Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case Series
Year : 2022 | Month : May | Volume : 16 | Issue : 5 | Page : PR01 - PR04 Full Version

Perforation of Jejunal Diverticula in COVID-19 Positive Patients: A Case Series


Published: May 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/52657.16363
Pushkar Galam, Nikhil Jillawar, Vinayaka Vishnu Vardhan Puppala, Mahesh Madhavrao Thombare

1. Assistant Professor, Department of General Surgery, Dr. D. Y. Patil Medical College and Research Centre, Pune, Maharashtra, India. 2. Assistant Professor, Department of Surgical Gastroenterology, Dr. D. Y. Patil Medical College and Research Centre, Pune, Maharashtra, India. 3. Junior Resident, Department of General Surgery, Dr. D. Y. Patil Medical College and Research Centre, Pune, Maharashtra, India. 4. Associate Professor, Department of Surgical Gastroenterology, Dr. D. Y. Patil Medical College and Research Centre, Pune, Maharashtra, India.

Correspondence Address :
Dr. Mahesh Madhavrao Thombare,
Associate Professor, Department of Surgical Gastroenterology, Dr. D. Y. Patil Medical College and Research Centre, Sant Tukaram Nagar, Pimpri-Chinchwad, Pune, Maharashtra, India.
E-mail: maheshthombare787@gmail.com

Abstract

Jejunal diverticulosis is the herniation of mucosa through weakened wall of jejunum on the mesenteric border. Individuals are usually asymptomatic for most of their lives and are diagnosed incidentally by radiological investigations or during surgery. Increased number of hospital admissions and investigations done to better understand the phenomenon of Coronavirus Disease 2019 (COVID-19) had increased the rate of incidental diagnosis. Four patients admitted to the COVID-19 ward of the hospital were diagnosed with COVID-19. They were treated according to the protocol followed in the state, which included high dose of steroids. During the course of treatment, they experienced abdominal pain with distension and were diagnosed with jejunal diverticulitis with perforation. Exploratory laparotomy with jejunal resection and jejuno-jejunal anastomosis with feeding jejunostomy was performed and adequate postoperative care was provided. Two out of the four patients survived and were discharged after they achieved full recovery and became COVID-19 negative. The cause of perforation can be attributed to the high dose of steroids used during the treatment as steroids have been proved to cause spontaneous bowel perforations.

Keywords

Diverticulosis, Diverticulitis, High dose steroids, Long term steroid

As of January 16, 2022, 323 million people were affected with COVID-19 with 5.5 million deaths (1). COVID-19 is a viral disease which predominantly affects respiratory system. It also affects gastrointestinal tract and liver. A 9% of 59294 patients with COVID-19 from 11 countries had gastrointestinal symptoms with longer hospital stay and worse prognosis (2). Many complications of gastrointestinal tract are noted but perforation of the viscera has not received much attention. No report of jejunal diverticular perforation in COVID-19 was reported prior to this case series. Four patients were admitted to the hospital during the period between January 2020 to August 2021 to the COVID-19 ward in Dr. DY Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India.

Case Report

Case 1

A 25-year-old male patient came to the Outpatient Department (OPD) with complaints of breathlessness, fever and generalised weakness for five days. Patient did not have any significant family history or past medical history. On examination, patient was febrile with a fever of 101°F, with a respiratory rate of 24 cycles per minute, oxygen saturation of 90% on room air, with equal air entry in both lungs and basal crept. He had no gastrointestinal symptoms and his abdominal and per rectal examination showed no obvious abnormality. Patient was diagnosed COVID-19 positive on the day of admission by Reverse Transcriptase Polymerase Chain Reaction (RT-PCR). Patient was shifted to the COVID-19 care ward, where he received the treatment as per the protocol for 15 days. He was administered injection methyl prednisolone, a dose of 80 mg/day for eight days followed by 40 mg/day for the next seven days. The patient improved symptomatically, on day 16 of hospital stay, he had two episodes of vomiting, abdomen was distended, tender, with guarding and absent bowel sounds. An X-ray erect abdomen was done, which displayed air under the diaphragm (Table/Fig 1), and a Contrast Enhanced Computed Tomography (CECT) of abdomen and pelvis showed irregular thickening of the jejunal wall with oedematous jejunal loops suggestive of jejunal diverticulitis with perforation. The patient underwent resection of the diverticular jejunal segment with jejuno-jejunostomy (Table/Fig 2), (Table/Fig 3), (Table/Fig 4). Patient required Intensive Care Unit (ICU) care for five days and then shifted to ward. Patient was discharged on postoperative day 14. The patient lost to follow-up.

