Systematic Reviews
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Jul 27, 2021; 13(7): 702-716
Published online Jul 27, 2021. doi: 10.4240/wjgs.v13.i7.702
Acute mesenteric ischemia and small bowel imaging findings in COVID-19: A comprehensive review of the literature
Lorena Pirola, Andrea Palermo, Giacomo Mulinacci, Laura Ratti, Maria Fichera, Pietro Invernizzi, Chiara Viganò, Sara Massironi
Lorena Pirola, Andrea Palermo, Giacomo Mulinacci, Laura Ratti, Maria Fichera, Pietro Invernizzi, Chiara Viganò, Sara Massironi, Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza 20900, Italy
Lorena Pirola, Andrea Palermo, Giacomo Mulinacci, Laura Ratti, Maria Fichera, Pietro Invernizzi, Chiara Viganò, Sara Massironi, European Reference Network on Hepatological Diseases, San Gerardo Hospital, Monza 20900, Italy
Author contributions: Pirola L and Viganò C planned the work; Pirola L, Viganò C and Massironi S contributed to the design and conceptualization of the study; Palermo A and Mulinacci G wrote the first draft of the manuscript and edited the figures and tables; Pirola L, Ratti L, Fichera M and Viganò C edited the subsequent versions of the manuscript; Viganò C and Massironi S revised the manuscript for relevant intellectual content; Invernizzi P corrected the final version; all the authors read and approved the final version of the manuscript.
Conflict-of-interest statement: The authors declare that they have no competing interests.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Chiara Viganò, MD, Doctor, Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, Monza 20900, Italy. c.vigano@hotmail.it
Received: February 8, 2021
Peer-review started: February 8, 2021
First decision: March 30, 2021
Revised: April 12, 2021
Accepted: July 2, 2021
Article in press: July 2, 2021
Published online: July 27, 2021
Processing time: 164 Days and 14.7 Hours
Abstract
BACKGROUND

Coronavirus disease 2019 (COVID-19), an infectious condition caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has rapidly spread worldwide since its first description in Wuhan in December 2019. Even though respiratory manifestations are the most prevalent and responsible for disease morbidity and mortality, extrapulmonary involvement has progressively gained relevance. In particular, gastrointestinal (GI) signs and symptoms, reported in up to two-thirds of patients with COVID-19, might represent the first and, in some cases, the only disease presentation. Their presence has been associated in some studies with an increased risk of a severe disease course. Proposed pathogenic mechanisms explaining GI tract involvement are either direct viral access to intestinal cells via angiotensin-converting enzyme 2 or indirect damage of the intestinal wall through mesenteric ischemia induced by the hypercoagulable state associated with COVID-19 infection. Although not typical of SARS-CoV-2 infection, several small bowel manifestations have been described in infected patients who underwent any form of abdominal imaging. The radiological findings were mainly reported in patients with abdominal symptoms, among which abdominal pain was the most common.

AIM

To discuss small bowel radiological manifestations of SARS-CoV-2 infection in abdominal imaging studies.

METHODS

Bibliographical searches were performed in PubMed, using the following keywords: “COVID-19” AND “imaging” AND “gastrointestinal” OR “abdominal” OR “small bowel”.

RESULTS

Of 62 patients with described radiologic small bowel alterations, mesenteric ischemia was diagnosed in 31 cases (50%), small bowel wall thickening in 10 cases (16%), pneumatosis in nine cases (15%), intussusception in eight cases (13%), pneumoperitoneum in two cases (3%) and paralytic ileus in two cases (3%). We also reported mesenteric adipose tissue hypertrophy and lymph nodes enlargement in a young woman.

CONCLUSION

So far it is difficult to establish whether these manifestations are the direct consequence of SARS-CoV-2 infection or collateral findings in infected patients, but their recognition would be pivotal to set a closer follow-up and to reduce missed diagnoses.

Keywords: COVID-19; SARS-CoV-2; Radiology; Small intestine; Abdomen

Core Tip: Gastrointestinal manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been increasingly reported and corresponding abdominal imaging findings have been recognized. The present review includes case reports, case series, and retrospective studies discussing small bowel radiological manifestations of SARS-CoV-2 infection in abdominal imaging studies. Out of 62 patients, the most commonly reported finding was mesenteric ischemia, with a prevalence of 50%. Other less frequent features were small bowel wall thickening (16%), pneumatosis intestinalis (15%), intussusception (13%), pneumoperitoneum (3%), and paralytic ileus (3%). We also report a patient with mesenteric adipose tissue hypertrophy and lymph node enlargement.