A0516 - Gastrointestinal Complications of COVID-19: A Rare Case of Intestinal Perforation, Budd-Chiari Syndrome and Liver Failure Requiring Liver Transplant
Creighton University/St. Joseph Hospital and Medical Center Abington, PA
Hadiatou Barry, MD, MPH1, Chinonso Ilo, MD2, Matthew M. Barvo, MD2, Osama Qasim Agha, MD3, Justin A. Reynolds, MD1, Olga Kalinkin, MD1 1Creighton University/St. Joseph Hospital and Medical Center, Phoenix, AZ; 2Creighton University, Phoenix, AZ; 3Creighton University/St. Joseph Medical Center, Phoenix, AZ
Introduction: COVID-19 commonly presents with upper respiratory illness, while some patients experience GI manifestations of nausea, vomiting or diarrhea. Rarely, other complications include transaminitis, cholecystitis, ileus, pancreatitis, or mesenteric ischemia. We discuss the unique presentation of a COVID-19 positive woman with severe abdominal pain due to duodenal perforation and Budd-Chiari syndrome. This is the first documented case in the medical literature of COVID-19 associated Budd-Chiari syndrome progressing to liver failure and requiring liver transplantation.
Case Description/Methods: A 46-year-old Female presented to the ER with severe epigastric abdominal pain, nausea, and vomiting. She was under the care of a naturopathic doctor for COVID-19 infection and received homeopathic treatment and Ivermectin. The patient reported that the ivermectin severely exacerbated her abdominal pain, and she decided to visit the ER.
Physical examination revealed an ill-appearing woman with conjunctival icterus, in distress due to abdominal pain. She was tachycardic and hypertensive. Abdominal exam revealed diffuse tenderness to palpation, hepatomegaly, and hypoactive bowel sounds.
Labs revealed leukocytosis, hyponatremia, lactic acidosis, hyperbilirubinemia, marked transaminitis, and an elevated INR. Acute viral hepatitis panel, along with alpha-1 antitrypsin, anti-smooth muscle antibody, and Phosphatidylethanol (PETH) were all found to be negative. CT scan revealed pneumoperitoneum, ascites, and heterogeneous liver enhancement consistent with acute hepatic injury.
Emergency laparotomy was performed, where a perforated duodenal ulcer was identified and repaired. 2L of ascitic fluid along with hepatomegaly and venous congestion and diffuse oozing consistent with coagulopathy were also identified.
Given acute liver failure and COVID-19 hypercoagulable state, Budd-Chiari syndrome was suspected, MRI imaging was obtained which revealed periportal edema, hepatomegaly, and hepatic vein thrombosis. Due to progressive coagulopathy, jaundice, and hepatic encephalopathy despite anticoagulation, she ultimately underwent liver transplant with no complications and has since made a complete recovery.
Discussion: There is a growing incidence of GI perforation and thromboembolic events associated with COVID-19. A high index of suspicion for Budd-Chiari Syndrome and GI perforation should be kept in mind in patients with a history of COVID-19, as early recognition of abdominal pain or transaminitis could be lifesaving.
Figure: Figure 1. Axial T1FS post contrast image during portal-venous phase demonstrates recognizable imaging findings of acute Budd-Chiari syndrome with diminutive (<3 mm in diameter) left and middle hepatic veins (thin white arrows) and non visualized right hepatic vein. There is heterogeneous hepatic parenchymal enhancement with predominantly central hyper enhancement around IVC (black arrowhead) and hypoenhancing periphery (white arrowhead) that correlates with relatively preserved central liver perfusion and drainage versus congested hypoperfused periphery. Large white arrow indicated additional finding of non occlusive suprahepatic IVC thrombus.
Disclosures:
Hadiatou Barry indicated no relevant financial relationships.
Chinonso Ilo indicated no relevant financial relationships.
Matthew Barvo indicated no relevant financial relationships.
Osama Qasim Agha indicated no relevant financial relationships.
Olga Kalinkin indicated no relevant financial relationships.
Hadiatou Barry, MD, MPH1, Chinonso Ilo, MD2, Matthew M. Barvo, MD2, Osama Qasim Agha, MD3, Justin A. Reynolds, MD1, Olga Kalinkin, MD1. A0516 - Gastrointestinal Complications of COVID-19: A Rare Case of Intestinal Perforation, Budd-Chiari Syndrome and Liver Failure Requiring Liver Transplant, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.
