Gastric ischemia and portal vein thrombosis in a COVID-19-infected patient

A 51-year-old man admitted with acute respiratory failure from a SARS-CoV-2 infection had large volume of bloody output via orogastric tube following initiation of heparin for a lower extremity deep vein thrombosis. Esophagogastroduodenoscopy revealed diffuse and severe mucosal ischemia involving the gastric fundus ([Fig. 1]), greater curvature, and posterior wall of the gastric body and antrum ([Fig. 2]) ([Video 1]). The anterior gastric wall and duodenum appeared normal. Computed tomography (CT) angiogram of the abdomen revealed gastric pneumatosis ([Fig. 3]), a non-occlusive thrombus in the right and left portal veins, and portal venous gas ([Fig. 4]). The small bowel and colon appeared normal. In addition to management of the underlying COVID infection and respiratory complications, management included nasogastric decompression and intravenous heparin. A repeat abdominal CT 1 week later showed resolution of the intramural gastric and portal venous gas, and no residual portal vein thrombosis ([Fig. 5]).

Fig. 1 Mucosal changes of ischemia involving entire gastric fundus.

Fig. 2 Mucosal changes of ischemia involving greater curvature with sparing of anterior wall.

Video 1 Esophagogastroduodenoscopy findings of gastric mucosal ischemia with normal duodenum in the setting of COVID-19 infection.

Fig. 3 Gastric pneumatosis seen on computed tomography angiogram.

Fig. 4 Non-occlusive thrombus in the right and left portal veins, and portal venous gas on computed tomography angiogram.

Fig. 5 Radiologic resolution of intramural gastric and portal venous gas, and portal vein thrombosis.

Gastrointestinal tract involvement, ranging from minor symptoms to small bowel ischemia, has been reported with the SARS-CoV-2 virus, which may be due to a high surface expression of angiotensin-converting enzyme 2 (ACE2) receptors on gastric cells and enterocytes [1] [2]. The underlying mechanism of small bowel ischemia is not known but might result from direct viral infiltration via ACE2 receptors on enterocytes and endothelial cells, complement-mediated small vessel thrombosis, non-occlusive mesenteric ischemia, or systemic coagulopathy [3] [4]. Gastric ischemia is a rare condition that results from vascular insufficiency due to local or systemic disorders and is associated with poor clinical outcomes if not recognized and treated early [5]. Our patient had gastric ischemia and portal vein thrombosis in the setting of a COVID-19 infection in the absence of other thromboembolic risk factors. Based on a review of the literature, we found no reported cases of COVID-19-associated gastric ischemia. A high index of suspicion may result in early recognition of this complication and treatment with anticoagulation.

Endoscopy_UCTN_Code_CCL_1AB_2AC_3AZ

Publication History

Article published online:
02 September 2020

• References

• 1 Bhayana R, Som A, Li MD. et al. Abdominal imaging findings in COVID-19: preliminary observations. Radiology 2020; DOI: 10.1148/radiol.2020201908.
• 2 Kumar VCS, Mukherjee S, Harne PS. et al. Novelty in the gut: a systematic review and meta-analysis of the gastrointestinal manifestations of COVID-19. BMJ Open Gastroenterol 2020; 7: 1-9
• 3 Magro C, Mulvey JJ, Berlin D. et al. Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID-19 infection: a report of five cases. Transl Res 2020; 220: 1-13
• 4 Zsuzsanna V, Flammer AJ, Steiger P. et al. Endothelial cell infection and endotheliitis in COVID-19. Lancet 2020; 395: 1417-1418
• 5 Sharma A, Mukewar S, Chari ST. et al. Clinical features and outcomes of gastric ischemia. Dig Dis Sci 2017; 62: 3550-3556