Clinical and intestinal histopathological findings in SARS-CoV-2/COVID-19 patients with hematochezia

Gastrointestinal (GI) symptoms of SARS-CoV2/COVID-19 in the form of anorexia, nausea, vomiting, abdominal pain and diarrhea are usually preceeded by respiratory manifestations and are associated with a poor prognosis. Hematochezia is an uncommon clinical presentation of COVID-19 disease and we hypothesize that older patients with significant comorbidites (obesity and cardiovascular) and prolonged hospitalization are suspectible to ischemic injury to the bowel.

We reviewed the clinical course, key laboratory data including acute phase reactants, drug/medication history in two elderly male patients admitted for COVID-19 respiratory failure. Both patients had a complicated clinical course and suffered from hematochezia and acute blood loss anemia requiring blood transfusion around day 40 of their hospitalization. Colonoscopic impressions were correlated with the histopathological findings in the colonic biopies and changes compatible with ischemia to nonspecific acute inflammation, edema and increased eosinophils in the lamina propria were noted. Both patients were on anticoagulants, multiple antibiotics and antifungal agents due to respiratory infections at the time of lower GI bleeding. Hematochezia resolved spontaneously with supportive care. Both patients eventually recovered and were discharged.

Elderly patients with significant comorbid conditions are uniquely at risk for ischemic injury to the bowel. Hypoxic conditions due to COVID-19 pneumonia and respiratory failure, compounded by preexisting cardiovascular complications, and/or cytokine storm orchestrated by the viral infection leading to alteration in coagulation profile and/or drug/medication injury can be difficult to distinguish in these critically ill patients. Presentation of hematochezia may further increase the mortality and morbidity of COVID-19 patients, and prompt consultation and management by gastroenterology is therefore warranted.