TRAUMATIC JEJUNAL PERFORATION SECONDARY TO COVID-19
Jonathan Kopel B.S., Linda Luong D.O., Irfan Warraich M.D., Grant Sorenson Ph.D., Gregory Brower D.V,M., Ph.D
Presenter: Linda Luong, DO, Texas Tech Lubbock
Introduction/Objective: The novel coronavirus, known as SARS-CoV-2/COVID-19, has continued to spread throughout the globe since early December 2019. In humans, patients present with several respiratory, gastrointestinal (GI), hepatic, and neurologic diseases. Among COVID-19 patients, GI symptoms, such as diarrhea, nausea, and vomiting, are the most common gastrointestinal symptoms. However, several case reports have suggested that COVID-19 may increase the risk of gastrointestinal perforation. We report a case of a gastrointestinal perforation in a COVID-19 patient secondary to a motor vehicle accident. Histological examination of the perforation provides insight into the inflammatory processes mediating the increased risk of gastrointestinal perforation in COVID-19 patients.
Case Presentation: A 23-year-old female presented to the hospital as a trauma after being involved in a head-on motor vehicle collision with an 18-wheeler at 80 miles-per-hour. The seat belt and airbag safely deployed to reduce the impact of the collision. There was no ejection or rollover at the time of the incident. At the time of admission, she had a Glasgow coma scale of 15 with a blood pressure of 108/75 mmHg, a heart rate of 89 beats-per-minute, and a BMI of 34.7. The patient’s airway was intact with breath sounds present bilaterally. Peripheral circulation was present in all four extremities with pupils equal, round and react to light (4 mm). The patient had two large lacerations in the right periorbital region. An obvious open right ankle fracture with dome of the talus extruded from the medial ankle wound and deformity to the right thumb were noted upon examination.A head computed tomography (CT) showed a large subgaleal hematoma with areas of active bleeding in the right frontoparietal region measuring up to 9 cm in the transverse dimensions and 2 cm in the vertical dimensions, without underlying calvarial fracture. There was no acute abnormality or fracture in the cervical spine. A CT with contrast of the body showed a small amount of free fluid in the right paracolic gutter and the cul-de-sac with some fatty infiltration of the liver. There was a nondisplaced fracture of the left first rib. A COVID-19 test was administered before surgery and the patient was found to be positive for COVID-19. The patient subsequently was sent to the operating room for repair of the ankle fracture and thumb. The patient successfully underwent the surgery without any intraoperative complications.After the surgery, the patient complained of shortness of breath and abdominal pain in the left upper quadrant. A chest and abdominal CT showed pneumoperitoneum throughout the upper abdomen with moderate perihepatic and perisplenic ascites, which was new since admission. The patient then underwent a exploratory laparotomy procedure to identify the cause of the pneumoperitoneum. The small bowel was inspected and run from the ligament of Treitz. There was noted to be an antimesenteric perforation in the jejunum and no other perforations along the small bowel, there was no injury to the small bowel mesentery that is usually seen in blunt abdominal injuries. The colon showed no abnormalities. The liver and gallbladder were inspected ad showed no abnormalities. A 3-0 Vicryl was used to close the perforated small bowel to help control contamination. A small bowel resection and a side to side anastomosis was performed. Of note, the patient had a Meckel’s diverticulum that had no areas of inflammation. The abdomen was closed. A scatological examination of the specimen containing the perforation showed effaced villi infiltrated with lymphocytes and plasma cells in the mucosa. The patient was subsequently discharged after she tolerated a normal diet.
Discussion: As the COVID-19 pandemic continues to increase, more case reports have reported patients developing GI perforations at all age groups. The mechanism behind GI perforations associated with COVID-19 remains unclear. Patients admitted to the ICU can present or develop gastric or duodenal ulcers, which increases the risk of perforation as the disease progresses. Stress related mucosal damage is a known phenomenon among ICU patients, which may be more prevalent given the long hospital stays documented among COVID-19 patients.Another hypothesis suggests an imbalance in autonomic innervation of the GI tract by coronavirus may be an additional mechanism involved in GI perforations in COVID-19 patients. Other authors have proposed small vessel thrombosis from inflammatory processes in the vascular endothelium and nonocclusive mesenteric ischemia. One common causes of GI perforation in COVID-19 patients has been with the administration of high dose steroids with tocilizumab, an IL-6 inhibitor. However, most authors agree that the ACE-2 receptor, which is one of the primary receptors for SARS-CoV-2, is likely involved. The ACE-2 is highly expressed in the gastrointestinal tract, specifically the stomach, duodenum, and rectum. The SARS-CoV-2 RNA was primarily detected in gastrointestinal epithelial cells where the SARS-CoV-2 virus could infect and replicate to surrounding epithelial cells. Previous case reports of gastrointestinal perforation did not present histological images, which would provide details into the pathophysiology of GI perforations. The pathologic slides from the case shows that there is extensive proliferation of both neutrophils and plasma cells into the gastrointestinal mucosa. Several reports have shown increased neutrophilia in COVID-19 patients.Autopsies of COVID-19 patients show neutrophil infiltration in pulmonary capillaries and alveolar spaces. Although the mechanism underlying neutrophilia with COVID-19 remains unknown, an increase in neutrophils is known to increase oxidative stress and damage, including lipid peroxidation and DNA oxidation. Depending on the severity of COVID-19, elevations in neutrophils within the gastrointestinal mucosa may increase oxidative stress and damage in gastrointestinal epithelial cells, which would increase the risk of gastrointestinal perforation. However, further pathophysiological studies are needed to assess the mechanisms by which COVID-19 may damage the gastrointestinal mucosa leading to gastrointestinal perforation.
Conclusion: The COVID-19 virus causes inflammatory changes in many areas of the human body, the GI tract is commonly involved. When evaluating patients with COVID-19 one must have a high index of suspicion in patients with worsening or unresolving abdominal pain as this could be the symptoms of a perforation.
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