Clinical Case Summary

An 80-year-old woman presented with recurrent dysphagia and emesis for two weeks. She also complained of cough, acid reflux and esophageal foreign body sensation.
On admission, routine blood count and biochemistry tests were normal. The nasopharyngeal swab was positive for SARS-CoV-2 RNA. Esophageal lipiodol radiography revealed beaked stenosis at the cardia, with an obvious expansion of the esophagus. Upper gastrointestinal endoscopy showed multiple large bezoars obstructing the esophagus. After bezoars were smashed by a snare, erosion and oozing of blood in cardiac mucosa was shown, where the biopsy was performed.
The patient’s symptoms greatly improved after esophagus bezoar removal. Then, esophageal impedance-pH monitoring was utilized to explore the cause. There was no pathological regurgitation during the 24-hour monitoring. However, esophageal body peristaltic waves were not detected after a total of 15 wet swallows and multiple rapid swallows. Thus, esophageal absent contractility was diagnosed, and domperidone was prescribed. Considering the temporal relationship between esophageal absent contractility and SARS-CoV-2 infection, we detected immunofluorescence of angiotensin-converting enzyme (ACE) 2, a vital receptor of SARS-CoV-2, and SARS-CoV-2 nucleocapsid, both of which stained highly positive in the cardiac mucosa. Finally, the patient was discharged with improved symptoms and negative SARS-CoV-2 RNA. She no longer complained about dysphagia or emesis at the 4-month follow-up.
Bezoars in the gastrointestinal tract is an uncommon clinical entity, especially in esophageal cases. Patients with motility disorders are prone to bezoar formation. Our case provides evidence for gastrointestinal infection with SARS-CoV-2, which occurred almost simultaneously with esophageal absent contractility. As increasing studies suggest autonomic nervous system damage related to SARS-CoV-2, we suspected that the esophageal absent contractility was caused by SARS-CoV-2.

References

Figure 1: Esophageal lipiodol radiography on an X-ray clearly revealed beaked stenosis at the cardia, with an obvious expansion of the esophagus.
Figure 2 and 3: Bezoars obstructing the esophagus detected by endoscopy and some were removed.
Figure 4: Impedance monitoring showed esophageal absent contractility after multiple rapid swallows.
Figure 5: Immunofluorescence showed that ACE2 and SARS-CoV-2 nucleocapsid stained highly positive in the cardiac mucosa.

Clinical Case Summary

Ogilvie’s syndrome is defined as an acute colonic dilatation without mechanical obstruction. Though its exact pathophysiology remains unclear, autonomic dysfunction is implicated. Known triggers include surgery, infections, electrolyte disturbances, and opioids. Viral causes are rare, but several viruses, including SARS-CoV-2, can affect autonomic regulation. A few cases have been reported discussing the incidence of Ogilvie’s syndrome in the setting of SARS-CoV-2 infection. SARS-CoV-2 binds ACE2 receptors, also present in gastrointestinal epithelial cells. We report a case of presumed Ogilvie’s syndrome associated with SARS-CoV-2 infection.
A 25-year-old man, previously healthy, presented in July 2024 with 2-day history of vomiting, watery diarrhea (6 stool per day, no blood), and crampy periumbilical pain. Initial labs revealed elevated CRP (165 mg/L); he was discharged with symptomatic treatment.
He returned 48 hours later with worsening abdominal pain, distension, constipation, and persistent vomiting. Examination revealed diffuse tenderness and distension. Abdominal CT showed moderate fluid-filled distension of colon and some small bowel segments, without obstruction.
Management included bowel rest, IV fluids and analgesia. Symptoms and lab markers improved and bowel movements resumed. Repeat CT showed resolution of distension. All infectious and metabolic workup was negative, except for a positive SARS-CoV-2 test. Based on clinical and imaging findings, a presumptive diagnosis of Ogilvie’s syndrome secondary to SARS-CoV-2 was made. No recurrence was noted after discharge.
Gastrointestinal manifestations of SARS-CoV2 are increasingly recognized. Although rare, SARS-CoV-2-related Ogilvie’s syndrome has been reported. Management is usually conservative. In refractory cases, neostigmine or decompression may be needed. This case supports including Ogilvie’s syndrome in the differential diagnosis for SARS-CoV2 patients with ileus-like symptoms.

