Can COVID 19 present like appendicitis?

The Impact of the COVID-19 Pandemic on the Incidence, Severity, and Management of Acute Appendicitis: A Single Center Experience in Thailand

PURPOSE

For more than two years since the COVID-19 pandemic, human lives have changed, including the healthcare system. Management of acute appendicitis, the most common emergency surgical disease, has been inevitably affected. This study aimed to assess the effect of the COVID-19 pandemic on the incident rate of complicated appendicitis, management, outcome, and complication of acute appendicitis. Patients and Methods. This study was a retrospective cohort study comparing 574 patients diagnosed with acute appendicitis before the COVID-19 outbreak and 434 patients diagnosed with acute appendicitis during the COVID-19 outbreak. Patient demographic data, type of appendicitis, type of treatment, time to surgery, length of stay, cost, and complications were collected and analyzed.

RESULTS

During the COVID-19 pandemic, the number of patients diagnosed with acute appendicitis was reduced. CT scan usage for diagnosis was increased compared to pre-COVID-19. Most patients diagnosed with acute appendicitis received operative treatment in both groups. Median time to surgery was significantly longer during the COVID-19 pandemic, 11.93 hours compared to 9.62 hours pre-COVID-19, p-value <0.001 (relative risk 1.5, 95% CI 1.29-1.76, p value 0.041). The incidence of complicated appendicitis was not higher during COVID-19. Compared to pre-COVID-19, ICU admission rate, the use of a mechanical ventilator, length of stay, and cost increased in the univariate analysis but were not statistically significant in the multivariate analyses. Other treatment complications had no statistically significant difference.

CONCLUSION

The incidence of complicated appendicitis did not increase during the COVID-19 pandemic. The operation waiting time significantly increased but did not increase the rate of treatment complications in a well-prepared hospital system.

Adenomesenteritis following SARS-CoV-2 Vaccination in Children: A Case Report and Review of The Literature

At present, the vaccine authorized in children aged 5 years and older is the BNT162b2 messenger RNA COVID-19 vaccine. Unlike adults, there is limited data available in the pediatric age describing adverse events after vaccine. We report a case of adenomesenteritis in a young girl following the first dose of vaccine.

Findings of Abdominal Imaging in Patients with COVID-19 - Part 1: Hollow Organs

Since COVID-19 has spread worldwide, the role of imaging for early detection of the disease has become more prominent. Abdominal symptoms in COVID-19 are common in addition to respiratory manifestations. This review collected the available data about abdominal computed tomography (CT) and ultrasonography indications in hollow abdominal organs in patients with COVID-19 and their findings. Since abdominal imaging is less frequently used in COVID-19, there is limited information about the gastrointestinal findings. The most common indications for abdominal CT in patients with COVID-19 were abdominal pain and sepsis. Bowel wall thickening and fluid-filled colon were the most common findings in abdominal imaging. Acute mesenteric ischemia (AMI) was one of the COVID-19 presentations secondary to coagulation dysfunction. AMI manifests with sudden abdominal pain associated with high morbidity and mortality in admitted patients; therefore, CT angiography should be considered for early diagnosis of AMI. Ultrasonography is a practical modality because of its availability, safety, rapidity, and ability to be used at the bedside. Clinicians and radiologists should be alert to indications and findings of abdominal imaging modalities in COVID-19 to diagnose the disease and its potentially serious complications promptly.

Factors Associated With Severe Gastrointestinal Diagnoses in Children With SARS-CoV-2 Infection or Multisystem Inflammatory Syndrome

IMPORTANCE

Severe gastrointestinal (GI) manifestations have been sporadically reported in children with COVID-19; however, their frequency and clinical outcome are unknown.

