Microvascular Thrombosis in the Bowel- Is There a Covid Connection?

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by Brenda F. Johnson Brenda F. Johnson, MSN

Specializes in Gastrointestinal Nursing. Has 30 years experience.

Working in the GI lab, I have noticed that some of the critically ill Covid patients end up with some severe gastrointestinal issues. I have seen colon tissue that looks raw, and it bleeds very easily. Is there a connection of Covid and a breakdown of the GI system?

Knowledge is Power: Is there a connection of Covid and a breakdown of the GI system?

Microvascular Thrombosis in the Bowel- Is There a Covid Connection?

The past two years have changed our world in many ways. We have seen unsuspecting patients, family, and friends get sick, and sometimes die from Covid.  The long-term effects of this virus have yet to be seen.

With my job in the GI lab, I am able to observe some trends associated with  GI diseases and conditions. I have noticed during colonoscopies that ICU Covid patients often suffer from fragile colon mucosa that bleeds very easily.  It turns out that Covid does have a multitude of effects on the GI tract.

The gastrointestinal tract and its ability to do the myriad of functions that it does, is at risk in  Covid patients, especially in the acutely ill. From hydration to waste elimination, the GI tract is vital to our survival. Complications such as intolerance to tube feedings, an ileus, to bowel ischemia can be found in 3 out of 4 patients who are critically ill with Covid1

Symptoms often begin with diarrhea, abdominal pain, or nausea: diarrhea being the most popular symptom2. These GI issues can escalate alongside the respiratory issues and become life threatening. In almost two-thirds of the critically ill, liver transaminases become elevated3.  Other organs that can also become inflamed are the gallbladder, and pancreas4. Acute colonic pseudo-obstruction described as severe distension from gas with no obstruction has been seen5. However, this could be from the length of the illness, rather than Covid. 

Mesenteric ischemia has been reported in about 4% of the critically ill Covid patients6. Nausea, vomiting, and abdominal pain from lack of blood flow to the small bowel could require surgery. These patients are not able to report how they feel due to the fact that they are ventilated, and sedated. So I suspect that conditions such as these can become serious before they are noticed.  The fact that these patients are on so many medications, prolonged ventilation, and ECMO, can lead to a watershed of  acute conditions.

In some patients, however, mesenteric ischemia develops even though their mesenteric vessels were patent7. Kaafarani tells us that the thrombosis may be implicated in the small intestinal vessels, rather than the larger ones8. Surgeons have been able to examine the bowel more closely during an operation for a resection. This observation has revealed some unusual things.

One of the observations is well-defined patchy areas of yellow discoloration of the bowel wall9. Another finding is that the mucosa can sometimes have considerable ulcerations and inflammation along the entire wall of the colon10. “Fibrin microthrombi were occasionally noted in the capillaries underlying areas of necrosis,” which alludes to the idea of blood clots on a micro level11.

There are several other reasons that these critically ill patients can develop mesenteric ischemia apart from Covid. Medications and metabolic or blood flow issues are a few other rationales.  However, mesenteric ischemia along with the above mentioned anomalies point to a Covid connection. Complications of the GI tract in a  Covid patient have been proven to be connected, and as more data is gathered, we will be able to definitely draw an association to the more serious symptoms. 

There are some statistical relationships seen in ICU Covid patients.  A large percentage of the severe cases are male, in fact 66.5% are men according to El Moheb et al.12. Out of 313 patients, over 72% had one or more GI symptoms13. And as can be expected, a large percentage had either a rectal tube, nasogastric tube, and/or a gastrostomy tube14

These patients are very sick, and having tubes in every orifice only sets them up for further problems. They are more prone to infections, bleeding, and medication or feeding intolerances. As these patients are studied further, hopefully, future patients will benefit and some of these problems will be prevented. These patients are not good candidates for major surgery, so prevention of bowel ischemia is vital. 

Although doctors aren’t sure yet of the entire pathophysiology of these occurrences, knowing that they exist will help in identifying them earlier and possibly prevent surgery or death of these patients. Have you had a Covid patient that had a bowel resection for ischemia? If so, how did they do?


References/Resources

1,2; 12-14 Gastrointestinal Complications in Critically Ill Patients With COVID-19

3-11          COVID-19: Gastrointestinal symptoms and complications

Brenda F. Johnson has 30 years experience as a MSN and specializes in Gastrointestinal Nursing.

