Subacute Enteritis Two Months After COVID-19 Pneumonia With Mucosal Bleeding, Perforation, and Internal Fistulas

Abstract

Chronic sequelae of COVID-19 remain undetermined. We report a case of postinfection sequelae in a patient presenting with subacute obstruction 2 months after COVID-19 infection. A 34-year-old man with a prior prolonged hospital stay due to COVID-19 complicated by upper gastrointestinal (GI) bleed presented with subacute obstruction and failure to thrive. Upper GI push enteroscopy revealed residual ulcers and multiple proximal jejuno-jejunal fistulae. Midline laparotomy revealed strictures with dense intra-abdominal adhesions, a large jejuno-jejunal fistula, and evidence of prior jejunal perforation following severe COVID-19 infection. The patient recovered after small bowel resection with anastomoses and was discharged home. Histopathological examination of resected specimen confirmed transmural infarction with evidence of prior hemorrhage, diffuse ulcers, and multifocal inflammation. This is the first report of a chronic GI sequelae resulting from COVID-19. As the pandemic evolves, medical professionals must be vigilant to consider alternative GI diagnoses in the COVID-19 survivors.

Gastrointestinal (GI) symptomatology has been increasingly described in both critical and mild illness associated with COVID-19. Symptoms including diarrhea, nausea, and abdominal pain are the most commonly reported. Bowel perforation and mesenteric ischemia have also been more recently described in critically ill COVID-19 patients.^1-4 These patients suffer worse outcomes and higher mortality.^3,4 However, the subacute and chronic clinical sequelae of this population have yet to be determined. We present a patient, with no prior surgical history, who developed multiple jejuno-jejunal fistulae, strictures with dense intra-abdominal adhesions, and evidence of prior perforation, 2 months after diagnosis with COVID-19.

A 34-year-old morbidly obese Hispanic man with no prior comorbidities presented to the emergency department who was recently discharged 2 weeks prior after a prolonged hospital stay, including 26 ICU days and 17 ventilator days. His prior respiratory therapeutics included dexamethasone, azithromycin, ceftriaxone, and remdesivir. His hospitalization was further complicated by new ulcerative disease and recurrent GI bleeds requiring multiple upper endoscopies; these numerous gastric and duodenal ulcers eventually required right gastric and gastroduodenal artery angioembolizations.

On this admission, the patient’s chief complaints were abdominal pain, intermittent nausea and emesis not entirely related to oral intake, and failure to thrive. Laboratory findings were unremarkable, and CT imaging revealed moderate dilation of proximal small bowel with decompressed loops distally and peri-jejunal stranding (Figure 1). Oral contrast reached the colon at 4 hours in a small bowel follow-through series. Upper endoscopy utilizing push enteroscopy revealed residual ulcerative disease despite continued proton pump inhibitor therapy, as well as multiple proximal jejunal fistulae, the largest one measuring 3 cm in diameter (Figure 2).

Figure 1.

CT imaging revealed moderate dilation of proximal small bowel with decompressed loops distally and peri-jejunal stranding.

Figure 2.

Jejunal fistulae in COVID-19 patient. Multiple fistulae in a side-to-side loop of jejunum, demonstrated both endoscopically (top left) and grossly (right) in a recovered COVID-19 patient with no prior abdominal surgical history. Wide arrows correspond with the largest fistula, though multiple are seen adjacent to it. Thin arrow corresponds with the true lumen of the loop of small bowel.

The patient was brought to the operating room and midline laparotomy performed. Dense adhesiolysis was conducted. An area of prior distal jejunal perforation with associated strictured segment was walled off along the sigmoid colon. A large jejuno-jejunal fistula along a 48 cm segment of small bowel was encountered as a single fused loop, with multiple inter-loop connections (Figure 2). Associated ulcerations as well as multiple narrowed segments were visualized along the mucosal surface on gross inspection. Two separate segmental small bowel resections with anastomoses were performed; the patient recovered from his symptoms postoperatively. Pathology confirmed transmural infarction with evidence of prior hemorrhage, diffuse ulcerative disease, and multifocal inflammation. The patient recovered well and was discharged home on postoperative day 9. Unfortunately, he presented 6 weeks later with acute chest pain and dyspnea, suffered cardiopulmonary arrest, and subsequently died.

Bowel wall abnormalities due to small-vessel thrombosis–associated ischemia have been previously reported in COVID-19.^1-3 However, intestinal fistula formation as a consequence of prior bowel wall ischemia, resulting in poor oral intake and inadequate nutrition, is a novel finding. We postulate that COVID-19 infection and concomitant microthrombi in the GI tract resulted in chronic nonhealing ulcers, which led to recurrent bleeding and resulting perforations with fistulization throughout the jejunum, as well as small bowel perforation spontaneously sealed by adjacent serosa from the sigmoid colon. Histopathologic examination of the resected specimen of our patient also showed ischemic changes with transmural infarction and hemorrhage suggesting a similar pathology, in contrast to that of previously described inflammatory bowel conditions. To our knowledge, this is the first report of a chronic GI sequelae resulting from COVID-19 associated hypercoagulability and bowel pathophysiology.

As the ongoing COVID-19 pandemic continues, survivors’ subsequent clinical course must be carefully considered and broad differentials undertaken. The entire medical community, especially those in primary or urgent care settings and surgical fields, must be vigilant to consider alternative potential GI diagnoses in this new and evolving patient demographic.