Case Study: COVID-19 Rule-Out Patient Presenting with GI Symptoms

Posted in: Announcements, Blog, COVID-19, Ultrasound Literature|April 15, 2020

This middle-aged female presents several weeks following hospitalization for bowel resection with malaise, nausea, and vomiting. No fevers or cough were noted. Patient had diffuse abdominal distention and tenderness to palpation. The patient was triaged as a rule-out COVID-19 patient due to high COVID-19 prevalence in the region and gastrointestinal symptoms.

Abdominal Ultrasound & CT Images

The accompanying short- and long-axis ultrasound clips reveal a distended small bowel measuring > 3 cm, which is consistent with small bowel obstruction. The characteristic location, presence of active peristalsis, and visible appearance of valvulae conniventes (plicae circulares) in the long-axis clip help identify this as small bowel. Free fluid is noted in between bowel loops.

This patient underwent a CT scan that confirmed a small bowel obstruction, and the trace free fluid was deemed post-operative. The patient was admitted with enhanced droplet precautions and responded to supportive care. Her COVID-19 test subsequently returned negative. She was discharged three days later with a diagnosis of a resolved small bowel obstruction.

Key Points

• Documented gastrointestinal manifestations in coronavirus disease 2019 (COVID-19) patients include anorexia, nausea, vomiting, abdominal pain, and diarrhea.
• Prevalence of gastrointestinal symptoms in COVID-19 patients at the time of initial presentation for medical evaluation ranges between 1% to 17% (Chen et al., de Souza et al., Gu et al., Guan et al., Huang et al., Jin et al., Luo et al., Ng & Tilg, Young et al.).
• Gastrointestinal manifestations may predate more commonly described signs and symptoms, such as cough and fever, by several days (de Souza et al., Song et al., Wang et al.).
• To date, characteristic gastrointestinal ultrasound findings in COVID-19 infected patients have not been described.
• An important application of ultrasound in COVID-positive or rule-out COVID patients presenting with gastrointestinal symptoms is to identify alternative etiologies for these symptoms (e.g., small bowel obstruction).

Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020 Feb 15;395(10223):507-513. doi: 10.1016/S0140-6736(20)30211-7. Epub 2020 Jan 30.

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Gu J, Han B, Wang J. COVID-19: gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology. 2020 Mar 3. pii: S0016-5085(20)30281-X. doi: 10.1053/j.gastro.2020.02.054. [Epub ahead of print]

Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020 Feb 28. doi: 10.1056/NEJMoa2002032. [Epub ahead of print]

Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020 Feb 15;395(10223):497-506. doi: 10.1016/S0140-6736(20)30183-5. Epub 2020 Jan 24.

Jin X, Lian J, Hu J, et al. Epidemiological, clinical and virological characteristics of 74 cases of coronavirus-infected disease 2019 (COVID-19) with gastrointestinal symptoms. Gut. 2020 Mar 24. pii: gutjnl-2020-320926. doi: 10.1136/gutjnl-2020-320926. [Epub ahead of print]

Luo S, Zhang X, Xu H. Don’t overlook digestive symptoms in patients with 2019 novel coronavirus disease (COVID-19). Clin Gastroenterol Hepatol. 2020 Mar 20. pii: S1542-3565(20)30401-8. doi: 10.1016/j.cgh.2020.03.043. [Epub ahead of print]

Ng SC, Tilg H. COVID-19 and the gastrointestinal tract: more than meets the eye. Gut. 2020 Apr 9. pii: gutjnl-2020-321195. doi: 10.1136/gutjnl-2020-321195. [Epub ahead of print]

Song Y, Liu P, Shi XL, et al. SARS-CoV-2 induced diarrhoea as onset symptom in patient with COVID-19. Gut. 2020 Mar 5. pii: gutjnl-2020-320891. doi: 10.1136/gutjnl-2020-320891. [Epub ahead of print]

Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA. 2020 Feb 7. doi: 10.1001/jama.2020.1585. [Epub ahead of print]

Young BE, Ong SWX, Kalimuddin S, et al. Epidemiologic features and clinical course of patients infected with SARS-CoV-2 in Singapore. JAMA. 2020 Mar 3. doi: 10.1001/jama.2020.3204. [Epub ahead of print]

Zhang H, Kang Z, Gong H, et al. The digestive system is a potential route of 2019-nCov infection: a bioinformatics analysis based on single-cell transcriptomes. BioRxiv 2020.01.30.927806 [Preprint]. 2020 [cited 2020 Apr 13]. Available from: https://www.biorxiv.org/content/10.1101/2020.01.30.927806v1.article-info doi: https://doi.org/10.1101/2020.01.30.927806

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