This document discusses gastrointestinal manifestations and liver injury associated with COVID-19. It finds that SARS-CoV-2 RNA has been detected in anal/rectal swabs in 54% of cases. Common GI symptoms in patients with COVID-19 include diarrhea, vomiting, and abdominal pain. Between 14.8-53.1% of COVID-19 patients show abnormal liver enzymes. The document also discusses GI complications seen in critically ill COVID-19 patients such as bowel ischemia, bleeding, and pancreatitis. Local surgical data found colon perforation and mesenteric ischemia to be common GI indications for surgery post-COVID-19 with a 40% mortality rate for those requiring abdominal surgery.

1. Acute Abdomen in Corona
Dr. Dhaval Mangukiya
GI HPB & Cancer Surgeon
SIDS Hospital & Research Center

2. Hypotheses
 small vessel thrombosis
or
 viral enteroneuropathy
Gastrointestinal manifestations
Liver injury

3. Gastrointestinal manifestations
 Diarrhea
 Vomiting
 Abdominal pain
Studies have identified the SARS-CoV-2 RNA in anal/rectal swabs
• Zhang W, Du RH, Li B et al. Molecular and serological investigation of 2019-nCoV infected
patients: implication of multiple shedding routes. Emerg. Microbes. Infect. 2020; 9: 386–9.
• Xu Y, Li X, Zhu B et al. Characteristics of pediatric SARS-CoV-2 infection and potential
evidence for persistent fecal viral shedding. Nat. Med. 2020
cohorts have reported frequencies
2.0–10.1%
1.0– 10.1%
2.2–5.8%

4. Liver injury in Covid-19 patients
 14.8–53.1% of Covid-19 patients had abnormal levels of alanine aminotransferase (ALT)
and aspartate aminotransferase (AST)
 Most of the liver injuries are mild and transient
 Mechanism
 Direct viral infection of hepatocytes
 Immune-related injury
 Drug hepatotoxicity
Xu L, Liu J, Lu M, Yang D, Zheng X. Liver injury during highly pathogenic human
coronavirus infections. Liver Int. 2020.

5. Critically ill patients with COVID-19
 Bowel ischemia
 Transaminitis
 Gastrointestinal bleeding
 Pancreatitis
 Ogilvie syndrome
 Severe ileus
Kaafarani HMA, El Moheb M, Hwabejire JO, et al. Gastrointestinal complications in critically ill
patients with COVID-19. Ann Surg. 2020;272(2)

6. Critically ill patients with COVID-19
High expression of angiotensin-converting
enzyme 2 receptors along the epithelial lining of
the gut that act as host-cell receptors for SARS-
CoV-2 could explain involvement of abdominal
organs
Higher opioid requirements and COVID-19–
induced coagulopathy may also explain the
disproportionately high rate of ileus and ischemic
bowel disease.2

7. Manifestations and prognosis of gastrointestinal and liver
involvement in patients with COVID-19: a systematic review and
meta-analysis
Lancet Gastroenterol Hepatol 2020; 5: 667–78
 The pooled estimate of SARS-CoV-2 viral RNA positivity in fecal samples was 54% (95% CI
44–64; I²=28%), with positivity persisting for up to 47 days after symptom onset
 Patients with severe COVID-19 were more likely to present with abdominal pain
 No significant difference between patients with severe and non-severe disease in loss of
appetite, diarrhea, or nausea or vomiting
 Higher risk of abnormal liver chemistry
 Gastrointestinal symptoms were reported in 15% of patients with COVID-19 and liver injury
in 19% of patients

8. GI Surgical Indication and outcome
Kaafarani HMA, El Moheb M, Hwabejire JO, et al. Gastrointestinal complications in critically
ill patients with COVID-19. Ann Surg. 2020;272(2)

9. GI Surgical Indication and outcome
 The overall 14-day patient mortality was 15%.
 The mortality rate of the subset of patients who required abdominal surgery was as
high as 40%
Kaafarani HMA, El Moheb M, Hwabejire JO, et al. Gastrointestinal complications in
critically ill patients with COVID-19. Ann Surg. 2020;272(2)

10. Our Data
 Colon perforation – 12
 2 patients within 10 days of Covid 19
 10 patients after 14 days of Covid 19
 Mesenteric Ischaemia – 5 (All after 20 days to 45 days post Covid 19)
 Splenic Infarction – 1 (Post Covid)
 Retroperitoneal Haematoma – 1 (Post Covid)
 Acute Cholecystitis – 1 (During Active phase)
 Acute Pancreatitis – 1 (During Active phase)

11. Mortality
 2 out of 17 patients who underwent surgery

12. Our Observation
 No strenuous activity post operatively
 Liberal use of steroids
 Proactive anticoagulation
 No General Anesthesia whenever possible
 Quick Surgery
 Routine Antibiotics
 Early Orals and Hydration
 Safety for Surgeon & Staff

13. Thank you