mesenteric ischamia in covid 19 patients

INTRODUCTION

In 2019 December the world faced with unknown cause of sever pneumonia., in Wuhan city in china it was sever acute respiratory distress syndrome by corona -2 (SARS- COV-2).¹

 on February the world health organization named the outbreak of disease covid 19 virus disease.² on march2020 World Health Organization declare that outbreak of covid 19 virus is pandemic.³

^.by the time of December 2020 about 70million cases diagnosed and 1.5 million deaths.⁴ at the start of covid 19 there is thought that it affects respiratory system onlyas rapid spread of covid 19 virus infection there is correlation between the covid19 virus infection with thrombosis and thromboembolism. ⁵

In covid 19 virus there are gastrointestinal manifestationsmesenteric vascular occlusion or thrombosis of big abdominal vessels either arterial or venous is fetal disease ⁶, if combined with covid 19 infection there is high mortality mesenteric ischemia is fatal disease 80-90%in operated patient and 100%in non-operated patient this mostly because unclear symptoms delaying diagnosis, and irreversible changes that happened in the intestinal wall. ⁷

the pathology behind the Mesenteric ischemia with covid 19 is unclear for long time, theory of endothelial injury is part of pathogenesis. Real of over amount of inflammatory cytokines like tumor necrosis factor, interleukin 6, Interleukin (IL) -6, IL-8, and IL-1β,is part of cytokines storm which leads to multi organ failure also patient with hypoxia has increases risk of thrombosis especially in immobile patients.^8&9

 presentation of mesenteric ischemia is vague of gastrointestinal symptoms, nausea, vomiting, diarrhea, and abdominal distention. Due to non-specific symptoms of mesenteric ischemia the radiological investigation is the main way to diagnosis of this disease.¹⁰

 Ultrasonography and abdominal radiology have low sensitivity and specificity C T is main line of radiological diagnosis replacing angiography.¹⁰

After diagnosis immediate surgical interference is best way of treatment to avoid the rate of mortality, ICU admission is needed in about 30% of patient with mesenteric ischemia even on anticoagulant.^11&12

The aim of this study is to evaluate the diagnosis and treatment of mesenteric ischemia in covid 19 positive patient

PATIENTS AND METHODS

this study is prospective study done on 15 patient presented to emergency room with manifestation of intestinal obstruction in surgical department in the new Damietta Al-Azhar university hospital, Arab republic of Egypt, from first July 2021 to first January 2022.

 preoperative preparations all patients exposed to detailed history examination and all investigation (CBC, liver function, kidney function, coagulation profile x ray of the abdomen chest x-ray, abdominal CT scan and chest C T was done to detect covid 19 with pneumonia) all of them are covid 19 positive d dimer 10 patients male and 5 patient female all patients underwent surgical operation laparotomy

Ethical consent: An approval of the study was obtained from Al-Azhar University Academic and Ethical Committee. Every patient signed an informed written consent for acceptance of the participation in the study. This work has been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for studies involving humans.

RESULTS

This study conducted over 15 patients with demographic distribution according to age, sex, symptoms, signs and anticoagulant

In our study the age of the patients ranges from 16 to 89 year with the mean age is 55.5 %the youngest age is 16 and the oldest is 89.

 6patient are female 40% ,8patient are male 60% with increased the incidence of coagulopathy in male mort than female.

15 patients presenting with abdominal pain 100% of the patient, 5patient presented with bleeding per rectum and hematemesis,33.3% one patient presented with nausea

6.6%.5patient started with LMWH33.3%,5patientwith acetyl salicylic acid (ASA) 33.3% and 5patients with no anticoagulant 33.3%and

5 patients with comorbidity diabetes mellitus and hypertension 33.3% 8patients underwent laparotomy 53.3% all exploration laparotomy resection anastomosis done for them, and intraoperative diagnosis of intestinal ischemia and 3patients no intervention20%,2patient of them 13.3% with anticoagulant not fit for surgery 9patients discharged in good condition,3patient20% of the expired patient were explored and 2patient 13.3%expired without intervention.

the mod of diagnosis as follow 9 patients diagnosed with PCR (polymerase chain reaction) by swab from the nasopharynx, for the covid 19about 60%and 5 patients diagnosed with CT chest about 33.4% with the characteristic ground glass appearance of covid 19, one patient diagnosed by both CT chest and PCR 6.6%. 9 patients discharged in good condition and 6 patients expired 40%, it is very high incidence of mortality when compared with non-pandemic time in usual situations.

Fig 1: Intestinal gangrene.

Fig 2: Intestinal gangrene after excision.

Fig 3: Colonic gangrene.

Fig 4: Colonic gangrene after excision

Table 1: Demographic distribution of the patient. (ASA: acetyl salicylic acid; APT: antiplatelet therapy; LMWH: low molecular weight heparin. ACT; anticoagulant therapy. CT; cat scan. PCR; polymerase chain reaction; DM: diabetes mellitus. IHD; ischemic heart disease; Exp; lap exploration laparotomy.