Yield of Adding chest CT to Abdominal CT to Detect COVID-19 in Patients Presenting With Acute Gastrointestinal Symptoms (SCOUT-3): Multicenter Study.

OBJECTIVE: To determine the incremental yield of standardized addition of chest CT to abdominal CT to detect COVID-19 in patients presenting with primarily acute gastrointestinal symptoms requiring abdominal imaging. Summary Background Data: Around 20% of patients with COVID-19 present with gastrointestinal symptoms. COVID-19 might be neglected in these patients, as the focus could be on finding abdominal pathology. During the COVID-19 pandemic, several centers have routinely added chest CT to abdominal CT to detect possible COVID-19 in patients presenting with gastrointestinal symptoms. However, the incremental yield of this strategy is unknown. METHODS: This multicenter study in 6 Dutch centers included consecutive adult patients presenting with acute nontraumatic gastrointestinal symptoms, who underwent standardized combined abdominal and chest CT between March 15, 2020 and April 30, 2020. All CT scans were read for signs of COVID-19 related pulmonary sequelae using the СО-RADS score. The primary outcome was the yield of high COVID-19 suspicion (СО-RADS 4-5) based on chest CT. RESULTS: A total of 392 patients were included. Radiologic suspicion for COVID-19 (СО-RADS 4-5) was present in 17 (4.3%) patients, eleven of which were diagnosed with COVID-19. Only 5 patients with СО-RADS 4-5 presented without any respiratory symptoms and were diagnosed with COVID-19. No relation with community prevalence could be detected. CONCLUSION: The yield of adding chest CT to abdominal CT to detect COVID-19 in patients presenting with acute gastrointestinal symptoms is extremely low with an additional detection rate of around 1%.

Factors Associated With Severe Gastrointestinal Diagnoses in Children With SARS-CoV-2 Infection or Multisystem Inflammatory Syndrome.

Importance: Severe gastrointestinal (GI) manifestations have been sporadically reported in children with COVID-19; however, their frequency and clinical outcome are unknown. Objective: To describe the clinical, radiological, and histopathologic characteristics of children with COVID-19 presenting with severe GI manifestations to identify factors associated with a severe outcome. Design, Setting, and Participants: A multicenter retrospective cohort study (February 25, 2020, to January 20, 2021) enrolled inpatient and outpatient children (aged <18 years) with acute SARS-CoV-2 infection, confirmed by positive real-time reverse-transcriptase-polymerase chain reaction on nasopharyngeal swab or fulfilling the US Centers for Disease Control and Prevention criteria for multisystem inflammatory syndrome in children (MIS-C). The study was conducted by pediatricians working in primary care or hospitals in Italy participating in the COVID-19 Registry of the Italian Society of Pediatric Infectious Diseases. Main Outcomes and Measures: The occurrence of severe GI manifestations, defined by a medical and/or radiological diagnosis of acute abdomen, appendicitis (complicated or not by perforation and/or peritonitis), intussusception, pancreatitis, abdominal fluid collection, and diffuse adenomesenteritis requiring surgical consultation, occurring during or within 4 to 6 weeks after infection with SARS-CoV-2 infection. Logistic regression was used to estimate odds ratios (ORs) with 95% CIs of factors potentially associated with severe outcomes. Results: Overall, 685 children (386 boys [56.4%]; median age, 7.3 [IQR, 1.6-12.4] years) were included. Of these children, 628 (91.7%) were diagnosed with acute SARS-CoV-2 infection and 57 (8.3%) with MIS-C. The presence of GI symptoms was associated with a higher chance of hospitalization (OR, 2.64; 95% CI, 1.89-3.69) and intensive care unit admission (OR, 3.90; 95% CI, 1.98-7.68). Overall, 65 children (9.5%) showed severe GI involvement, including disseminated adenomesenteritis (39.6%), appendicitis (33.5%), abdominal fluid collection (21.3%), pancreatitis (6.9%), or intussusception (4.6%). Twenty-seven of these 65 children (41.5%) underwent surgery. Severe GI manifestations were associated with the child's age (5-10 years: OR, 8.33; 95% CI, 2.62-26.5; >10 years: OR, 6.37; 95% CI, 2.12-19.1, compared with preschool-age), abdominal pain (adjusted OR [aOR], 34.5; 95% CI, 10.1-118), lymphopenia (aOR, 8.93; 95% CI, 3.03-26.3), or MIS-C (aOR, 6.28; 95% CI, 1.92-20.5). Diarrhea was associated with a higher chance of adenomesenteritis (aOR, 3.13; 95% CI, 1.08-9.12) or abdominal fluid collection (aOR, 3.22; 95% CI, 1.03-10.0). Conclusions and Relevance: In this multicenter cohort study of Italian children with SARS-CoV-2 infection or MIS-C, 9.5% of the children had severe GI involvement, frequently associated with MIS-C. These findings suggest that prompt identification may improve the management of serious complications.