References

- First abdominal Computed Tomography scan: moderate fluid-filled distension of the entire colon (including rectum) and some segments of small bowel, with no evidence of mechanical obstruction
- Second abdominal Computed Tomography scan: significant improvement of colonic and small bowel distension

Introduction

Transjugular intrahepatic portosystemic shunt (TIPS) is now an effective and standard procedure to prevent variceal bleeding and recurrent ascites in decompensated cirrhosis (1). Moreover, there is increasing evidence (2, 3) showing that TIPS is feasible in patients with partial or occlusive portal vein thrombosis (PVT). However, thrombosis may develop at intrahepatic branches of the portal vein after TIPS, even in patients without PVT before the procedure. Our retrospective study showed that warfarin could prevent portal branch PVT and might improve liver function among cirrhosis patients receiving TIPS (4). Thus, to obtain clinical evidence with higher quality, a prospective study on post-TIPS de novo PVT regarding the incidence, risk factors, and impact on liver function is necessary.

Aims & Methods

Aim: We aimed to assess the incidence and risk factors for thrombosis developed at branches of the portal vein after TIPS in cirrhosis patients without preexisting PVT. In addition, we aimed to evaluate the influence of post-TIPS PVT on liver function and cirrhosis-related events.
Methods: A total of 70 decompensated cirrhosis patients who received TIPS without PVT were included. Routine laboratory and radiological examinations and assessment of cirrhosis-related complications proceed at 1, 3, 6 and 12 months after TIPS. For the primary outcome, the presence of post-TIPS PVT was assessed by doppler ultrasound showing that the blood flow signal partially or completely disappeared or by contrast-enhanced computed tomography showing filling defects or occlusion in the portal vein branches. For the liver function and complications comparison within 1 year after TIPS (secondary outcome), a 1:1 match using propensity score matching (PSM) based on age, sex and preoperative Child‒Pugh score was conducted between patients with and without post-TIPS PVT.

Results

Among 70 patients, 34 (48.6%) were Child‒Pugh class A, and the median Child‒Pugh score was 7 (5-8). The most common indication for TIPS was variceal bleeding (76.8%), followed by refractory ascites (21.4%). During the follow-up, 25 (35.7%) patients developed post-TIPS PVT, with incidences of 8.0%, 16.0% and 26.8% at 1, 2 and 3 months after TIPS, respectively. Univariate analysis showed that lower serum albumin (p = 0.023), Child‒Pugh B/C class (p = 0.029) and stenting at the left branch of the portal vein (p = 0.020) were significantly associated with post-TIPS PVT. Multivariate analysis showed that lower serum albumin (OR 0.87, p = 0.022) and stenting at the left branch of the portal vein (OR 6.56, p = 0.020) were independent risk factors. Twenty four of 25 patients with post-TIPS PVT were matched with 24 of 45 patients without post-TIPS PVT. Preoperative clinical characteristics of the matched patients were compared, and no significant differences were shown between the two groups. However, the Child‒Pugh score was significantly higher in the PVT group at 1 year after TIPS compared with non-PVT group [7 (6-8) vs 8 (7-9), p = 0.044]. In addition, the incidence of overt hepatic encephalopathy (50.0% vs 20.8%, p = 0.035) and the presence of ascites (54.2% vs 25.0%, p = 0.039) at 1 year after TIPS were significantly higher in the PVT group.

Conclusion

PVT may develop at intrahepatic branches of the portal vein early in the post-TIPS period in cirrhosis, leading to further liver damage and cirrhosis-related complications. Lower serum albumin levels and stenting at the left branch of the portal vein were independent risk factors for de novo PVT within 1 year after TIPS.

References

1.de Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, Ripoll C; Baveno VII Faculty. Baveno VII - Renewing consensus in portal hypertension. J Hepatol. 2022 Apr;76(4):959-974.
2.Lv Y, Bai W, Li K, Wang Z, Guo W, Luo B, Wang J, Wang Q, Wang E, Xia D, Li X, Yuan J, Han N, Niu J, Yin Z, Fan D, Han G. Anticoagulation and Transjugular Intrahepatic Portosystemic Shunt for the Management of Portal Vein Thrombosis in Cirrhosis: A Prospective Observational Study. Am J Gastroenterol. 2021 Jul 1;116(7):1447-1464.
3.Guo DF, Fan LW, Le Q, Huang CB. Transjugular intrahepatic portosystemic shunt for the prevention of rebleeding in patients with cirrhosis and portal vein thrombosis: Systematic review and meta-analysis. Front Pharmacol. 2022 Aug 16;13:968988.
4.Zhang L, Huan H, Tong H, Wei B, Wang Z, Liu C, Wu H. Warfarin prevented de novo portal vein thrombosis after transjugular intrahepatic portosystemic shunt: A retrospective study. Medicine (Baltimore). 2020 Jan;99(2):e18737.

