Colonic Ileus, Distension, and Ischemia Due to COVID-19-Related Colitis: A Case Report and Literature Review

Abstract

Coronavirus disease 2019 (COVID-19) predominantly presents with respiratory symptoms, however, the involvement of the gastrointestinal system has also been reported. Isolated gastrointestinal manifestation due to COVID-19 presenting as colonic distension is uncommon. Colonic ileus from COVID-19 infection presents as dilatation on imaging, with the risk of subsequent ischemia and perforation if not recognized and treated promptly. There is no consensus on the treatment modality for COVID-19-related colitis, however, COVID-19-targeted medications in conjunction with surgical intervention have been performed for management. We present a case of a 73-year-old man who presented with abdominal pain, distention, and diarrhea. He tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and was found to have marked dilatation of the colon on imaging. He was initially given convalescent plasma to reduce inflammatory markers, as tocilizumab was contraindicated due to suspected bowel obstruction. Once more stable, he underwent surgical intervention followed by tocilizumab infusion. Pathological specimens of the colon demonstrated hemorrhagic colitis with microthrombi suggestive of COVID-19-related colitis. Recognizing COVID-19-related colitis allows for timely diagnosis and management with targeted interventions in addition to surgery, which may prevent perforation. We suggest convalescent plasma followed by the formation of colostomy and finally infusion of tocilizumab as a feasible option for the treatment of COVID-19-related colitis. However, further research is needed in order to fully understand this entity and provide guidance for its management.

Keywords: bowel ischemia; colitis; colostomy; convalescent plasma; covid 19; gastrointestinal obstruction; gastrointestinal surgery; pseudo-colonic obstruction; sars-cov-2; tocilizumab.

Figure 1. CT scan of the abdomen with contrast on admission demonstrating mild dilatation of the right colon with diffuse wall thickening and surrounding inflammation along the splenic flexure and descending colon

CT: computed tomography

Figure 2. Flexible sigmoidoscopy revealing a polypoid lesion near the proximal sigmoid colon with adjacent ulcerated friable colonic mucosa

Figure 3. Initial chest X-ray demonstrating a subtle left upper lobe infiltrate

Figure 4. A repeat CT scan of the abdomen demonstrating colonic dilatation and wall thickening involving the distal transverse and descending colon, with pericolonic infiltrative changes representative of inflammatory colitis

CT: computed tomography