Abdominal and gastrointestinal manifestations in COVID-19 patients: Is imaging useful?

Coronavirus disease 2019 (COVID-19) can be considered a systemic disease with a specific tropism for the vascular system, in which the alterations of the microcirculation have an important pathogenetic role. The lungs are the main organ involved in COVID-19, and severe progressive respiratory failure is the leading cause of death in the affected patients; however, many other organs can be involved with variable clinical manifestations. Concerning abdominal manifestations, the gastrointestinal tract and the hepatobiliary system are mainly affected, although the pancreas, urinary tract and spleen may also be involved. The most common gastrointestinal symptoms are loss of appetite, followed by nausea and vomiting, diarrhea and abdominal pain. Gastrointestinal imaging findings include bowel wall thickening, sometimes associated with hyperemia and mesenteric thickening, fluid-filled segments of the large bowel and rarely intestinal pneumatosis and ischemia. Hepatic involvement manifests as an increase in the enzymatic levels of alanine aminotransferase, aspartate aminotransferase, serum bilirubin and γ-glutamyl transferase with clinical manifestations in most cases mild and transient. The most frequent radiological features are hepatic steatosis, biliary sludge and gallstones. Edematous acute pancreatitis, kidney infarct and acute kidney injury from acute tubular necrosis have been described more rarely in COVID-19. Lastly, splenic involvement is characterized by splenomegaly and by the development of solitary or multifocal splenic infarcts with classic wedge-shaped or even rounded morphology, with irregular or smooth profiles. In summary, the abdominal radiological findings of COVID-19 are nonspecific and with poor pathological correlation reported in the literature. Ultrasound and particularly computed tomography with multiphasic acquisition are the diagnostic methods mainly utilized in COVID-19 patients with abdominal clinical symptoms and signs. Although radiological signs are not specific of abdominal and gastrointestinal involvement, the diagnostic imaging modalities and in particular computed tomography are helpful for the clinician in the management, evaluation of the severity and evolution of the COVID-19 patients.

The eyes see what the mind seeks: a systematic review of abdominal imaging findings in patients with COVID-19.

OBJECTIVES: With the increasing recognition of gastrointestinal (GI) manifestation of coronavirus disease-19 (COVID-19), various abdominal imaging findings are increasingly being noted. We scoped the existing literature on the abdominal imaging findings in COVID-19. METHODS: A systematic literature search was performed on PubMed, Embase, Google scholar and World Health Organization COVID-19 database. RESULTS: 35 studies were included in the final descriptive synthesis. Among the studies reporting positive abdominal imaging findings in patients with COVID-19, majority described imaging abnormalities of the GI tract (16 studies), of which bowel wall thickening was most frequently reported. Other findings noted were abdominal imaging manifestations of bowel ischemia with thrombosis of the splanchnic vasculature, and imaging features suggestive of pancreatitis. Imaging findings suggestive of solid organ infarction were reported in nine studies. An association between imaging evidence of hepatic steatosis and COVID-19 was noted in three studies. Incidental lung base findings on abdominal imaging were noted in 18 studies, where patients presented with predominant GI symptoms. The most common finding was bilateral ground glass opacities (90.7%) with predominant multilobar (91.1%) and peripheral (64.4%) distribution. CONCLUSION: This systematic review provides insight into the abdominal imaging findings in patients with COVID-19. Knowledge of these imaging manifestations will not only help in further research but also will aid in curtailing transmission of the SARS-CoV-2. Further prospective studies are needed to gain better insight into the pathophysiology of these imaging manifestations. ADVANCES IN KNOWLEDGE: This review highlights the abdominal imaging findings in patients with COVID-19, to gain insight into the disease pathophysiology and gear the abdominal radiologist through the pandemic.

Ischemic gastrointestinal complications of COVID-19: a systematic review on imaging presentation.

