During this time period, 141 individuals were admitted to the ICU with severe acute respiratory syndrome coronavirus 2 infection confirmed by reverse-transcriptaseCpolymerase-chain-reaction screening. The median (interquartile range) age was 57 (47, 70) years, 65% of them were males, and 45% experienced GI symptoms (eg, abdominal pain, diarrhea, vomiting) on hospital presentation (Table ?(Table1).1). The median (interquartile range) Sequential Organ Failure Assessment Score upon admission to the ICU was 5 (4, 7.5), and 128 (91%) required mechanical air flow. A total of 104 individuals (74%) developed at least 1 GI complication. TABLE 1 Characteristics of Patients With Severe Coronavirus Disease 2019 Admitted to the Intensive Care Unit Open in a separate window We stratified the GI complications into 4 categories: hepatobiliary, hypomotility, bowel ischemia, and other. Among the hepatobiliary complications, transaminitis was the most common (67%). The mean highest values recorded for aspartate aminotransferase and alanine aminotransferase were 420.7 and 479.0?U/L respectively, representing a 7.5- and 12-fold increase from the physiological values. Four patients (4%) developed acute acalculous cholecystitis and 1 patient (1%) developed acute pancreatitis during their ICU stay. Half of the patients developed hypomotility-related complications of variable severity. Almost all patients with GI complications required nasogastric or orogastric tubes. Forty-six percent of patients had gastric feeding held for at least 24?hours due to high gastric residuals, and 58 (56%) developed an ileus diagnosed clinically and/or radiologically. Four of the patients with severe ileus had clinical and radiologic findings concerning for bowel ischemia and were taken to the operating room on days 11, 14, 15, and 22 of hospitalization, respectively, for an exploratory laparotomy. Two patients were found to have extensive patchy bowel necrosis involving half to two thirds of the total bowel length, despite patent proximal mesenteric vessels on the computed tomography scan, perhaps suggesting microvascular thrombosis. Intraoperatively, the necrotic bowel had a distinct bright yellow color in contrast to the common locating of purple-black color [(Fig. 1 in the Supplementary Appendix (Supplemental Shape 1. Diffuse patchy regions of necrosis of the complete small colon and right digestive tract, concerning brief and large extends from the wall structure. Note the very clear demarcation, the around shape, as well as the antimesenteric area, http://links.lww.com/SLA/C197)]. Another affected person was discovered to possess ischemia without frank necrosis of the terminal ileum. The fourth patient developed liver ischemia and necrosis, and had similar areas of yellow discoloration on the antimesenteric side of the small bowel, without frank transmural necrosis. Two additional individuals were identified as having a colonic paralytic ileus, clinically identical to colonic pseudoobstruction (Ogilvie symptoms) on times 6 and Cd200 14 of hospitalization. Shape 2 in the Supplementary Appendix (Supplemental Shape 2. Abdominal x-ray of an individual with an Ogilvie-like symptoms displaying significant distention from the digestive tract, http://links.lww.com/SLA/C198.) displays an stomach x-ray of just one 1 of the 2 individuals demonstrating significant colonic dilation with cecal wall structure pneumatosis. On exploratory laparotomy, patchy regions of necrosis of the complete digestive tract were noted; a complete colectomy and an final end ileostomy had been performed. The pathology from the resected bowel showed focal transmural areas of necrosis with acute fibrinopurulent serositis. The overall 14-day patient mortality was 15%. The mortality rate of the subset of patients who required abdominal surgery was as high as 40%. In this series of critically ill patients with COVID-19, we report a high incidence of hepatobiliary, hypomotility, and ischemic GI complications. Of 141 patients, 58 had ileus, 2 had an Ogilvie-like symptoms, 1 had intensive hepatic necrosis, and 4 had colon ischemia necessitating emergent colon and medical procedures resection. Although these GI problems could be related to pharmacologic undesirable occasions and metabolic and electrolyte disruptions occasionally experienced in critically sick individuals, severe severe respiratory symptoms coronavirus 2Cinduced little vessel thrombosis or viral enteroneuropathy are 2 feasible hypotheses that warrant additional analysis.4,5 In conclusion, critically ill COVID-19 patients have a higher incidence of GI complications having a subset that progress to bowel ischemia requiring emergent surgical intervention. Front-line clinicians should be made aware of these complications and should keep a high index of suspicion for GI symptoms warranting surgical consultation. Footnotes The authors of this study have no relevant conflicts of interest, financial or otherwise, to declare. No funding was received for this study. Ethics committee approval: Institutional review table approval was obtained for this report. Consent for publishing the unidentifiable patient imaging and operative pictures was obtained. Supplemental digital content is available for this short article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article around the journal’s Web site (www.annalsofsurgery.com). REFERENCES 1. Bangalore S, Sharma A, Slotwiner A, et al. ST-segment elevation in patients with covid-19a case series. em N Engl J Med /em 2020; [Epub ahead of print]. [PMC free article] [PubMed] [Google Scholar] 2. Toscano G, Palmerini