Abdominal symptoms as initial manifestation of COVID-19: a case series

Abstract

The COVID-19 became a pandemic in early 2020. It was found, at first, that the main manifestations of this new virus occur through respiratory and constitutional symptoms. Therefore, chest tomography was elected as the best imaging test to assess the extent of pulmonary involvement and as a good prognostic predictor for the disease. However, as new studies were produced, the gastrointestinal involvement of COVID-19 becomes more evident, with reports from patients who manifested mainly or only gastrointestinal symptoms in the course of the disease. Thus, in some cases, the initial investigation is carried out at the emergency department with an abdominal computed tomography. We report a case series of ten patients who came to the emergency department of our institution with a chief gastrointestinal complaint, and were initially submitted to an abdominal computed tomography as the first investigation. Although most of the patients did not have significant changes in the abdominal images, most reported patients had pulmonary findings visualized at the lung bases, which were later designated as typical COVID-19 pulmonary findings on chest computed tomography. Only one patient had atypical COVID-19 lung changes on chest computed tomography. All patients had a positive real-time polymerase chain reaction for COVID-19. It is imperative to alert radiologists, especially abdominal radiologists, with the possibility of COVID-19 isolated gastrointestinal symptoms. Besides, it must become a habit to radiologists to assess the pulmonary basis on abdominal scans, a site commonly affected by the new coronavirus.

Figure 1. Axial (A, C), coronal (B) and sagital (D) images of chest computed tomography showing typical COVID-19 pulmonary findings

Figure 2. Axial (A) and coronal (B) chest computed tomography images show an unique pulmonary consolidation in the right lower lobe, an atypical finding in COVID-19

Figure 3. Axial (A) and sagital (B) images of an abdomen computed tomography illustrates multiple diverticula in the sigmoid colon. One showed thickened walls (arrows) with adjacent fat stranding, findings consistent with acute diverticulitis

Figure 4. Axial (A) and coronal (B) images of a chest computed tomography illustrate multiple and bilateral ground glass opacities, septal thickening and reticulation, findings consistent with COVID-19

Figure 5. Axial images (A and B) of the lung basis in an abdomen computed tomography show subtle ground glass opacities with some septal thickening, which possibly represented incipient COVID-19 changes (arrows)

Figure 6. Axial (A) and coronal (B) images of a non-enhanced abdomen computed tomography show thickened walls in the cecum and terminal ileum, with fat stranding (arrows), consistent with enterocolitis

Figure 7. Axial (A) and sagital (B) images of the lung basis in an abdomen computed tomography show ground-glass opacities with septal thickening and fine reticulation, typical COVID-19 pulmonary findings

Figura 1. Imagens axial (A, C), coronal (B) e sagital (D) de tomografia computadorizada de tórax, retratando achados pulmonares comuns da COVID-19

Figura 2. Imagens axial (A) e coronal (B) de tomografia computadorizada de tórax ilustram consolidação alveolar no lobo inferior direito, um achado incomum para COVID-19

Figura 3. Imagens axial (A) e sagital (B) de tomografia computadorizada do abdome demonstra múltiplos divertículos no cólon sigmoide. Um deles está com paredes espessadas (setas) e estriações da gordura adjacente, achados consistentes com diverticulite aguda

Figura 4. Imagens axial (A) e coronal (B) de tomografia computadorizada de tórax ilustram múltiplas opacidades em vidro fosco bilaterais, espessamento septal e fina reticulação, achados típicos de COVID-19

Figura 5. Imagens axiais (A e B) das bases pulmonares da primeira tomografia computadorizada do abdome mostram sutis opacidades em vidro fosco arredondadas, com algum espessamento septal, sugestivas de infecção incipiente pela COVID-19 (setas)

Figura 6. Imagens axial (A) e coronal (B) da tomografia computadorizada do abdome sem contraste, mostrando paredes espessadas no ceco e íleo terminal com estriações de gordura (setas), condizentes com enterocolite

Figura 7. Imagens axial (A) e sagital (B) das bases pulmonares da tomografia computadorizada de abdome mostram opacidades em vidro fosco com espessamento septal e reticulação fina, achados pulmonares típicos da COVID-19