BACKGROUND: Limited data is available addressing gastrointestinal (GI) ischemia in coronavirus disease 2019 (COVID-19). We reviewed the clinical and radiologic features of GI ischemia and its related complications in thirty-one COVID-19 patients reported in literature. METHODS: A systematic literature review was performed using a search strategy on all studies published from January 1, 2020, to June 13, 2020, and updated on September 6, 2020, on databases from PubMed, Scopus, Embase, Web of Science, and Google Scholar. Every study with at least one presentation of COVID-19-related GI ischemia complication and one GI imaging finding was included. RESULTS: In total, twenty-two studies and thirty-one patients with the mean age of 59 ± 12.7 (age range: 28-80) years old were included, of which 23 (74.2%) patients were male, 7 (22.5%) female, and one unknown gender. The significant GI imaging findings include mesenteric arterial or venous thromboembolism, followed by small bowel ischemia. Nine patients (29%) presented with arterial compromise due to superior mesenteric thromboembolism, resulting in bowel ischemia. Also, 6 patients (19.3%) demonstrated occlusive thrombosis of the portal system and superior mesenteric vein. More than two-thirds of patients (20, 64.5%) required laparotomy and bowel resection. Eventually, five (16.1%) patients were discharged, of whom four cases (12.9%) readmitted. Five (16.1%) patients remained ICU hospitalized at the report time and 12 (38.7%) patients died. CONCLUSION: Macrovascular arterial/venous thrombosis is identified in almost half of COVID-19 patients with bowel ischemia. Overall mortality in COVID-19 patients with GI ischemia and radiologically evident mesenteric thrombotic occlusion was 38.7% and 40%, retrospectively.

Cross-sectional Imaging Manifestations of Extrapulmonary Involvement in COVID-19 Disease.

ABSTRACT: Coronavirus disease 2019 (COVID-19) disease has spread worldwide since it was first discovered in China's Hubei province in December 2019. Respiratory illness is the primary manifestation of COVID-19 disease, and its pathophysiology as well as the clinical and cross-sectional imaging manifestations has been adequately reported. However, there is emerging evidence of its multisystemic nature, with associated extrapulmonary manifestations including gastrointestinal, cardiovascular, renal, and neurological findings. There is still limited understanding with regard to the extrapulmonary involvement in this disease. This review aims to put together the prevalence, proposed pathophysiology, and the spectrum of clinical and cross-sectional imaging manifestations of associated extrapulmonary findings in COVID-19 disease.

COVID-19: looking beyond the peak. Challenges and tips for radiologists in follow-up of a novel patient cohort.

As the coronavirus pandemic evolves, the focus of radiology departments has begun to change. The acute phase of imaging a new disease entity whilst rationalising radiology services in the face of lockdown has passed. Radiologists are now becoming familiar with the complications of COVID-19, particularly the lung parenchymal and pulmonary vascular sequelae and are considering the impact follow-up imaging may have on departments already struggling with a backlog of suspended imaging in the face of reduced capacity. This review from the British Society of Thoracic Imaging explores both the thoracic and extra-thoracic complications of COVID-19, recognising the importance of a holistic approach to patient follow-up. The British Thoracic Society guidelines for respiratory follow-up of COVID-19 will be discussed, together with newly developed reporting templates, which aim to provide consistency for clinicians as well as an opportunity for longer-term data collection.

Abdominal CT in COVID-19 patients: incidence, indications, and findings.

PURPOSE: The purpose of this study was to evaluate the frequency, indications, and findings of abdominal CTs ordered in the initial evaluation of patients who had a positive COVID-19 test performed in our institution. METHODS: Retrospective chart review was performed on all patients who had a positive test for COVID-19 performed at a single quaternary care center from 1/20/2020 through 5/8/2020. In a subset of patients undergoing abdominal CT as part of the initial evaluation, the demographics, suspected COVID-19 status at the time of scan, presenting complaints, and abdominal CT findings were recorded. Cardiothoracic radiologists reviewed and scored the visualized lung bases for the likelihood of COVID-19. RESULTS: Only 43 (4.1%) of 1057 COVID-19 patients presented with abdominal complaints sufficient to warrant an abdominal CT. Of these 43 patients, the vast majority (39, 91%) were known or suspected to have COVID-19 at the time of the scan. Most (27/43, 63%) scans showed no acute abdominal abnormality, and those that were positive did not share a discernable pattern of abnormalities. Lung base abnormalities were common, and there was moderate inter-reviewer reliability. CONCLUSION: A minority of COVID-19 patients present with abdominal complaints sufficient to warrant a dedicated CT of the abdomen, and most of these studies will be negative or have abdominal findings not associated with COVID-19. Appropriate lung base findings are a more consistent indication of COVID-19 infection than abdominal findings.

