Volume 79, Issue 6 pp. 1004-1017

Original Article

Clinicopathological findings in patients with COVID-19-associated ischaemic enterocolitis

M Lisa Zhang,

Corresponding Author

M Lisa Zhang

[email protected]

orcid.org/0000-0002-8029-4787

Department of Pathology, Massachusetts General Hospital, Boston, MA, USA

Harvard Medical School, Boston, MA, USA

Address for correspondence: M L Zhang, MD, Department of Pathology, Massachusetts General Hospital, 55 Fruit Street, Warren 125, Boston, MA 02114, USA. e-mail: [email protected]

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Frank Jacobsen,

Frank Jacobsen

Department of Pathology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany

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Brian J Pepe-Mooney,

Brian J Pepe-Mooney

Harvard Medical School, Boston, MA, USA

Harvard–MIT Division of Health Sciences and Technology, Cambridge, MA, USA

Genetics Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

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Mari Mino-Kenudson,

Mari Mino-Kenudson

orcid.org/0000-0002-9092-2265

Department of Pathology, Massachusetts General Hospital, Boston, MA, USA

Harvard Medical School, Boston, MA, USA

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Vikram Deshpande,

Vikram Deshpande

orcid.org/0000-0003-4230-9308

Department of Pathology, Massachusetts General Hospital, Boston, MA, USA

Harvard Medical School, Boston, MA, USA

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Angela R Shih,

Angela R Shih

orcid.org/0000-0002-8945-5997

Department of Pathology, Massachusetts General Hospital, Boston, MA, USA

Harvard Medical School, Boston, MA, USA

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Anthony R Mattia,

Anthony R Mattia

Department of Pathology, Massachusetts General Hospital, Boston, MA, USA

Harvard Medical School, Boston, MA, USA

Department of Pathology, Newton-Wellesley Hospital, Newton, MA, USA

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Wolfram Goessling,

Wolfram Goessling

Harvard Medical School, Boston, MA, USA

Harvard–MIT Division of Health Sciences and Technology, Cambridge, MA, USA

Genetics Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA

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John O Hwabejire,

John O Hwabejire

Harvard Medical School, Boston, MA, USA

Department of Surgery, Massachusetts General Hospital, Boston, MA, USA

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George C Velmahos,

George C Velmahos

Harvard Medical School, Boston, MA, USA

Department of Surgery, Massachusetts General Hospital, Boston, MA, USA

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Joseph Misdraji,

Joseph Misdraji

Department of Pathology, Massachusetts General Hospital, Boston, MA, USA

Harvard Medical School, Boston, MA, USA

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M Lisa Zhang,

Corresponding Author

M Lisa Zhang

[email protected]

orcid.org/0000-0002-8029-4787

Department of Pathology, Massachusetts General Hospital, Boston, MA, USA

Harvard Medical School, Boston, MA, USA

Address for correspondence: M L Zhang, MD, Department of Pathology, Massachusetts General Hospital, 55 Fruit Street, Warren 125, Boston, MA 02114, USA. e-mail: [email protected]

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Frank Jacobsen,

Frank Jacobsen

Department of Pathology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany

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Brian J Pepe-Mooney,

Brian J Pepe-Mooney

Harvard Medical School, Boston, MA, USA

Harvard–MIT Division of Health Sciences and Technology, Cambridge, MA, USA

Genetics Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

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Mari Mino-Kenudson,

Mari Mino-Kenudson

orcid.org/0000-0002-9092-2265

Department of Pathology, Massachusetts General Hospital, Boston, MA, USA

Harvard Medical School, Boston, MA, USA

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Vikram Deshpande,

Vikram Deshpande

orcid.org/0000-0003-4230-9308

Department of Pathology, Massachusetts General Hospital, Boston, MA, USA

Harvard Medical School, Boston, MA, USA

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Angela R Shih,

Angela R Shih

orcid.org/0000-0002-8945-5997

Department of Pathology, Massachusetts General Hospital, Boston, MA, USA

Harvard Medical School, Boston, MA, USA

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Anthony R Mattia,

Anthony R Mattia

Department of Pathology, Massachusetts General Hospital, Boston, MA, USA

Harvard Medical School, Boston, MA, USA

Department of Pathology, Newton-Wellesley Hospital, Newton, MA, USA

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Wolfram Goessling,

Wolfram Goessling

Harvard Medical School, Boston, MA, USA

Harvard–MIT Division of Health Sciences and Technology, Cambridge, MA, USA

Genetics Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA

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John O Hwabejire,

John O Hwabejire

Harvard Medical School, Boston, MA, USA

Department of Surgery, Massachusetts General Hospital, Boston, MA, USA

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George C Velmahos,

George C Velmahos

Harvard Medical School, Boston, MA, USA

Department of Surgery, Massachusetts General Hospital, Boston, MA, USA

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Joseph Misdraji,

Joseph Misdraji

Department of Pathology, Massachusetts General Hospital, Boston, MA, USA

Harvard Medical School, Boston, MA, USA

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First published: 22 July 2021

https://doi.org/10.1111/his.14457

Citations: 11

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Abstract

Aims

Coronavirus disease 2019 (COVID-19) has been recognised as a predominantly respiratory tract infection, but some patients manifest severe systemic symptoms/coagulation abnormalities. The aim of this study was to evaluate the impact of severe COVID-19 infection on the gastrointestinal tract.

Methods and results

We examined clinicopathological findings in 28 resected ischaemic bowels from 22 patients with severe COVID-19. Most patients required intubation preoperatively and presented with acute decompensation shortly before surgery. D-dimer levels were markedly elevated in all measured cases (mean, 5394 ng/ml). Histologically, 25 cases (19 patients) showed evidence of acute ischaemia with necrosis. In this group, the most characteristic finding was the presence of small vessel fibrin thrombi (24 of 25 cases, 96%), which were numerous in 64% of cases. Patients with COVID-19 were significantly more likely than a control cohort of 35 non-COVID-19-associated acute ischaemic bowels to show isolated small intestine involvement (32% versus 6%, P < 0.001), small vessel fibrin thrombi (100% versus 43%, P < 0.001), submucosal vessels with fibrinous degeneration and perivascular neutrophils (90% versus 54%, P < 0.001), fibrin strands within submucosal vessels (58% versus 20%, P = 0.007), and histological evidence of pneumatosis (74% versus 34%, P = 0.010). Three cases in this cohort had histopathological findings normally seen in the setting of chronic ischaemia, notably prominent fibroblastic proliferation affecting the outer layer of the muscularis propria.

Conclusions

Herein, we describe the histopathological findings in COVID-19-associated ischaemic bowels and postulate a relationship with the hypercoagulable state seen in patients with severe COVID-19 infection. Additional experience with these cases may further elucidate specific features or mechanisms of COVID-19-associated ischaemic enterocolitis.

Graphical Abstract

Conflicts of interest

The authors state that they have no conflicts of interest.

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Citing Literature

Volume79, Issue6

December 2021

Pages 1004-1017