OBJECTIVE

To describe the clinical, radiological, and histopathologic characteristics of children with COVID-19 presenting with severe GI manifestations to identify factors associated with a severe outcome.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter retrospective cohort study (February 25, 2020, to January 20, 2021) enrolled inpatient and outpatient children (aged <18 years) with acute SARS-CoV-2 infection, confirmed by positive real-time reverse-transcriptase-polymerase chain reaction on nasopharyngeal swab or fulfilling the US Centers for Disease Control and Prevention criteria for multisystem inflammatory syndrome in children (MIS-C). The study was conducted by pediatricians working in primary care or hospitals in Italy participating in the COVID-19 Registry of the Italian Society of Pediatric Infectious Diseases.

MAIN OUTCOMES AND MEASURES

The occurrence of severe GI manifestations, defined by a medical and/or radiological diagnosis of acute abdomen, appendicitis (complicated or not by perforation and/or peritonitis), intussusception, pancreatitis, abdominal fluid collection, and diffuse adenomesenteritis requiring surgical consultation, occurring during or within 4 to 6 weeks after infection with SARS-CoV-2 infection. Logistic regression was used to estimate odds ratios (ORs) with 95% CIs of factors potentially associated with severe outcomes.

RESULTS

Overall, 685 children (386 boys [56.4%]; median age, 7.3 [IQR, 1.6-12.4] years) were included. Of these children, 628 (91.7%) were diagnosed with acute SARS-CoV-2 infection and 57 (8.3%) with MIS-C. The presence of GI symptoms was associated with a higher chance of hospitalization (OR, 2.64; 95% CI, 1.89-3.69) and intensive care unit admission (OR, 3.90; 95% CI, 1.98-7.68). Overall, 65 children (9.5%) showed severe GI involvement, including disseminated adenomesenteritis (39.6%), appendicitis (33.5%), abdominal fluid collection (21.3%), pancreatitis (6.9%), or intussusception (4.6%). Twenty-seven of these 65 children (41.5%) underwent surgery. Severe GI manifestations were associated with the child's age (5-10 years: OR, 8.33; 95% CI, 2.62-26.5; >10 years: OR, 6.37; 95% CI, 2.12-19.1, compared with preschool-age), abdominal pain (adjusted OR [aOR], 34.5; 95% CI, 10.1-118), lymphopenia (aOR, 8.93; 95% CI, 3.03-26.3), or MIS-C (aOR, 6.28; 95% CI, 1.92-20.5). Diarrhea was associated with a higher chance of adenomesenteritis (aOR, 3.13; 95% CI, 1.08-9.12) or abdominal fluid collection (aOR, 3.22; 95% CI, 1.03-10.0).

CONCLUSIONS AND RELEVANCE

In this multicenter cohort study of Italian children with SARS-CoV-2 infection or MIS-C, 9.5% of the children had severe GI involvement, frequently associated with MIS-C. These findings suggest that prompt identification may improve the management of serious complications.

Gastrointestinal Perspective of Coronavirus Disease 2019 in Children-An Updated Review

Gastrointestinal symptoms are common findings in children with severe acute respiratory syndrome coronavirus 2 infection, including vomiting, diarrhoea, abdominal pain, and difficulty in feeding, although these symptoms tend to be mild. The hepato-biliary system and the pancreas may also be involved, usually with a mild elevation of transaminases and, rarely, pancreatitis. In contrast, a late hyper-inflammatory phenomenon, termed multisystem inflammatory syndrome (MIS-C), is characterized by more frequent gastrointestinal manifestations with greater severity, sometimes presenting as peritonitis. Gastrointestinal and hepato-biliary manifestations are probably related to a loss in enterocyte absorption capability and microscopic mucosal damage caused by a viral infection of intestinal epithelial cells, hepatocytes and other cells through the angiotensin conversion enzyme 2 receptor resulting in immune cells activation with subsequent release of inflammatory cytokines. Specific conditions such as inflammatory bowel disease (IBD) and liver transplantation may pose a risk for the more severe presentation of coronavirus disease 2019 (COVID-19) but as adult data accumulate, paediatric data is still limited. The aim of this review is to summarize the current evidence about the effect of COVID-19 on the gastrointestinal system in children, with emphasis on the emerging MIS-C and specific considerations such as patients with IBD and liver transplant recipients.