91 Articles   309 Posts

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12 Comment(s)

JBMmom, MSN, NP

Specializes in New NP Hospitalist, Critical care, Med-surg, LTC. Has 10 years experience. 4 Articles; 2,104 Posts

This is a very well written article about one of the MANY side effects we are seeing in our COVID patients. I know of one patient that developed mesenteric ischemia, but she was never stable enough for surgery and was made CMO and died not long after developing the ischemia. 

Thank you for sharing the information here. 

agencynurse_rn

Specializes in Trauma, ICU, Critical Care, Recovery. Has 18 years experience. 16 Posts

We have a current case right now of a triple vaxxed patient (who had Covid) with ischemic bowel that required surgery, and then he developed sepsis. It's been almost 3 months with several surgeries and he still has a vac dressing.  One more more surgery hopefully to close his abdomen this week.  He was at death's door with blood pressure and respiratory issues, and still will require extensive rehab before he can be back to a semblance of this former self. 

traumaRUs

traumaRUs, MSN, APRN, CNS

Specializes in Nephrology, Cardiology, ER, ICU. Has 30 years experience. 164 Articles; 21,139 Posts

We are seeing this too. I see pts in several dialysis units and we are seeing more clotting in the dialyzers then ever before.

Also, as an aside I had a relative who got Covid, intubated, trach'd/Peg'd after 16 days, developed sepsis due to ischemic bowel and died. 

 

Brenda F. Johnson, MSN

Specializes in Gastrointestinal Nursing. Has 30 years experience. 91 Articles; 309 Posts

10 hours ago, traumaRUs said:

We are seeing this too. I see pts in several dialysis units and we are seeing more clotting in the dialyzers then ever before.

Also, as an aside I had a relative who got Covid, intubated, trach'd/Peg'd after 16 days, developed sepsis due to ischemic bowel and died. 

 

Very interesting, and I'm sorry about your relative. My sister just went on a vent today. She is very compromised, so I don't expect her to live very long

Brenda F. Johnson, MSN

Specializes in Gastrointestinal Nursing. Has 30 years experience. 91 Articles; 309 Posts

8 hours ago, toomuchbaloney said:

Haven't we known for awhile now that covid infection is associated with arterial and venous thrombosis? 

This article was focusing on the micro vascular aspect on colon health. As a GI nurse, I am seeing the ICU patients having severe problems that lead to ischemia

JBMmom, MSN, NP

Specializes in New NP Hospitalist, Critical care, Med-surg, LTC. Has 10 years experience. 4 Articles; 2,104 Posts

37 minutes ago, Brenda F. Johnson said:

My sister just went on a vent today. She is very compromised, so I don't expect her to live very long

Very sorry to hear about your sister. Wishing peace for her, and for your family, in difficult times.

40 minutes ago, Brenda F. Johnson said:

This article was focusing on the micro vascular aspect on colon health. As a GI nurse, I am seeing the ICU patients having severe problems that lead to ischemia

I understand.   There doesn't seem to be much recognition of the gut's vulnerability to microvascular thrombosis.  Mostly the literature speaks of the issues in lungs, kidneys, liver...etc. 

Years ago, in the PICU, some kids would have terrible gut problems following their acute infection or sepsis. I am not surprised that you are seeing problems with covid. 

subee

subee, MSN, CRNA

Specializes in CRNA, Finally retired. Has 50 years experience. 3,787 Posts

On 1/25/2022 at 7:09 PM, toomuchbaloney said:

I understand.   There doesn't seem to be much recognition of the gut's vulnerability to microvascular thrombosis.  Mostly the literature speaks of the issues in lungs, kidneys, liver...etc. 

Years ago, in the PICU, some kids would have terrible gut problems following their acute infection or sepsis. I am not surprised that you are seeing problems with covid. 

It makes total sense to me since so many people were getting limb amputations, one has to assume that clots were generalized.  It's more than interestsing to see what Covid brings to the various specialties.

5 hours ago, subee said:

It makes total sense to me since so many people were getting limb amputations, one has to assume that clots were generalized.  It's more than interestsing to see what Covid brings to the various specialties.

That's what I was trying to convey.  

T-Bird78

T-Bird78

Has 6 years experience. 990 Posts

What about an increase in appendicitis in kids post COVID?  My 9-year-old was diagnosed with COVID in late January, for the second time (he had it last March also), and nine days later we were back in the ED and he was diagnosed with appendicitis and transported to the children’s hospital for an emergency appendectomy. One of my non-clinical coworkers said she’d heard about an increase in appendicitis in kids.