Cho Margaret, Liu Weiguo, Balzora Sophie, Suarez Yvelisse, Hoskoppal Deepthi, Theise Neil D, Cao Wenqing, Sarkar Suparna A
Department of Pathology, NYU Langone Health, New York, New York, USA.
Division of Gastroenterology and Hepatology, NYU Langone Health, New York, New York, USA.
Case Rep Gastroenterol. 2021 Mar 22;15(1):408-417. doi: 10.1159/000513375. eCollection 2021 Jan-Apr.
Gastrointestinal (GI) symptoms of SARS-CoV-2/COVID-19 in the form of anorexia, nausea, vomiting, abdominal pain and diarrhea are usually preceded by respiratory manifestations and are associated with a poor prognosis. Hematochezia is an uncommon clinical presentation of COVID-19, and we hypothesize that older patients with significant comorbidities (obesity and cardiovascular) and prolonged hospitalization are susceptible to ischemic injury to the bowel. We reviewed the clinical course, key laboratory data including acute-phase reactants, and drug/medication history in 2 elderly male patients admitted for COVID-19 respiratory failure. Both patients had a complicated clinical course and suffered from hematochezia, acute blood loss, and anemia which led to hemodynamic instability requiring blood transfusion around day 40 of their hospitalization. Colonoscopic impressions were correlated with the histopathological findings in the colonic biopsies that included changes compatible with ischemia and nonspecific acute inflammation, edema, and increased eosinophils in the lamina propria. Both patients were hemodynamically stable, on prophylactic anticoagulants, multiple antibiotics, and antifungal agents due to respiratory infections at the time of lower GI bleeding. Hematochezia resolved spontaneously with supportive care. Both patients eventually recovered and were discharged. Elderly patients with significant comorbid conditions are uniquely at risk for ischemic injury to the bowel. This case report highlights hematochezia as an uncommon GI manifestation of spectrum of COVID-19 complications. The causes of bleeding in these COVID-19 associated cases are likely multifactorial and can be attributed to concomitant etiologies based on their age, multiple comorbid conditions, prolonged hospitalization compounded by lung injury, and hypoxia precipitated by the virus. We hypothesize that rather than a direct viral cytopathic effect, ischemia and hypoperfusion may be unleashed due to the cytokine storm orchestrated by the virus that leads to abnormal coagulation profile. Additional factors that may contribute to ischemic injury are prophylactic use of anticoagulants and polypharmacy. There were no other causes to explain the brisk lower GI bleeding. Presentation of hematochezia was followed by hemodynamic instability that may further increase the mortality and morbidity of COVID-19 patients, and prompt consultation and management by gastroenterology is therefore warranted.
严重急性呼吸综合征冠状病毒2型/冠状病毒病（SARS-CoV-2/COVID-19）的胃肠道（GI）症状表现为食欲不振、恶心、呕吐、腹痛和腹泻，通常先于呼吸道症状出现，且与预后不良相关。便血是COVID-19的一种不常见临床表现，我们推测，患有严重合并症（肥胖和心血管疾病）且住院时间延长的老年患者易发生肠道缺血性损伤。我们回顾了2例因COVID-19呼吸衰竭入院的老年男性患者的临床病程、关键实验室数据（包括急性期反应物）以及药物/用药史。两名患者的临床病程均较为复杂，均出现便血、急性失血和贫血，导致血流动力学不稳定，在住院第40天左右需要输血。结肠镜检查印象与结肠活检的组织病理学结果相关，活检结果包括与缺血相符的改变以及非特异性急性炎症、水肿和固有层嗜酸性粒细胞增多。两名患者在发生下消化道出血时，因呼吸道感染正在接受预防性抗凝治疗、多种抗生素和抗真菌药物治疗，血流动力学稳定。便血经支持治疗后自行缓解。两名患者最终康复出院。患有严重合并症的老年患者尤其有发生肠道缺血性损伤的风险。本病例报告强调便血是COVID-19并发症谱中一种不常见的胃肠道表现。这些与COVID-19相关病例的出血原因可能是多因素的，可归因于其年龄、多种合并症、因肺部损伤导致的住院时间延长以及病毒引发的缺氧等伴随病因。我们推测，缺血和低灌注可能不是由直接的病毒细胞病变效应引起，而是由病毒引发的细胞因子风暴导致凝血异常所致。可能导致缺血性损伤的其他因素包括预防性使用抗凝剂和多种药物联用。没有其他原因可解释明显的下消化道出血。便血出现后会导致血流动力学不稳定，这可能会进一步增加COVID-19患者的死亡率和发病率，因此有必要及时咨询胃肠病学专家并进行处理。
