Along with the typical upper and lower respiratory symptoms of COVID-19, "attention should also be paid to extra-respiratory manifestations of the disease," Dr. Christian Toso of University Hospitals of Geneva told Reuters Health by email.
"Acute abdominal pain can also be a preliminary clinical feature of COVID-19," he said. The findings "suggest that clinicians should be aware of this type of rarer presentation, especially in areas of high COVID-19 prevalence, and primarily direct patients toward conservative, non-surgical, management, considering the fatal outcome in one of our patients."
In the Journal of Hepatology, Dr. Toso and colleagues describe an 84-year-old woman who presented to the emergency department with a urinary tract infection and fever for 24 hours. The initial diagnosis was sepsis due to pyelonephritis and she was given ceftriaxone and supportive care.
On day three, she experienced right upper quadrant pain, and on day five, a positive Murphy sign was detected. Gallbladder perforation was ruled out and she underwent laparoscopic cholecystectomy on day eight.
After extubation, she developed acute respiratory distress syndrome, and nasopharyngeal swabs confirmed the presence of 2019-SARS-CoV2 RNA. She passed away from multiorgan failure on postoperative day five. The gallbladder was not inflamed, but SARS-CoV-2 was found in the gallbladder wall.
The second case was an 83-year-old diabetic man on dialysis with arterial hypertension and moderate aortic stenosis. He was admitted for fever, but had no other symptoms. On day five, he developed right upper quadrant pain with a positive Murphy sign, degradation of his inflammatory markers and increased liver enzymes. Ultrasonography showed thickening of the gallbladder wall, presence of peri-vesicular liquid, but no gallstones.
Conservative management with ceftriaxone and metronidazole led to a slow recovery. On day six, he experienced respiratory symptoms and COVID-19 was confirmed.
Dr. Toso said, "The presence of SARS-CoV-2 in the gallbladder wall may result from a direct pathogenic effect of the virus on the gallbladder. Larger series are required to determine the incidence of abdominal presentation in patients with COVID-19, and further investigation is needed to better understand the suspected direct pathogenic impact of the virus on the gallbladder."
Dr. Niket Sonpal, a professor at Touro College of Osteopathic Medicine in New York City, commented in an email to Reuters Health, "This is a thought-provoking topic that needs more evidence. I have seen a few (COVID) patients with new-onset biliary issues but at the same time, they also had other risk factors, which could be a confounding variable for their gallbladder issues."
"Patients can have high levels of virus during active infection," he said, "and we need more studies to decide whether it's an innocent bystander in the biliary issues or partaking in the etiology."
Dr. William Lang, Chief Medical Officer of WorldClinic, a U.S. concierge medical practice, also commented by email. He noted that the angiotensin converting enzyme-2 receptor that SARS-CoV-2 uses to enter cells is found on multiple tissues throughout the body, including the gut. "For this reason alone, it is not surprising that SARS-CoV-2 was found in a patient's gallbladder, and may have been found even without having developed gallbladder problems."
Like Dr. Sonpal, he noted, "The big question...is what was the role of SARS-CoV-2 in the gall bladder inflammation? In the case of the 84-year-old woman...even without COVID-19, she had risk factors which could have led to acalculous cholecystitis. But it is not unreasonable to expect that SARS-CoV-2 induced inflammation made a potential situation go over the edge, resulting in the need to urgently remove her gall bladder."
From a practical standpoint, he said, "just like physicians have learned that it is important to assess for potential vascular effects of COVID-19 such as clots or heart inflammation, it is also important to look for potential gastrointestinal effects, and to include gallbladder disease, especially in patients with multiple other disease process."
By Marilynn Larkin
SOURCE: https://bit.ly/3krTP5q Journal of Hepatology, online September 2, 2020.
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