Abdominal imaging findings in patients with SARS-CoV-2 infection: a scoping review.

PURPOSE: This scoping review evaluated the currently available data related to abdominal imaging in the SARS-CoV-2 infection. METHOD: A systematic review of MEDLINE, EMBASE, SCOPUS, and Web of Science was performed from inception to July 15, 2020 using PRISMA-ScR guidelines. The review included case reports and series discussing radiologic manifestations of SARS-CoV-2 infection in abdominal imaging studies. Studies published from inception to March 31, 2020, were independently screened and reviewed by one author, and another author reviewed studies published after March 31 to July 15, 2020. Study screening and full-text review for publications before March 31, 2020, was performed by one author, and another author for publications after March 31 to July 15, 2020. RESULTS: Thirty-six studies were included in qualitative synthesis. The prevalence of gastrointestinal symptoms is roughly 18% and includes loss of appetite, nausea, vomiting, diarrhea, and abdominal pain. Sixteen percent of COVID-19 cases may only present with gastrointestinal symptoms. Many patients presenting this way demonstrate evidence of COVID-19 incidentally through abdominal CT imaging at the lung bases. Studies published to date have also reported abdominal imaging findings including small and large bowel wall thickening, fluid-filled colon, pneumatosis intestinalis, pneumoperitoneum, intussusception, and ascites. CONCLUSION: Gastrointestinal manifestations and imaging manifestations of SARS-CoV-2 infection are increasingly reported and warrant specific attention during abdominal imaging.

Abdominopelvic CT findings in patients with novel coronavirus disease 2019 (COVID-19).

PURPOSE: Some patients with novel coronavirus disease 2019 (COVID-2019) present with abdominal symptoms. Abdominal manifestations of COVID on imaging are not yet established. The goal of this study was to quantify the frequency of positive findings on abdominopelvic CT in COVID-positive patients, and to identify clinical factors associated with positive findings to assist with imaging triage. MATERIALS AND METHODS: This retrospective study included adult COVID-positive patients with abdominopelvic CT performed within 14 days of their COVID PCR nasal swab assay from 3/1/2020 to 5/1/2020. Clinical CT reports were reviewed for the provided indication and any positive abdominopelvic findings. Demographic and laboratory data closest to the CT date were recorded. Multivariate logistic regression model with binary outcome of having no reported positive abdominopelvic findings was constructed. RESULTS: Of 141 COVID-positive patients having abdominopelvic CT (average age 64 years [± 16], 91 [64%] women), 80 (57%) had positive abdominopelvic findings. Abdominal pain was the most common indication, provided in 54% (43/80) and 74% (45/61) of patients with and without reported positive abdominopelvic findings, respectively (p = 0.015). 70% (98/141) of patients overall had reported findings in the lung bases. Findings either typical or intermediate for COVID were reported in 50% (40/80) and 64% (39/61) of patients with and without positive abdominopelvic findings, respectively (p = 0.099). Of 80 patients with positive abdominopelvic findings, 25 (31%) had an abnormality of gastrointestinal tract, and 14 (18%) had solid organ infarctions or vascular thromboses. In multivariate analysis, age (OR 0.85, p = 0.023), hemoglobin (OR 0.83, p = 0.029) and male gender (OR 2.58, p = 0.032) were independent predictors of positive abdominopelvic findings, adjusted for race and Charlson comorbidity index. CONCLUSION: Abdominopelvic CT performed on COVID-positive patients yielded a positive finding in 57% of patients. Younger age, male gender, and lower hemoglobin were associated with higher odds of having reportable positive abdominopelvic CT findings.

Abdominal Imaging Findings in COVID-19: Preliminary Observations.

