Imaging of abdominal complications of COVID-19 infection
Caruso D, Zerunian M, Pucciarelli F, Lucertini E, Bracci B, Polidori T, Guido G, Polici M, Rucci C, Iannicelli E, Laghi A.
BJR Open. 2021 Jul 5;2(1):20200052. doi:10.1259/bjro.20200052
The severe acute respiratory syndrome Coronavirus 2 (Sars-CoV-2) is typically characterized by respiratory symptoms. However, during the pandemic, other abdominal organs seem to be involved in the disease due to systemic effects of the SARS-CoV-2.
Currently, it is world-wide accepted that in some cases COVID-19 infection can present primarily with abdominal symptoms such as abdominal pain, diarrhea.
Abdominal symptoms seem to be related to angiotensin converting enzyme 2 (ACE) expression in the gastrointestinal and biliary tract. Briefly, COVID-19 may affect various abdominal organs, and cause typical and less typical abdominal imaging findings. Caruso et al. reported in their review article the imaging of abdominal complications related to COVID-19 infection [1].
1. Small and large bowel - high expression of ACE2 receptors on enterocytes membrane. CECT (contrast-enhanced CT) is the imaging modality of choice and shows gastrointestinal complications in up to 49% of the cases [2,4]:
- typical bowel wall thickening, submucosal oedema, bowel dilatation, pericolic fluid and fat stranding; bowel ischemia due to mesenteric and portal vein thrombosis
- atypical CECT findings include pneumatosis intestinalis, appendicitis
2. Liver - direct cytopathic virus effect; up to 62% of the COVID-19 patients have elevated ALS, AST and GGT enzymes, with hepatic steatosis, but no typical imaging features have been reported [5].
3. Kidneys - expression of ACE2 receptors on podocytes and proximal convoluted tubules cells and also direct virus-induced cytopathic effect; up to 19% of COVID-19 patients develop acute renal dysfunction; no typical imaging findings were reported [6].
4. Pancreas - SARS-CoV-2 was isolated from a pancreatic pseudocyst, but the pathogenesis is not totally clear yet. Up to 16% of the patients have pancreatic involvement, with acute pancreatitis associated with COVID-19 as the main finding [7].
5. Gallbladder - expression of ACE2 receptors in the biliary system. Imaging shows typical acute cholecystitis findings: gallbladder distension, wall thickening, with mural/mucosal hyperenhancement, fluid and fat stranding [8].
6. Spleen - involvement is related to the prothrombotic effect of COVID-19. Splenic infarction with typical CECT findings was reported: peripheral, wedge-shaped hypo enhancing area [9,10].
In conclusion, abdominal involvement of COVID-19 is related in many cases to the ACE2 receptors expression, and it is not such a rare event. It is crucial that radiologists keep in mind a possible abdominal finding of COVID-19 patients. The above-mentioned paper provides an overview of all COVID-19-related abdominal complications and should be kept in mind by members-in-training as well as senior doctors.
References:
- Caruso D, Zerunian M, Pucciarelli F, Lucertini E, Bracci B, Polidori T, Guido G, Polici M, Rucci C, Iannicelli E, Laghi A. Imaging of abdominal complications of COVID-19 infection. BJR Open. 2021 Jul 5;2(1):20200052. doi: 10.1259/bjro.20200052.
- Carvalho A, Alqusairi R, Adams A, Paul M, Kothari N, Peters S, et al. SARSCoV-2 gastrointestinal infection causing hemorrhagic colitis: implications for detection and transmission of COVID-19 disease. Am J Gastroenterol 2020; 115: 942–6. doi: doi.org/10.14309/ajg. 0000000000000667
- Zhang J-J, Dong X, Cao Y-Y, Yuan Y-D, Yang Y-B, Yan Y-Q, et al. Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan, China. Allergy 2020; 75: 1730–41. doi: doi.org/10.1111/all.14238
- Pan L, Mu M, Yang P, Sun Y, Wang R, Yan J, et al. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional, multicenter study. Am J Gastroenterol 2020; 115: 766–73. doi: doi.org/10.14309/ ajg.0000000000000620
- Xu Z, Shi L, Wang Y, Zhang J, Huang L, Zhang C, et al. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med 2020; 8: 420–2. doi: doi.org/10.1016/S2213- 2600(20)30076-X
- Behzad S, Aghaghazvini L, Radmard AR, Gholamrezanezhad A. Extrapulmonary manifestations of COVID-19: radiologic and clinical overview. Clin Imaging 2020; 66: 35–41. doi: doi.org/10.1016/j. clinimag.2020.05.013
- Mukherjee R, Smith A, Sutton R. Covid-19- related pancreatic injury. Br J Surg 2020; 107: e190. doi: doi.org/10.1002/bjs.11645
- Xiao F, Tang M, Zheng X, Liu Y, Li X, Shan H. Evidence for gastrointestinal infection of SARS-CoV-2. Gastroenterology 2020; 158: 1831–3. doi: doi.org/10.1053/j.gastro. 2020.02.055 11. Behzad S, Aghagh
- Santos Leite Pessoa M, Franco Costa Lima C, Farias Pimentel AC, Godeiro Costa JC, Bezerra Holanda JL. Multisystemic infarctions in COVID-19: focus on the spleen. Eur J Case Rep Intern Med 2020; 7: 001747. doi: doi.org/10.12890/2020_ 001747
- Bhayana R, Som A, Li MD, Carey DE, Anderson MA, Blake MA, et al. Abdominal imaging findings in COVID-19: preliminary observations. Radiology 2020; 297: E207–15. doi: doi.org/10.1148/radiol. 2020201908
Dr. Roxana Pintican is a fourth year radiology resident at the County Clinical Emergency Hospital in Cluj-Napoca, Romania and also a PhD student at the “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca. Abdominal imaging is one of many fields she is interested in. She is very engaged in research and has also spent three months at the Cambridge University Hospital. She has participated in many congresses and conferences and published several articles in international journals as author/co-author.
Besides radiology, Roxana is also passionate about travelling and sports.
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