Abdominal Imaging Findings in COVID-19: Preliminary Observations
Authors: Rajesh Bhayana , Avik Som, Matthew D Li, Denston E Carey, Mark A Anderson, Michael A Blake, Onofrio Catalano, Michael S Gee, Peter F Hahn, Mukesh Harisinghani, Aoife Kilcoyne, Susanna I Lee, Amirkasra Mojtahed, Pari V Pandharipande, Theodore T Pierce, David A Rosman, Sanjay Saini, Anthony E Samir, Joseph F Simeone, Debra A Gervais, George Velmahos, Joseph Misdraji, Avinash Kambadakone
Journal: Radiology, 201908. 11 May. 2020, doi:10.1148/radiol.2020201908
Dr. Damiano Caruso, Young ESGAR, ESGAR Educational Committee, Radiology Department, Sant’Andrea Academic Hospital, Sapienza University of Rome, Rome, Italy.
Dr. Elena Lucertini, ESGAR Member and radiology resident, Radiology Department, Sant’Andrea Academic Hospital, Sapienza University of Rome, Rome, Italy.
Prof. Andrea Laghi, ESGAR Vice President and Director of the Radiology Department, Sant’Andrea Academic Hospital, Sapienza University of Rome, Rome, Italy.
The coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), rapidly spread all over the world and it was declared pandemic on March 2020 [1, 2].
Despite most common clinical symptoms are fever, cough, and dyspnea, several cases of COVID-19 patients with gastrointestinal (GI) symptoms such as diarrhea, nausea/vomiting, abdominal pain have been observed [3].
Angiotensin-converting enzyme 2 (ACE2) receptors, considered the main virus cellular carriers, are highly surface expressed on enterocytes of the small intestine and biliary epithelium, offering a possible explanation of GI manifestations in COVID-19 patients [4, 5].
A recent retrospective cross-sectional study on the GI manifestations of COVID-19 has been published by Bhayana et al. The Authors have enrolled a total of 412 adult patients consecutively admitted at their institution, from March 27 to April 10, who tested positive for SARS-CoV-2.
Abdominal symptoms were reported in 34% of these patients (142/412) and imaging findings of 134 patients (33%) were analyzed by a team of expert abdominal radiologists: radiography, US, CT of the abdomen and pelvis and MRI images were included in data collection.
CT imaging findings includes abnormalities of bowel wall (such as colonic or small bowel thickening, pneumatosis or portal venous gas and perforation), fluid-filled colon, solid organ infarct, pancreatitis and other findings suggestive of hepatitis.
Otherwise, US imaging findings includes presence of biliary sludge in gallbladder lumen, with or without distension, gallbladder wall thickening, pericholecystic fluid, fatty liver, portal venous gas and portal vein thrombosis.
Finally, the Authors compared demographic, clinical, and imaging data between intensive care unit (ICU) patients and other inpatients. The aim of this retrospective study is to investigate abdominal imaging findings in COVID-19 patients.
Statistical analysis revealed on CT scans presence of bowel abnormalities in 31% of patients, including pneumatosis/thickening of bowel wall and portal venous gas; these findings resulted significantly associated with ICU admission (OR 15.5, p=0.01).
Dr. Gisella Guido is a radiology resident at the University of Rome "Sapienza" - Sant'Andrea University Hospital in Rome, attending the second year of residency. Her main field of interest is abdominal and oncologic radiology. She already worked in this area during the residency and considering pursuing her career in oncological radiology.
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Direct viral infection sustained by ACE2 surface expression in enterocytes of small intestine and vascular endothelium [5, 6], and small vessel thrombosis or nonocclusive mesenteric ischemia, both probably caused by systemic coagulopathy [7], could explain the spectrum of bowel disease in COVID-19 patients.
US imaging showed detection of cholestasis in 54% of patients, mainly in critically ill ones.
Nevertheless, ICU patients with COVID-19 are often hypercoagulable [8], the authors did not identify portal vein thrombosis with US, as reported in other studies [9].
The retrospective single center nature of the study represents the major limitation because of the introduction of selection bias. Furthermore, the lack of pathologic correlation and clinical follow-up for many patients with imaging abnormalities is another weak point of the study.
In conclusion, this study, despite the limits demonstrated, showed that abdominal symptoms should not be underestimate and radiologist should be aware of abdominal imaging findings, such as bowel abnormalities and cholestasis, in patients with COVID-19.
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[9] Franco-Moreno A, Piniella-Ruiz E, Montoya-Adarraga J, et al. Portal vein thrombosis in a patient with COVID-19 [published online ahead of print, 2020 Jun 13]. Thromb Res. 2020;doi:10.1016/j.thromres.2020.06.019
Dr. Tiziano Polidori is a radiology resident at the University of Rome "Sapienza" - Sant'Andrea University Hospital in Rome, attending the second year of residency. His main fields of interest are clinical radiology and research. He has numerous ongoing projects and aspires to take part in further research studies in the near future.
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