Background Angiotensin-converting enzyme 2, a target of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), demonstrates its highest surface expression in the lung, small bowel, and vasculature, suggesting abdominal viscera may be susceptible to injury. Purpose To report abdominal imaging findings in patients with coronavirus disease 2019. Materials and Methods In this retrospective cross-sectional study, patients consecutively admitted to a single quaternary care center from March 27 to April 10, 2020, who tested positive for SARS-CoV-2 were included. Abdominal imaging studies performed in these patients were reviewed, and salient findings were recorded. Medical records were reviewed for clinical data. Univariable analysis and logistic regression were performed. Results A total of 412 patients (average age, 57 years; range, 18 to >90 years; 241 men, 171 women) were evaluated. A total of 224 abdominal imaging studies were performed (radiography, n = 137; US, n = 44; CT, n = 42; MRI, n = 1) in 134 patients (33%). Abdominal imaging was associated with age (odds ratio [OR], 1.03 per year of increase; P = .001) and intensive care unit (ICU) admission (OR, 17.3; P < .001). Bowel-wall abnormalities were seen on 31% of CT images (13 of 42) and were associated with ICU admission (OR, 15.5; P = .01). Bowel findings included pneumatosis or portal venous gas, seen on 20% of CT images obtained in patients in the ICU (four of 20). Surgical correlation (n = 4) revealed unusual yellow discoloration of the bowel (n = 3) and bowel infarction (n = 2). Pathologic findings revealed ischemic enteritis with patchy necrosis and fibrin thrombi in arterioles (n = 2). Right upper quadrant US examinations were mostly performed because of liver laboratory findings (87%, 32 of 37), and 54% (20 of 37) revealed a dilated sludge-filled gallbladder, suggestive of bile stasis. Patients with a cholecystostomy tube placed (n = 4) had negative bacterial cultures. Conclusion Bowel abnormalities and gallbladder bile stasis were common findings on abdominal images of patients with coronavirus disease 2019. Patients who underwent laparotomy often had ischemia, possibly due to small-vessel thrombosis. © RSNA, 2020.

CT Scans Obtained for Nonpulmonary Indications: Associated Respiratory Findings of COVID-19.

Background Atypical manifestations of coronavirus disease 2019 (COVID-19) are being encountered as the pandemic unfolds, leading to non-chest CT scans that may uncover unsuspected pulmonary disease. Purpose To investigate patients with primary nonrespiratory symptoms who underwent CT of the abdomen or pelvis or CT of the cervical spine or neck with unsuspected findings highly suspicious for pulmonary COVID-19. Materials and Methods This retrospective study from March 10, 2020, to April 6, 2020, involved three institutions, two in a region considered a hot spot (area of high prevalence) for COVID-19. Patients without known COVID-19 were included who presented to the emergency department (ED) with primary nonrespiratory (gastrointestinal or neurologic) symptoms, had lung parenchymal findings suspicious for COVID-19 at non-chest CT but not concurrent chest CT, and underwent COVID-19 testing in the ED. Group 1 patients had reverse transcription polymerase chain reaction (RT-PCR) results obtained before CT scan reading (COVID-19 suspected on presentation); group 2 had RT-PCR results obtained after CT scans were read (COVID-19 not suspected). Presentation and imaging findings were compared, and outcomes were evaluated. Descriptive statistics and Fisher exact tests were used for analysis. Results Group 1 comprised 62 patients (31 men, 31 women; mean age, 67 years ±17 [standard deviation]), and group 2 comprised 57 patients (28 men, 29 women; mean age, 63 years ± 16). Cough and fever were more common in group 1 (37 of 62 [60%] and 29 of 62 [47%], respectively) than in group 2 (nine of 57 [16%] and 12 of 57 [21%], respectively), with no significant difference in the remaining symptoms. There were 101 CT scans of the abdomen or pelvis and 18 CT scans of the cervical spine or neck. In group 1, non-chest CT findings provided the initial evidence of COVID-19-related pneumonia in 32 of 62 (52%) patients. In group 2, the evidence was found in 44 of 57 (77%) patients. Overall, the most common CT findings were ground-glass opacity (114 of 119, 96%) and consolidation (47 of 119, 40%). Major interventions (vasopressor medication or intubation) were required for 29 of 119 (24%) patients, and 27 of 119 (23%) died. Patients who underwent CT of the cervical spine or neck had worse outcomes than those who underwent abdominal or pelvic CT (P = .01). Conclusion In a substantial percentage of patients with primary nonrespiratory symptoms who underwent non-chest CT, CT provided evidence of coronavirus disease 2019-related pneumonia. © RSNA, 2020.