Gastric ischemia and portal vein thrombosis in a COVID-19-infected patient.

A 51-year-old man admitted with acute respiratory failure from a SARS-CoV-2 infection had large volume of bloody output via orogastric tube following initiation of heparin for a lower extremity deep vein thrombosis. Esophagogastroduodenoscopy revealed diffuse and severe mucosal ischemia involving the gastric fundus ( Fig. 1 ), greater curvature, and posterior wall of the gastric body and antrum ( Fig. 2 ) ( Video 1 ). The anterior gastric wall and duodenum appeared normal. Computed tomography (CT) angiogram of the abdomen revealed gastric pneumatosis ( Fig. 3 ), a non-occlusive thrombus in the right and left portal veins, and portal venous gas ( Fig. 4 ). The small bowel and colon appeared normal. In addition to management of the underlying COVID infection and respiratory complications, management included nasogastric decompression and intravenous heparin. A repeat abdominal CT 1 week later showed resolution of the intramural gastric and portal venous gas, and no residual portal vein thrombosis ( Fig. 5 ).

Fig. 1

 Mucosal changes of ischemia involving entire gastric fundus.

Fig. 2

 Mucosal changes of ischemia involving greater curvature with sparing of anterior wall.

Fig. 3

 Gastric pneumatosis seen on computed tomography angiogram.

Fig. 4

 Non-occlusive thrombus in the right and left portal veins, and portal venous gas on computed tomography angiogram.

Fig. 5

 Radiologic resolution of intramural gastric and portal venous gas, and portal vein thrombosis.

Video 1  Esophagogastroduodenoscopy findings of gastric mucosal ischemia with normal duodenum in the setting of COVID-19 infection.

Gastrointestinal tract involvement, ranging from minor symptoms to small bowel ischemia, has been reported with the SARS-CoV-2 virus, which may be due to a high surface expression of angiotensin-converting enzyme 2 (ACE2) receptors on gastric cells and enterocytes 1 2 . The underlying mechanism of small bowel ischemia is not known but might result from direct viral infiltration via ACE2 receptors on enterocytes and endothelial cells, complement-mediated small vessel thrombosis, non-occlusive mesenteric ischemia, or systemic coagulopathy 3 4 . Gastric ischemia is a rare condition that results from vascular insufficiency due to local or systemic disorders and is associated with poor clinical outcomes if not recognized and treated early 5 . Our patient had gastric ischemia and portal vein thrombosis in the setting of a COVID-19 infection in the absence of other thromboembolic risk factors. Based on a review of the literature, we found no reported cases of COVID-19-associated gastric ischemia. A high index of suspicion may result in early recognition of this complication and treatment with anticoagulation.

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