Fatal gastrointestinal bleeding associated with acute pancreatitis as a complication of Covid-19: a case report

Abstract

Clinical manifestations of Covid-19 vary widely among patients. Recent studies suggest that up to 15% of patients with severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) infections develop gastrointestinal symptoms. The location of virus-host cell receptors angiotensin-converting enzyme 2 and transmembrane serine protease 2 has an important role in the pathophysiology and presentation of disease. They are expressed in the respiratory tract, as well as other organs and tissues including exocrine and endocrine pancreatic cells. These cells are therefore a possible target for the virus, which could explain the relationship between SARS-CoV-2 infection and pancreatic injury. We report a disastrous collateral effect of the Covid-19 pandemic on a 33-year-old man with chronic renal insufficiency and asymptomatic SARS-CoV-2 infection, who developed acute pancreatitis. Inflammation progressed rapidly toward necrosis and the development of a peripancreatic pseudoaneurysm which subsequently ruptured, causing death.

Keywords: Covid-19; Pancreatitis; bleeding pseudoaneurysm; pancreatic pseudoaneurysm; peripancreatic necrosis; severe acute respiratory syndrome coronavirus type 2.

Figure 1.

Non-contrast chest and abdominal CT examination. (a) Axial scan showing discrete peripheral ground-glass opacities typical of pulmonary manifestation of Covid-19 and (b) Axial view showing hypodense area inside the pancreatic head, suggestive of intraparenchymal necrosis. Discrete peripancreatic fat stranding can also be seen, without acute necrotic or liquid collection. CT, computed tomography.

Figure 2.

(a) Axial scan and (b) coronal reconstruction of contrast-enhanced abdominal CT showing central enhancing component inside walled-off pancreatic necrosis in the head of the pancreas. This correlates with the pseudoaneurysm originating from the pancreaticoduodenal artery.

Figure 3.

(a) Multidetector CT of the abdomen in the arterial phase showing enlarged WOPN with a ruptured pseudoaneurysm and active intralesional bleeding. (b) Edematous medial wall of the D2 duodenal segment with a discrete defect suggesting fistulation with necrotic collection and (c) Hyperdense, hemorrhagic content in the lumen of the small intestine showing a small amount of free fluid in the peritoneal space CT, computed tomography.

Figure 4.

(a) Duodenoscopy showing diffusely altered wall of the duodenum with extensive inflammation and exulceration and (b) Minor defect on the wall of the duodenum and penetration of the dense hemorrhagic content into the lumen.