Assistant Professor of Medicine Weill Cornell Medical College, Cornell University New York, New York
Sanad Dawod, MD1, Shawn Shah, MD1, Kennry Chiu, MD1, David Wan, MD2; 1New York-Presbyterian/Weill Cornell Medical Center, New York, NY; 2Weill Cornell Medical College, Cornell University, New York, NY
Introduction: Lower gastrointestinal bleeding (LGIB) is blood loss originating distal to the ligament of Treitz. The most common causes are diverticulosis, angioectasias, post-polypectomy bleeding, and colon ischemia. We present a Coronavirus disease 2019 (COVID-19) patient presenting with a life-threatening LGIB.
Methods: A 71-year-old male patient with a history of dyslipidemia presented to the emergency room with three days of dyspnea, cough and lightheadedness. A SARS-CoV-2-RT-PCR carried out was positive. During his stay, he developed hematochezia with hemodynamic instability and a hemoglobin (Hb) of 5.2 g/dl. A CTA showed active extravasation in the splenic flexure. He was transfused 5 blood units with minimal Hb improvement to 5.7 g/dl. The GI team deferred intervention and the patient was transferred to our center for radiological intervention. He is on a statin and had used Aspirin 2 days before admission for pain relief. Physical exam was deferred due to COVID-19 status. Admission vitals were only notable for a heart rate of 121 BPM. Other labs showed a platelet count of 517x 109/L, a BUN of 24.9 mg/dl, and a serum creatinine of 1.25 mg/dl. An angiogram failed to localize the bleeding site, and no empiric embolization was done. He was transfused a total of 9 units of blood, 1 unit of platelets at our center, and 4 units of plasma. Endoscopy was deferred as the patient was unfit. Surgery was consulted and he was taken to the operating room and underwent a left hemicolectomy with creation of a transverse colostomy. The splenic flexure was confirmed as the bleeding site with blood in the lumen, but no source was identified. Microscopic changes were not typical of ischemia and are speculated to be COVID-19 Infection related. (Figure 1) (Figure 2) His course was complicated by PE despite anticoagulation and as a result, had an IVC filter placed. He was later discharged. Discussion: Most acute LGIB are managed through endoscopy and infrequently require interventions by radiology or surgery. While evidence of GI bleeds in COVID-19 patients exists, there are, to the best of our knowledge, none requiring surgery. Our patient developed severe refractory acute LGIB likely due to SARS-CoV-2 that could not be localized by radiological studies and was hence taken into the operating room to stop the bleed. Our case highlights the possible implication of COVID-19 in a life-threatening LGIB and further broadens the spectrum of possible manifestations that COVID-19 patients could exhibit.
Figure 1. The crypts show regenerative changes and the submucosa shows edema.
Figure 2. The superficial epithelium showed depletion of goblet cells, nuclear stratification with tufting, nuclear pleomorphism and hyperchromatism. These epithelial changes were not typical of ischemia; it was speculated that these changes may be related to COVID infection.
Disclosures: Sanad Dawod indicated no relevant financial relationships. Shawn Shah indicated no relevant financial relationships. Kennry Chiu indicated no relevant financial relationships. David Wan indicated no relevant financial relationships.