Clinical Case Summary

A 24-year-old man presented with recurrent hematemesis and hematochezia for 8 months. He had a 3-year history of inherited thrombophilia, in which the celiac trunk and branches and portal vessels were extensively involved, and variceal bleeding, and portal cavernous transformation developed. Two sessions of endoscopic band ligation combined with sclerotherapy were performed to prevent re-bleeding, and he was hospitalized for third endoscopic therapy. During the procedure, spurting bleeding occurred when sclerosing agents were injected, and hemostasis was achieved utilizing titanium clip. At 30 hours after endoscopic treatment, he developed persistent pain in the left upper abdomen and left waist, accompanied by low-grade fever. Blood tests revealed an increased white blood cell count. Abdominal contrast-enhanced CT scanning showed large hypodense splenic areas. In conjunction with symptoms, and leukocytosis, splenic infarction was diagnosed. To understand cause of splenic infarction, CTA combined with 3D visualization was used, and revealed complete occlusion of splenic artery and several enlarged abnormal arteries traveling along gastric fundus to supply the spleen, which originated from the left gastric artery. Obviously, sclerosing agents were injected into the enlarged arterial branches of LGA, then caused splenic infarction. The patient received oral antibiotics and nonsteroidal anti-inflammatory drugs, and the symptoms gradually subsided.
Splenic infarction after cyanoacrylate injection in gastric varices has been documented¹, but the cause remains unclear. Although mucosal variceal vessels mostly originate from the deep submucosal veins, it may be difficult to distinguish when anatomical variation of arteries coexists. We report that sclerosing causes splenic infarction along abnormal LGA into spleen and indicate that pre-operative CTA combined with 3D visualization would be a valuable approach for visualizing vascular distribution and structural abnormality.

References

1. Tan YM, Goh KL, Kamarulzaman A, et al. Multiple systemic embolisms with septicemia after gastric variceal obliteration with cyanoacrylate. Gastrointest Endosc 2002;55:276-8.

Introduction

Acute variceal hemorrhage (AVH) is a dreaded complication of liver cirrhosis and continues to be associated with high mortality despite significant medical knowledge and advances in recent years. In addition, the severe acute respiratory syndrome coronavirus-2 (SARS-COV-2) pandemic has led to a temporary reduction in the diagnosis, surveillance and treatment of chronic liver diseases and their complications due to the necessary protective measures.

Aims & Methods

This study aimed to analyze the impact of the SARS-COV-2 pandemic on the course of disease in patients with AVH. In this retrospective multi-center study of patients with AVH due to cirrhosis disease courses during to two different time periods (01.03.2016-28.02.2020, and 01.03.2020-28.02.2022, termed COVID period) were compared regarding patients baseline characteristics, management, post-bleeding infections, rebleeding and mortality.

Results

For the COVID and pre-COVID period 96 and 151 patients were analyzed, respectively. During the COVID period the amount of alcohol-associated liver disease or active alcohol consumption did not differ between cohorts (58.2% vs. 47.9%; p=0.147 and 44.2% vs 39.1%; p= 0.496). There was a trend towards a higher median Model for End-Stage Liver Disease (MELD) (16 vs. 19; p=0.06) while the Child-Pugh Score was comparable (10 vs. 10; p=0.304). Intubation rates during endoscopy (16.1% vs. 16.0%; p= 1.000) as well as active bleeding rates (59.6% vs. 50.0%; p=0.150) did not differ but transjugular intrahepatic portosystemic shunt placement (11.3% vs. 23.2%; p=0.019) was performed more frequently during the pandemic. Additionally, during the pandemic there was a trend to a higher incidence of post-bleeding infections in patients without present infection at the time of AVH, who received antibiotic prophylaxis (21.6% vs. 35.4%; p=0.068). A Coronavirus-infection was present in only one patient. The 6-week recurrent bleeding and mortality rates did not differ between groups (22.3% vs. 22.8%; p=1.000 and 30.1% vs. 32.2%; p=0.767).

