TP10.1.3SARS-Cov-2 and Colitis: A Case Series

Background Up to a third of patients with COVID-19 infection present with gastrointestinal (GI) symptoms. The Sars-Cov-2 virus enters enterocytes through a novel mechanism via ACE- 2 receptors, which are expressed throughout the GI tract, especially in the mid-gut. Small bowel and colonic inflammation and alteration of the gut microbiome (“altered inflammasome”) have been observed. Aims We report a cluster of cases during the first and second wave UK pandemics involving young patients with unexplained segmental CT-proven colitis. Methods All patients diagnosed with CT proven colitis with no history of IBD, ischaemic colitis or significant medical comorbidities were included. Results Fifteen patients (median age 33 years; 8 females) were admitted under Emergency General Surgery between Mar 2020 & Jan 2021. All patients were previously well with no history of IBD, ischaemic colitis or significant medical comorbidities. Thirteen patients underwent CT imaging, showing evidence of colitis in 12, with changes affecting the right colon predominating. Campylobacter jejuni was identified in 4 of 7 stool cultures but only 1 patient had a positive PCR nasal swab and another had COVID antibodies detected in serum. Endoscopic and histological appearances of those undergoing colonoscopy were non-specific. Conclusion These cases may represent Covid-19 involvement of the gut. Nasal swabs are not validated for use in the GI tract and detection of SARS-Cov-2 virus requires faecal or mucosal sampling. Disruption of the microbiome permits emergence of pathogenic species such as Campylobacter. More work is required in this important area to further define and elucidate COVID-19 GI involvement.

SARS-CoV-2 identified by transmission electron microscopy in lymphoproliferative and ischaemic intestinal lesions of COVID-19 patients with acute abdominal pain: two case reports

Background SARS-CoV-2 may produce intestinal symptoms that are generally mild, with a small percentage of patients developing more severe symptoms. The involvement of SARS-CoV-2 in the physiopathology of bowel damage is poorly known. Transmission electron microscopy (TEM) is a useful tool that provides an understanding of SARS-CoV-2 invasiveness, replication and dissemination in body cells but information outside the respiratory tract is very limited. We report two cases of severe intestinal complications (intestinal lymphoma and ischaemic colitis) in which the presence of SARS-CoV-2 in intestinal tissue was confirmed by TEM. These are the first two cases reported in the literature of persistence of SARS-CoV-2 demonstrated by TEM in intestinal tissue after COVID 19 recovery and SARS-CoV-2 nasopharyngeal clearance. Case presentation During the first pandemic peak (1st March–30th April 2020) 932 patients were admitted in Hospital Universitari Mútua Terrassa due to COVID-19, 41 (4.4%) required cross-sectional imaging techniques to assess severe abdominal pain and six of them (0.64%) required surgical resection. SARS-CoV-2 in bowel tissue was demonstrated by TEM in two of these patients. The first case presented as an ileocaecal inflammatory mass which turned to be a B-cell lymphoma. Viral particles were found in the cytoplasm of endothelial cells of damaged mucosa. In situ hybridization was negative in tumour cells, thus ruling out an oncogenic role for the virus. SARS-CoV-2 remained in intestinal tissue 6 months after nasopharyngeal clearance, suggesting latent infection. The second patient had a severe ischaemic colitis with perforation and SARS-CoV-2 was also identified in endothelial cells. Conclusions Severe intestinal complications associated with COVID-19 are uncommon. SARS-CoV-2 was identified by TEM in two cases, suggesting a causal role in bowel damage.

Colon Ischaemia Induced by Amoxicillin-related Anaphylactic Shock

Colon ischaemia is the most frequent type of ischaemia of the digestive tract. It is more common among the elderly, especially patients with haemodynamic disturbance. In young patients, it is associated with particular drugs such as oral contraceptives and ergotamine derivatives. Anaphylaxis is characterized by acute onset and skin and mucosal involvement together with cardiovascular involvement. Gastrointestinal symptoms are common in anaphylaxis, but gastrointestinal bleeding and acute colon ischaemia are rarely described. Here, we present the case of a 52-year-old woman with acute ischaemic colitis associated with an anaphylactic reaction to amoxicillin.

Ischaemic colitis diagnosed by sigmoidoscopy during pregnancy

A 21-year-old woman visited out hospital for lower abdominal pain and bloody diarrhoea at 19 weeks of pregnancy. Endoscopic findings revealed longitudinal ulcerations with hyperaemia and oedema in the sigmoid colon. These findings and clinical presentation confirmed the diagnosis of ischaemic colitis. Conservative treatment, including fasting and intravenous hydration, was administered, and the patient made a good recovery. After discharge, there was no recurrence during pregnancy and postpartum period. It is important to make early diagnosis and treatment, and multidisciplinary teamwork between obstetricians, gastroenterologist and endoscopist is required.

A Case of Fatal Intestinal Infarct Preceded by Recurrent Ischaemic Colitis due to the Enterotoxic Effect of Sodium Polystyrene Sulfonate

Case description: A 64-year-old patient with chronic renal failure and persistent hyperkalaemia not corrected by dialysis, was prescribed sodium polystyrene sulfonate (SPS) at a low dose (30 g/day for 2 days a week during the long interdialytic interval). After 3 months of therapy, the patient developed intense abdominal pain with non-specific colitis identified with a colonoscopy. In addition, the biopsy specimens showed rhomboid SPS crystals in the intestinal mucosa. Fourteen months after discontinuing therapy, the patient again presented with colitis and persistent biopsy finding of SPS crystals. The patient died a few months later due to intestinal infarction. Discussion and conclusion: SPS is a cation exchange resin used to treat hyperkalaemia resistant to dialysis, but may cause inflammation and ischaemia of the colon. In our patient, a short 3-month course of low-dose SPS therapy (without sorbitol, which is used to counter iatrogenic constipation caused by SPS) induced relapsing colitis, which was followed by massive intestinal infarction a few months later. In light of frequent reports of its enterotoxic effects, SPS should be replaced with the new potassium chelators (patiromer and sodium zirconium cyclosilicate).