A Systematic Review of Abdominal Imaging Findings in COVID-19 Patients

OBJECTIVE

The objective of this systematic review was to evaluate key imaging manifestations of COVID-19 on abdominal imaging by utilizing a comprehensive review of the published literature.

METHOD

A systematic literature search from PubMed, Google Scholar, and Scopus was performed for studies mentioning abdominal imaging findings in COVID-19 patients. Studies published from inception to 15 March 2021 were included.

RESULTS

A total of 116 studies comprising 1,198 patients were included. Abdominal pain was the most common indication for abdominal imaging in 50.2% of the patients. No abnormality was seen in 48.1% of abdominopelvic computed tomography scans. Segmental bowel wall thickening (14.7%) was the most common imaging abnormality, followed by bowel ischemia (7.1%), solid organ infarction (6.7%), vessel thrombosis (6.7%), and fluid-filled colon (6.2%). Other relevant findings were dilated air-filled bowel, pancreatitis, pneumatosis/portal venous gas, bowel perforation, and appendicitis. Other than abdominal findings, COVID-19-related basal lung changes were incidentally detected in many studies. Moreover, the presence of bowel imaging findings was positively correlated with the clinical severity of COVID-19 infection.

CONCLUSION

This review describes the abdominal imaging findings in COVID-19 patients. This is pertinent for the early diagnosis of COVID-19 in patients presenting solely with abdominal symptoms as well as in identifying abdominal complications in a known case of COVID-19.

Appendicitis as a presentation of COVID-19: A case report

Background

Coronavirus disease-19 (COVID-19) is an infectious respiratory disease caused by Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2). Respiratory symptoms and flu-like presentation are the most defined clinical manifestations. However, gastrointestinal symptoms with acute abdomen have been reported in a small percentage, occasionally mimicking acute appendicitis. Hence, the diagnosis of COVID-19 should be suspected and investigated in every case of acute abdomen in the present situation.

Case presentation

We report a case of a 25-year-old male who presented with features of acute appendicitis. Despite the equivocal ultrasound results, he was scheduled for an emergency appendectomy for Alvarado's score 7 out of 10, who underwent a successful appendectomy. The patient had initially tested negative on an upper respiratory COVID-19 reverse transcription-polymerase chain reaction (RT-PCR) with normal chest X-ray but few hours after the surgery patient developed a high-grade fever. An RT-PCR for COVID-19 was resent following a suspicion that came out to be positive.

Clinical discussion

Several case reports have suggested a probable association between COVID-19 and appendicitis. This case shows the limited effectiveness of clinical diagnosis for the surgical abdomen in COVID-19 patients as these two conditions share similar symptoms often needing a clinical vigilance.

Conclusion

This case reports acute appendicitis in a patient who tested positive for SARS-CoV-2 subsequently following emergency appendectomy highlighting the acute gastrointestinal presentation of COVID-19. This case exemplifies the necessity to be familiar with the gastrointestinal symptoms of COVID-19 and maintain a high level of suspicion for COVID-19 infection in cases of abdominal pain.

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Acute appendicitis can be one of the presentation of COVID-19.

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Clinicians need to be familiar with the gastrointestinal symptoms of COVID-19.

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Rapid diagnosis of COVID-19 in patients with acute abdominal pain should be done to prevent the virus from spreading.

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A negative RT-PCR for COVID-19 can't totally exclude COVID-19.

Imaging of abdominal complications of COVID-19 infection

Coronavirus disease 2019 (COVID-19) is a respiratory syndrome caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) first described in Wuhan, Hubei Province, China in the last months of 2019 and then declared as a pandemic. Typical symptoms are represented by fever, cough, dyspnea and fatigue, but SARS-CoV-2 infection can also cause gastrointestinal symptoms (vomiting, diarrhoea, abdominal pain, loss of appetite) or be totally asymptomatic. As reported in literature, many patients with COVID-19 pneumonia had a secondary abdominal involvement (bowel, pancreas, gallbladder, spleen, liver, kidneys), confirmed by laboratory tests and also by radiological features. Usually the diagnosis of COVID-19 is suspected and then confirmed by real-time reverse-transcription-polymerase chain reaction (RT-PCR), after the examination of the lung bases of patients, admitted to the emergency department with abdominal symptoms and signs, who underwent abdominal-CT. The aim of this review is to describe the typical and atypical abdominal imaging findings in patients with SARS-CoV-2 infection reported since now in literature.

