expression of angiotensin-converting

enzyme 2 receptors along the epithelial lining of
the gut that act as host-cell receptors for SARS-
CoV-2 could explain involvement of abdominal
organs

Higher opioid requirements and COVID-19–

induced coagulopathy may also explain the
disproportionately high rate of ileus and ischemic
bowel disease.2
Manifestations and prognosis of gastrointestinal and liver
involvement in patients with COVID-19: a systematic review and
meta-analysis

Lancet Gastroenterol Hepatol 2020; 5: 667–78

 The pooled estimate of SARS-CoV-2 viral RNA positivity in fecal samples was 54% (95% CI
44–64; I²=28%), with positivity persisting for up to 47 days after symptom onset
 Patients with severe COVID-19 were more likely to present with abdominal pain
 No significant difference between patients with severe and non-severe disease in loss of
appetite, diarrhea, or nausea or vomiting
 Higher risk of abnormal liver chemistry
 Gastrointestinal symptoms were reported in 15% of patients with COVID-19 and liver injury
in 19% of patients
 GI Surgical Indication and outcome
Kaafarani HMA, El Moheb M, Hwabejire JO, et al. Gastrointestinal complications in critically
ill patients with COVID-19. Ann Surg. 2020;272(2)
GI Surgical Indication and outcome

 The overall 14-day patient mortality was 15%.

 The mortality rate of the subset of patients who required abdominal surgery was as
high as 40%

Kaafarani HMA, El Moheb M, Hwabejire JO, et al. Gastrointestinal complications in

critically ill patients with COVID-19. Ann Surg. 2020;272(2)
Our Data

 Colon perforation – 12
 2 patients within 10 days of Covid 19
 10 patients after 14 days of Covid 19
 Mesenteric Ischaemia – 5 (All after 20 days to 45 days post Covid 19)
 Splenic Infarction – 1 (Post Covid)
 Retroperitoneal Haematoma – 1 (Post Covid)
 Acute Cholecystitis – 1 (During Active phase)
 Acute Pancreatitis – 1 (During Active phase)
Mortality

 2 out of 17 patients who underwent surgery

 Our Observation

 No strenuous activity post operatively

 Liberal use of steroids
 Proactive anticoagulation
 No General Anesthesia whenever possible
 Quick Surgery
 Routine Antibiotics
 Early Orals and Hydration
 Safety for Surgeon & Staff
Thank you