COVID-19 WITH ACUTE COLONIC PSEUDO-OBSTRUCTION

ABSTRACT

CASE A 83-year-old male with a history of non-insulin dependent diabetes mellitus, and coronary artery disease presented with four days of worsening myalgias, subjective fevers, and abdominal distention. He had no history of abdominal surgery, sick contacts or medication changes. He had a temperature of 99.2°F, a heart rate of 80 beats per minute, a respiratory rate of 18 breaths per minute, a blood pressure of 105/80 mmHg, and an oxygen saturation of 96% on room air. On examination, the abdomen was distended but without tenderness or guarding. Abdomen Computed Tomography (CT) scan revealed pancolonic severe gaseous dilatation with no transition point. COVID 19 polymerase chain reaction was noted to be positive, along with an elevated D-dimer of 2.58, ESR of 60 mm/h and CRP 40 mg/l;otherwise the laboratory workup including a respiratory and gastrointestinal panel, blood and sputum culture were negative. Following multidisciplinary and shared decisionmaking, a rectal tube was placed and the patient was given neostigmine with resolution of symptoms and subsequent radiographic demonstration of improvement in the colonic distention within 48 hours. Unfortunately, the patient suffered a cardiac arrest on day 5 of his hospitalization and per the family's request, aggressive treatment was aborted in favor of comfort measures. IMPACT/DISCUSSION: While COVID-19 is primarily an airborne infection, widespread expression of its receptor, Angiotensin Converting Enzyme type 2 (ACE2), throughout the gastrointestinal (GI) tract causes GI tract-related clinical symptoms in the absence of respiratory symptoms, leading to a delay in COVID-19 infection diagnosis. While anorexia (50.2%) and diarrhea (49.5%) are the most common gastrointestinal symptoms of COVID 19, our patient presented with abdominal discomfort (2%). Acute colonic pseudo-obstruction or Ogilvie syndrome is a functional disorder characterized by profound dilatation of the colon without a true mechanical obstruction. An association between certain viral infections (Herpes) and intestinal pseudo-obstruction has been demonstrated previously. The mechanism of such a development is hypothesized to be due to the viral invasion of the myenteric plexus. Similarly, COVID-19 has demonstrated neurotropic potential leading to the development of Ogilvie syndrome. Treatment modalities available for the treatment include bowel rest, nasogastric and rectal tube placement, electrolyte correction, neostigmine and possible endoscopic/surgical intervention with a preferably good prognosis. CONCLUSION: 1. The full range of effects of the COVID 19 virus are yet to be discovered. Loss of parasympathetic spinal control of bowel motility may be one possible manifestation of this disease. 2. Gastrointestinal sequelae of COVID 19 respond well to conservative management and should warrant a low threshold for the investigation and implementation of such treatment.