Coronavirus Disease and Abdominal Pain: Mechanism, Diagnostic, and Treatment

BACKGROUND: On March 11, 2020, the General Director of the World Health Organization has announced that according to the organization, the level of spread and severity of symptoms of coronavirus disease (COVID-19) is becoming alarming and because of that, it can be characterized as a pandemic. The assessment of the World Health Organization stimulated more urgent and belligerent actions from the governments as the number of case reports and studies on COVID-19 symptoms and treatment increased dramatically. AIM: In this paper, the aim is to make a review of the studies and case reports/series that indicate that abdominal pain is one of the manifestations of COVID-19. METHODS: A search was performed on two electronic databases: PubMed Central and Google Scholar, using the key words “COVID-19 and abdominal pain.” Case reports and case series in adults and children were included regardless of the language, region, or the publication date. The methods of synthesis and comparison were also used. RESULTS: In general, it can be noted that the manifestation of the COVID-19 infection on the digestive tract and the consequences on the same are not fully examined. CONCLUSION: The conclusion of the analyzed papers is that clinical practitioners in COVID-19 pandemic should carefully distinguish abdominal pain and other GI symptoms from COVID-19 manifestations and should exclude acute surgical condition.

The Great Gut Mimicker: A case report of MIS-C and appendicitis clinical presentation overlap in a teenage patient

BACKGROUND

Abdominal pain and other gastrointestinal symptoms are common presenting features of multisystem inflammatory syndrome in children (MIS-C) and can overlap with infectious or inflammatory abdominal conditions, making accurate diagnosis challenging.

CASE PRESENTATION

We describe the case of a 16-year-old female who presented with clinical symptoms suggestive of appendicitis and an abdominal computed tomography (CT) that revealed features concerning for appendicitis. After laparoscopic appendectomy, histopathology of the appendix demonstrated only mild serosal inflammation and was not consistent with acute appendicitis. Her overall clinical presentation was felt to be consistent with MIS-C and she subsequently improved with immunomodulatory and steroid treatment.

CONCLUSIONS

We note that MIS-C can mimic acute appendicitis. This case highlights MIS-C as a cause of abdominal imaging with features concerning for appendicitis, and MIS-C should be considered in the differential for a patient with appendicitis-like symptoms and a positive COVID-19 IgG. Lab criteria, specifically low-normal white blood cell count and thrombocytopenia, appears to be of high relevance in differing MIS-C from acute appendicitis, even when appendix radiologically is dilated.

An unusual and atypical presentation of the novel coronavirus: A case report and brief review of the literature

The coronavirus disease 2019 (COVID-19) is a highly contagious novel infection that predominantly presents with fever and respiratory symptoms. However, COVID-19 can masquerade as an acute coronary syndrome, leg pain or swelling with venous thrombosis, loss of consciousness with cerebral venous thrombosis, confusion, limb weakness with brain infarction, facial neuralgia, acute conjunctivitis, acute appendicitis, and testicular pain. We report on a 42-year-old man who presented with mild symptoms of COVID-19. The patient's electrocardiogram showed an ST-segment elevation myocardial infarction (STEMI) due to a left coronary thrombosis. The patient was managed conservatively with medicines and had an uneventful recovery. Emergency physicians should have a high index of suspicion for the unusual presentations of COVID-19.

