COLONIC PERFORATION SECONDARY TO COVID-19 INDUCED HEMORRHAGIC COLITIS

Objectives: Respiratory symptoms are the most common manifestation amidst the ongoing COVID-19 pandemic. However, up to 17.6% of patients can present with gastrointestinal symptoms1 and bowel wall abnormalities have been described in up to 31% of COVID-19 positive patients. Here, we present a case of a 40-year-old male diagnosed with COVID-19 complicated by hemorrhagic colitis leading to colonic perforation.

Case:
A 40-year-old male previously diagnosed with COVID-19 induced hemorrhagic colitis presents with increasing abdominal pain, fevers, and chills. His white blood cell count was 17.9, hemoglobin 12.1, lactic acid 2.5, and creatinine was 0.90. CT scan of abdomen and pelvis demonstrated markedly distended distal descending and sigmoid colon with poorly defined wall, pneumatosis, and numerous foci of pneumoperitoneum in the lower abdomen. There was also associated mesenteric haziness and some free fluid suspicious for colonic perforation.
The patient was taken emergently to the operating room for exploratory laparotomy. He was found to have over 2 liters of stool within his peritoneal cavity. His entire left colon was necrotic. He underwent extended left hemicolectomy, partial omentectomy, transverse colostomy creation, abdominal washout, takedown of splenic flexure, extensive lysis of adhesions, repair of small bowel, and appendectomy. Surgical pathology of left colon demonstrated nonviable colon with hemorrhage, peri-colonic fat necrosis, acute serositis with surface adhesions (Figure 1).
The patient was brought back to the operating room for a second and third look exploratory laparotomy, abdominal washout, debridement, ICG perfusion assessment, placement of retention sutures and wound vac for closure of complex, contained midline wound. Patient’s postoperative course was complicated by ileus, left exudative pleural effusion requiring thoracentesis and chest tube placement, and extensive bilateral acute iliofemoral deep venous thrombosis requiring thrombectomy using Penumbra device. Patient was found to be heterozygous for factor V Leiden mutation. Of note, he was never vaccinated for COVID-19.
Discussion
There is a growing body of evidence describing colonic involvement in COVID-19 positive patients.5 There have been no studies which have demonstrated the use of indocyanine green (ICG) to assess perfusion after colonic perforation from COVID-19 induced colitis. ICG can be infused intravenously as a real-time method to assess vascular perfusion using near-infrared light.
Our patient was found to be heterozygous for factor V Leiden mutation which increases the lifetime thrombotic risk by 7-fold. Our case underscores the importance of completing a thorough hypercoagulable evaluation following COVID-19 induced thrombotic event.

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