Case 2

A 55-year-old postmenopausal diabetic female came to the hospital with complaints of pain in abdomen, nausea, diarrhoea and fever for seven days. The patient did not have any significant family history. The old records showed the diabetes was under control.

On examination, she was afebrile, with a respiratory rate of 16 per minute, oxygen saturation of 85% on room air, with equal air entry on both sides and no adventitious sounds. Per abdominal and per rectal examination revealed no obvious abnormalities. The RT-PCR was performed and patient was diagnosed as COVID-19 positive. She was shifted to the COVID-19 ward and started on the treatment protocol which included injection Remdesivir-200 mg intravenous (i.v.) on first day and 100 mg once daily for next four days and injection methyl prednisolone with 40 mg/day for 15 days followed by 20 mg/day for the next 15 days as the oxygen saturation improved. On day 30 of treatment, she complained of pain and distension of abdomen. On examination patient had tachycardia, with abdominal distension, guarding and absent bowel sounds. An erect X-ray of abdomen revealed air under the diaphragm. The CECT abdomen revealed multiple diverticula arising from the mesenteric border of jejunum. There was one inflamed diverticulum in the left hypochondriac region with increased attenuation, forming small inflammatory mass (Table/Fig 5). At laparotomy the patient had multiple jejunal perforations with 20 mL pus collection for which resection and anastomosis was performed (Table/Fig 6). The patient required ICU care for three days and was discharged on postoperative day 10. She was followed-up for a period of four months and was doing well.

Case 3

A 70-year-old male hypertensive and asthmatic patient came to the hospital with complaints of generalised weakness, breathlessness, cough and body pains of three days duration. The patient had medical risk factors such as systemic hypertension and asthma. On examination patient was febrile with a temperature of 100°F, with a respiratory rate of 30/minute, oxygen saturation of 85% on room air with bilateral air entry and wheeze in both lungs. Patient was diagnosed COVID-19 positive and started on treatment according to the protocol. Patient was started on non invasive ventilation on 40% FiO2, injection methyl prednisolone 40 mg/day, along with nebulisation with budecortisone 0.5 mg thrice daily. Patient was maintaining stable vitals for one week. On day 8 of treatment, patient complained of mild abdominal pain with nausea. Over the course of two days patient did not pass stools, the abdominal pain became severe and associated with distension. An erect X-ray of the abdomen revealed multiple air fluid levels and air under the diaphragm. CECT abdomen revealed, dilated jejunal loops with a single outpouching at mesenteric border and pneumoperitoneum (Table/Fig 7). At laparotomy, patient has single jejunal diverticular perforation for which jejunal resection anastomosis was done (Table/Fig 8). He continued to need ICU care and died on postoperative day 3 due to respiratory failure.