F, Ravaglia S, et al. GuillainCBarr syndrome associated with SARS-CoV-2. em N Engl J Med /em 2020; [Epub ahead of print]. [PMC free article] [PubMed] [Google Scholar] 3. Zhang Y, Xiao M, Zhang S, et al. Coagulopathy and antiphospholipid antibodies in sufferers with Covid-19. em N Engl J Med /em 2020; 382:e38. [PMC free of charge content] [PubMed] [Google Scholar] 4. Wells CI, OGrady G, Bissett IP. Acute colonic pseudo-obstruction: a systematic overview of aetiology and mechanisms. em Globe J Gastroenterol /em 2017; 23:5634C5644. [PMC free of charge content] [PubMed] [Google Scholar] 5. Connors JM, Levy JH. Thromboinflammation as well as the hypercoagulability of COVID-19. em J Thromb Haemost /em 2020; [Epub before print out]. [PubMed] [Google Scholar]. Among the hepatobiliary problems, transaminitis was the most frequent (67%). The mean highest beliefs documented for aspartate aminotransferase and alanine aminotransferase had been 420.7 and 479.0?U/L respectively, representing a 7.5- and 12-collapse increase in the physiological values. Four sufferers (4%) developed severe acalculous cholecystitis and 1 affected individual (1%) developed severe pancreatitis throughout their ICU stay. Half from the sufferers developed hypomotility-related problems of variable intensity. Almost all sufferers with GI problems needed nasogastric or orogastric pipes. Forty-six percent of sufferers had gastric nourishing kept for at least 24?hours because of great gastric residuals, and 6H05 (TFA) 58 (56%) developed an ileus diagnosed clinically and/or radiologically. Four from the sufferers with serious ileus had scientific and radiologic results concerning for colon ischemia and had been taken up to the operating room on days 11, 14, 15, and 22 of hospitalization, respectively, for an exploratory laparotomy. Two patients were found to have considerable patchy bowel necrosis including half to two thirds of the total bowel length, despite patent proximal mesenteric vessels around the computed tomography scan, probably recommending microvascular thrombosis. Intraoperatively, 6H05 (TFA) the necrotic colon had a definite bright yellowish color as opposed to the common selecting of purple-black color [(Fig. 1 in the Supplementary Appendix (Supplemental Amount 1. Diffuse patchy regions of necrosis of the complete small colon and right digestive tract, involving huge and short exercises of the wall structure. Note the apparent demarcation, the around shape, as well as the antimesenteric area, http://links.lww.com/SLA/C197)]. Another affected individual was discovered to possess ischemia without frank necrosis from the terminal 6H05 (TFA) ileum. The 4th patient developed liver organ ischemia and necrosis, and acquired similar regions of yellowish discoloration over the antimesenteric aspect of the tiny colon, without frank transmural necrosis. Two extra sufferers were identified as having a colonic paralytic ileus, medically similar to colonic pseudoobstruction (Ogilvie symptoms) on times 6 and 14 of hospitalization. Shape 2 in the Supplementary Appendix (Supplemental Shape 2. Abdominal x-ray of an 6H05 (TFA) individual with an Ogilvie-like symptoms displaying significant distention from the digestive tract, http://links.lww.com/SLA/C198.) displays an stomach x-ray of just one 1 of the 2 individuals demonstrating significant colonic dilation with cecal wall structure pneumatosis. On exploratory laparotomy, patchy regions of necrosis of the complete digestive tract were noted; a complete colectomy and a finish ileostomy had been performed. The pathology from the resected colon demonstrated 6H05 (TFA) focal transmural regions of necrosis with severe fibrinopurulent serositis. The entire 14-day affected person mortality was 15%. The mortality price from the subset of individuals who needed abdominal medical procedures was up to 40%. With this group of critically sick individuals with COVID-19, we report a high incidence of hepatobiliary, hypomotility, and ischemic GI complications. Of 141 patients, 58 had ileus, 2 had an Ogilvie-like syndrome, 1 had extensive hepatic necrosis, and 4 had bowel ischemia necessitating emergent surgery and bowel resection. Although these GI complications could be attributed to pharmacologic adverse events and metabolic and electrolyte disturbances occasionally encountered in critically ill patients, severe acute respiratory syndrome coronavirus 2Cinduced small vessel thrombosis or viral enteroneuropathy are 2 possible hypotheses that warrant further investigation.4,5 In summary, critically ill COVID-19 patients have a high incidence of GI complications with a subset that progress to bowel ischemia requiring emergent surgical intervention. Front-line clinicians should be made aware of these complications and should keep a higher index of suspicion for GI symptoms warranting medical consultation. Footnotes The writers of the scholarly research haven’t any relevant issues appealing, financial or elsewhere, to declare. No financing was received because of this research. Ethics committee acceptance: Institutional review panel approval was attained for this record. Consent for posting the unidentifiable patient imaging and operative pictures was obtained. Supplemental digital content is available for this short article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article around the journal’s Web site (www.annalsofsurgery.com). Recommendations 1. Bangalore S, Sharma A, Slotwiner A, et al. ST-segment elevation in patients with covid-19a case series. em N Engl J Med /em 2020; [Epub ahead of print]. [PMC free article] [PubMed] [Google.