Meckel's diverticulitis in a COVID-19 adult

Meckel’s diverticulitis is an unusual cause of acute abdomen condition in adults requiring prompt surgical treatment. We report a case of a 53-year-old male with coronavirus disease 19 (COVID-19), admitted to the emergency department with an acute abdominal pain. A computed tomography scan with intravenous contrast performed on the patient confirmed an inflamed short segment of the small bowel and the presence of a localized free peritoneal fluid. The definitive diagnosis was made intraoperatively, by means of an emergent ileal resection with primary anastomosis, which confirmed Meckel’s diverticulitis. Postoperative evolution was ordinary. The association of COVID-19 with the acute abdomen is found to be weak, therefore surgical consultation is advised to minimize delayed treatment.

A challenging case of COVID-19 infection presented with isolated acute abdominal pain: A case report and literature review

COVID-19 is an infectious disease, which often presents with fever and respiratory symptoms. However, gastrointestinal symptoms have also been reported to occur in patients with COVID-19. Although abdominal pain was described in some reports of COVID-19, it was uncommon and often associated with other symptoms. We describe a challenging case of a COVID-19 patient who presented with severe isolated abdominal pain initially, then developed pneumonia symptoms which led to the diagnosis of COVID-19 thereafter.

Case series of acute appendicitis association with SARS-CoV-2 infection

Background

Describe the indications for surgical interventions in asymptomatic patients with SARS-CoV-2. We are unaware of previous reports of an association between SARS-CoV-2 and acute appendicitis.

Methods

We performed a single institution retrospective review of SARS-CoV-2 pre-procedure testing and indications for surgical intervention. Statistical comparisons were performed using Chi Square analysis or two-tailed Student T test.

Results

We report a high prevalence of SARS-CoV-2 in both all testing and pre-procedure testing during the enrollment period. We observe a high prevalence of acute appendicitis among patients identified to be SARS-CoV-2 positive during pre-procedure testing and without recognized symptoms of COVID19.

Conclusion

We report a previously unrecognized association between SARS-CoV-2 and acute appendicitis.

Perforated Appendicitis: An Unintended Consequence During the Coronavirus-19 Pandemic

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has had major clinical impact across the globe. Delayed presentation for medical emergencies has been noted by the medical community. There has been limited reporting on the impact for the care for emergent surgical conditions. We sought to describe the effect of the global pandemic on the presentation and outcomes for the most common urgent general surgery disease process, acute appendicitis.

METHODS

We performed a retrospective review of patients admitted to the United States Naval Hospital Okinawa during the COVID-19 pandemic, from January 2020 to May 2020 (COVID cohort), and compared them to a historical cohort (pre-COVID cohort) over the prior 2 years. Demographics, clinical presentation data, and interventions were collected.

RESULTS

Of the 80 patients with appendicitis, 20% presented perforated. Most patients were male (71%), presented with 1 day of symptoms and had a length of stay of 1 to 2 days. Comparing groups, 13% of the pre-COVID group vs. 31% of the COVID cohort presented perforated (P = .04), with a symptom duration of 1.6 vs. 2.7 days before presentation (P = .075), respectively.

CONCLUSIONS

The COVID-19 pandemic and the global systematic response has impacted unrelated medical and surgical conditions. At our overseas military hospital with minimal disease burden, we observed a delay in presentation for acute appendicitis with a higher incidence of perforation. Patients should be empowered to continue to seek care for urgent and emergent medical and surgical conditions so that they are not harmed by fear of COVID-19 rather than by COVID-19 itself.

Impact of the COVID-19 pandemic on appendicitis treatment in Germany-a population-based analysis

PURPOSE

Acute appendicitis is one of the most common reasons for emergency medical consultation. While simple appendicitis can be treated with antibiotics or surgery, complex appendicitis including gangrene, abscess, and perforation requires appendectomy. During the COVID-19 pandemic in early 2020, an overall drop in emergency room consultations was observed. We therefore aimed to investigate the incidence and treatment strategies of acute appendicitis during that period.