Case 4

A 66-year-old male with no co-morbidities came to the casualty with complaints of fever, cough, body pains and diarrhoea of four days duration. The patient did not have any significant family and personal history. On examination, he was febrile with a temperature of 101°F, with a respiratory rate of 20 cycles per minute, saturation of 95% on room air, basal crepitations in bilateral lungs. Patient was shifted to suspect ward and diagnosed as COVID-19 positive, the following day. He was started on the treatment protocol, which included injection methyl prednisolone 40 mg/day for the first five days. However, his oxygen saturation dropped to 90% in the next two days and the dose of methyl prednisolone was increased to 80 mg/day for the next 20 days. The patient complained of severe pain in abdomen with distension, fever and loss of appetite on 27th day of hospitalisation. The patient was febrile with a temperature of 102oF, tachycardia, with distended abdomen with tender and guarding all over and absent bowel sounds. An X-ray erect abdomen showed air under the diaphragm. The CECT abdomen showed irregular thickening of jejunum with outpouchings and break in the continuity of the bowel at the outpouchings and pneumoperitoneum, suggestive of multiple jejunal diverticula with perforation. The patient had multiple jejunal perforation and underwent jejunal resection and anastomosis (Table/Fig 9), (Table/Fig 10). The patient died after 12 hours due to respiratory failure.

Discussion

Gastrointestinal perforation is a rare complication of COVID-19 and its treatment (3). Small bowel diverticulosis is an uncommon condition with presenting symptoms of abdominal pain, constipation, diarrhoea, dyspepsia and malnutrition. Individuals are often asymptomatic for a long period of time, before being incidentally diagnosed with the condition. The incidence varies from 0.06-1.3% and prevalence increases with age. Elderly population above the age of 60 years are most affected. Jejunal diverticulosis can progress to diverticulitis and result in complications such as perforation (2.1-7%), obstruction (2.3-4.6%) and bleeding (2-8.1%) (4). Four patients in present series were diagnosed incidentally after they complained of acute abdomen, during the course of their treatment for COVID-19. In a review of 28 cases of gastrointestinal perforation, none of the patients had jejunal diverticular perforation (3).

During the course of their hospital stay, all the patients were treated according to the treatment guidelines issued by the state of Maharashtra. High dose systemic corticosteroids were administered during the therapy and the dose was tapered or increased based on the patient’s response. COVID-19 results in a cytokine release syndrome leading to massive inflammatory cell infiltration and acute lung injury (5). Corticosteroids by acting intracellularly, down regulate transcription factors that are responsible for producing proinflammatory mediators and upregulate transcription factors of anti-inflammatory mediators, thus suppressing inflammation and immune response (6).

However, long term corticosteroid therapy is often associated with perforations of the gastrointestinal tract. The first three weeks of corticosteroid therapy have 40.3% chance of gastrointestinal perforation (7). Two of the four patients have received systemic corticosteroid for less than three weeks, the other two received for 25 and 30 days following which they were diagnosed with jejunal diverticular perforation. Gastroerosive properties of corticosteroids contribute to the ulcer formation and subsequent perforation of intestinal mucosa (8).

Extrapulmonary manifestations of COVID-19 can involve the gastrointestinal tract due to its high expression of Angiotensin Converting Enzyme-2 (ACE2) receptors in the epithelial lining which act as host cell receptors for the virus. The infection promotes local coagulopathy leading to the necrosis of the intestinal wall followed by perforation or bleeding (9). Given the asymptomatic nature of jejunal diverticula (3), the local effect of COVID-19 infection (5) and the gastro-erosive effects high dose of steroids (7) would have led to diverticular mucosal injury leading to diverticulitis followed by perforation. Perforations have been reported in COVID-19 as a presenting pathology even without any treatment such as steroids and anti-interleukin-6 medications such as tocilizumab (3).

In patients presenting with acute abdomen, jejunal diverticulitis should be considered for differential diagnosis, as it is associated with a high mortality rate of 40% (10). A delayed diagnosis would be fatal in such a case, and therefore an immediate CT scan would decrease the time required to diagnose and result in a better outcome (11). For all the four patients’ intestinal perforation was considered as provisional diagnosis, which after CT scan was found out to be jejunal diverticulitis leading to perforation.