Conclusion

Despite an observed trend to a higher incidence of post-bleeding infections and a lower MELD score mortality in patients with AVH was not increased during the SARS-COV-2 pandemic.

Clinical Case Summary

Introduction: This case describes a rare complication, triggered by SARS-CoV2 infection in a patient with Crohn’s disease (CD) and a long history of gastrointestinal and extraintestinal manifestations but otherwise stable at the infection onset.
Case Presentation: 25-year old male,non smoker, unvaccinated against COVID-19,with fistulizing and stricturing CD diagnosed at age 12 with multiple extraintestinal complications (articular,ocular, thrombotic, malnutrition). Therapeutic history is marked of various failed attempts over the years, ranging from many courses of steroids, anti-TNFalfa drugs, immunosupresives to holistic approaches until the age of 24 when he presented at our clinic and we initiated treatment with ustekinumab with a good response. During his previous visit,he presented with fever and COVID-19 infection. Radiologic image of the lung was normal but a computed tomography scan was performed to rule out a complication of CD. Both clinical and imaging evaluations confirmed a stable condition with colo-cutaneous fistula in partial remission. Four days later he presented with signs of acute abdomen, extremely distressed, hypotensive,tachycardic.
Tests revealed: leukocytosis, rised inflammatory markers, thrombocytopenia, high D-dimer. The scan suggested a perforation and was taken to surgery where the laparotomy confirmed it, at the level of the transverse colon. He suffered a cardiopulmonary arrest during the surgery and died despite resuscitative efforts.
Discussion: SARS-CoV2 virus binds to the human angiotensin-converting enzyme 2 receptors and triggers direct endothelial lesions and activation of prothrombotic factors resulting in a cascade of microvascular injury and ultimately ischemic tissue damage. Ischemia weakens the bowel wall, increasing risk of ulceration, necrosis,and perforation, especially in Crohn’s patients with fragile mucosa.
Conclusion: The case highlights the potential for fatal outcomes and the importance of close observation in CD patients during SARS CoV2 infection.

References

Images with the colo-cutaneous fistula before and after the treatment with ustekinumab
Ragiologic and computed tomography imaging from his previous visit with the first SARS-CoV2 positive test
Radiologic and computed tomography imaging from his last visit when he presented with acute abdomen

Clinical Case Summary

SARS-COV2 infection has accumulated more than 670 million cases since its onset in 2019. Its clinical spectrum varies from asymptomatic patients to bilateral pneumonia with a mortality rate of 1%. Digestive symptoms include nausea, abdominal pain and diarrhea. Multiple complications as hepatitis, pancreatitis, cholecystitis, mesenteric ischemia or venous thrombosis have also been described.
We present the case of a 60-year-old woman who came to ER for abdominal pain. A CT showed acute cholecystitis with a 30mm liver abscess and choledocholithiasis. It was treated with empirical Piperacillin-Tazobactam, thromboprophylaxis and drainage by ERCP. During admission the patient presented bilateral SARS-COV2 pneumonia requiring Dexamethasone and Remdesivir. Due to the reappearance of abdominal discomfort, an US was performed showing a new left portal thrombosis. Given these findings, a coagulation study was performed, with no genetic or cytological alterations. Finally it was decided to maintain antibiotic for 6 weeks and anticoagulation, performing outpatient US control, with deferred surgical treatment.
The portal thrombosis is a complication mostly related to chronic liver diseases and hepatic tumors, being much rarer the septic portal thrombophlebitis associated with abdominal infections or related to proliferative neoplasms. On the other hand, SARS-COV2 infection triggers an inflammatory reaction after binding to ACE-II receptor that leads to a generalized prothrombotic environment. In relation to this process, PTE, DVT and in multiple other locations has been described. One of the the most infrequent locations is abdominal, with very few cases described in the literature.
The scarce clinical repercussion of portal thrombosis and the serious complications derived from it, added to the high prevalence of SARS-COV2, means that we should early rule out this process in patients with abdominal infections with regular evolution and active or recent SARS-COV2 infection.