METHODS

Data of insurance holders with the ICD code for "acute appendicitis" or OPS procedure of appendectomy of a major health insurance company in Germany were analyzed retrospectively. Groups were built, containing of the means of March-June of 2017, 2018, and 2019, defined as "pre-COVID group" with the "COVID group," defined as data from March to June of 2020. Data was analyzed by age, sex, comorbidities, length of hospital stay, diagnoses, and treatment. Data of the COVID group was analyzed for simultaneous COVID-19 infection.

RESULTS

During the COVID-19 pandemic of early 2020, an overall reduction by 12.9% of patients presenting with acute appendicitis was noticeable. These results were mainly due to decreased rates of uncomplicated appendicitis, while complicated appendicitis was scarcely affected. Especially in the group of females < 40 years, a drastic reduction was visible. Rates of extended surgery did not change. Likewise, the complication rate like appendix stump leakage or need for re-operation did not differ. In March 2020, 4.8% of acute appendicitis patients had concomitant COVID-19 infection.

CONCLUSION

In line with the overall drop of emergency room visits during the COVID-19 pandemic of spring 2020 in Germany, a significantly lowered number of patients with uncomplicated appendicitis were noticeable, whereas complicated appendicitis did not differ. Also, treatment and complication rate of acute appendicitis did not change. These findings might be a hint that acute appendicitis is not a progressing disease but caused by different entities for uncomplicated and complicated appendicitis and therefore another clue that uncomplicated appendicitis can be treated with antibiotics or observation. Nevertheless provided data does not cover outpatient treatment; therefore, no statement observation or antibiotics in outpatients can be made.

A Surge in Pediatric Coronavirus Disease 2019 Cases: The Experience of Texas Children's Hospital From March to June 2020

BACKGROUND

An understanding of the clinical characteristics of children with coronavirus disease 2019 in diverse communities is needed to optimize the response of healthcare providers during this pandemic.

METHODS

We performed a retrospective review of all children presenting to the Texas Children's Hospital system with testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from March 10, 2020, through June 28, 2020. Demographics were recorded for all patients undergoing testing and clinical characteristics and outcomes were recorded for children with positive tests.

RESULTS

Of 16 554 unique patients ≤ 21 years of age who were tested for SARS-CoV-2, 1215 (7.3%) patients tested positive. Infants under 1 year of age and patients aged 18-21 years had the highest percent of positive tests at 9.9% (230/2329) and 10.7% (79/739), respectively. Hispanic children accounted for 66% (802/1215) of positive tests, though they only represented 42.1% (6972/16 554) of all children tested for SARS-CoV-2. Of the 1215 children with a positive test, 55.7% had fever, 40.9% had cough, 39.8% had congestion or rhinorrhea, 21.9% had gastrointestinal complaints, and 15.9% were asymptomatic. Only 97 (8%) patients were hospitalized (of which 68% were Hispanic). Most of the hospitalized patients had underlying medical conditions (62/97, 63.9%), including obesity. Thirty-one hospitalized patients (31/97, 32%) required respiratory support and 9 patients (9/97, 9.3%) received SARS-CoV-2 antiviral therapy. Two patients died.

CONCLUSIONS

A relatively high percentage of Hispanic children tested positive for SARS-CoV-2 and were hospitalized. Most of the children with detection of SARS-CoV-2 had uncomplicated illness courses; some children were critically ill; and 2 patients died.

Rare case of COVID-19 presenting as acute abdomen and sepsis

Coronavirus disease 2019 (COVID-19) may present as acute abdomen, although the pathophysiology remains obscure. We report the case of a 45-year-old-man with severe COVID-19 pneumonia with associated pulmonary embolism who presented with acute abdomen. He underwent emergency laparotomy and resection of an ischaemic area of the jejunum. Postoperatively, he had septic shock, acute respiratory distress syndrome and acute kidney injury necessitating continuous renal replacement therapy. We administered antibiotics and therapeutic anticoagulation along with two sessions of haemoadsorption by CytoSorb filter, in conjunction with continuous renal replacement therapy. The patient survived. Bowel ischaemia due to thromboembolic disease should be promptly treated. Extracorporeal blood purification may be useful in managing sepsis in severe COVID-19.