In a case of uncomplicated jejunal diverticulitis, medical management with antibiotics is preferable. However, in cases of complicated jejunal diverticulitis, resulting in a peri-diverticular abscess may be treated with intravenous antibiotics and a CT-guided percutaneous drainage has been advised (12). In cases with generalised peritonitis, a surgical approach had been advised where the affected part of the jejunum is to be excised (13). All the four patients in present series, had signs and symptoms of generalised peritonitis, and underwent surgery which revealed jejunal diverticula with perforation.

Surgeons dealing COVID-19 positive patients with gastrointestinal complications have to focus on reaching an early diagnosis, adequate source control to stop contamination, appropriate antimicrobial therapy and prompt resuscitation. On a case-by-case basis, based on the haemodynamic status after the initial resuscitative measures, age and co-morbidities, the need for surgical management has to be evaluated. If chosen to be managed conservatively, clinical and radiological surveillance should be carried out every 12-24 hours till the condition settles. However, if the signs symptoms and haemodynamic parameters of the patients show a deteriorating trend, surgery can be undertaken (13).

Postoperative care is of prime importance in COVID-19 patients undergoing surgery. Most common perioperative complications include thromboembolic episodes, infection and pulmonary complications. All patients were shifted to an ICU, two of the four patients suffered from respiratory failure 12 hours after surgery and on Post-operative day 3. The postoperative rate of ICU admission in COVID-19 patients is 15%, with the prevalence of perioperative mortality for undergoing an emergency surgical procedure is 29% (14). Postoperative ICU admission would offer better monitoring for complications in a COVID-19 patient taken for emergency surgery.

COVID-19 patients with prolonged hospital stay on systemic steroids should be monitored for complications. Acute abdominal symptoms should be examined with a high suspicion for perforation. Jejunal diverticulitis should be considered as an important differential while planning for further management.

Conclusion

All the four patients were incidentally diagnosed with jejunal diverticulitis with perforation upon presenting with symptoms of acute abdomen during the course of treatment for COVID-19. COVID-19 being a thromboembolic phenomenon, ischaemic changes in the intestinal mucosa could have caused an initial insult, accelerated by the erosive effects of prolonged course of systemic steroids on the intestinal mucosa resulting in perforation. While the surgical management was successful, lung parenchymal damage due to COVID-19 resulted in patients experiencing respiratory failure postoperatively resulting in death. Jejunal diverticulitis complicating with perforation has to be considered as a differential diagnosis while treating patients with peritonitis with COVID-19 infection, on treatment with long term course of high dose systemic steroids.

References

1.
COVID-19 Weekly Epidemiological Update. 2022 COVID-19 Jan;18:75. [Available from: CoV-weekly-sitrep18Jan22-eng.pdf (who.int)].
2.
Santana GO, de Santana AC, Pfeilsticker VB. Ileum perforation in Crohn’s disease patient during SARS-Cov-2 infection. Inflammatory Bowel Diseases. 2021;27(4):e42. [crossref] [PubMed]
3.
Bulte JP, Postma N, Beukema M, Inberg B, Stegeman AG, van der Hoeven H. COVID-19 and the risk of gastro-intestinal perforation: A case series and literature review. Journal of Critical Care. 2022;67:100-03. [crossref] [PubMed]
4.
Fleres F, Viscosi F, Bertilone E, Mazzeo C, Cucinotta E. Therapeutic strategies for jejunal diverticulitis: Our experience and a review of the recent literature. J Vis Surg. 2018;4:152. [crossref]
5.
Fu Y, Cheng Y, Wu Y. Understanding SARS-CoV-2-mediated inflammatory responses: From mechanisms to potential therapeutic tools. Virologica Sinica. 2020;35(3):266-71. [crossref] [PubMed]
6.
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DOI and Others

DOI: 10.7860/JCDR/2022/52657.16363

Date of Submission: Oct 16, 2021
Date of Peer Review: Dec 21, 2021
Date of Acceptance: Mar 16, 2022
Date of Publishing: May 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Oct 18, 2021
• Manual Googling: Mar 16, 2022
• iThenticate Software: Apr 02, 2022 (5%)

ETYMOLOGY: Author Origin

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