Journal of Surgery: Open Access

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CASE REPORT Volume 7 - Issue 3

COVID-19 and its Repercussions on Vascular and Abdominal Medical

Emergency Scenario. Interinstitutional, Multidisciplinary Approach
Carlos Adrián Torrejón-Hernández1,*, Héctor Bizueto-Rosas2, Moisés Alejandro Perdomo Galván3, Ana Karen Trujillo-Araujo3,
Francisco Jazir Castro Carrillo3, Alfonso Cossío-Zazueta4, Raúl Beder Caltenco-Solís1, Camilo Andrés Echeverry-Fernández1,
Jaime Roberto Magaña-Salcedo1, Jesús Nicolás Hidalgo-Delgado1, Jesús Eduardo Prior-Rosas1, Mayerlin Calvache-Muñoz1,
Noelly Noemí Bizueto-Blancas5, Jesús García-Chávez2, José Alberto Valdés-Serafín2, and Noemí Antonia Hernández-Pérez6
1
General Surgery Resident, Dario Fernandez Fierro General Hospital, Institute for Social Security and Services for State Workers (ISSSTE), Mexico City,
Mexico
2
General Surgeon, Dario Fernandez Fierro General Hospital, ISSSTE, Mexico City, Mexico
3
Angiology Resident, Dr. Antontio Fraga Mouret High Specialty Hospital, Mexican Social Security Institute (IMSS), Mexico City, Mexico
4
Chief of Angiology Service, Dr. Antonio Fraga Mouret High Specialty Hospital, IMSS, Mexico City, Mexico
5
Medicine Student, Saint Luke School of Medicine, Mexico City¸ Mexico
6
Family and Laboral Medic, Mexico City¸ Mexico
*Corresponding authors: Carlos Adrián Torrejón Hernández, General Surgery Resident, Dario Fernandez Fierro General Hospital, Institute for
Social Security and Services for State Workers (ISSSTE), Mexico City, Mexico; E-mail: [email protected]
Received: 10 Apr, 2021 | Accepted: 14 Jun, 2021 | Published: 23 Jun, 2021

Citation: Torrejón-Hernández CA, Bizueto-Rosas H, Galván MAP, Trujillo-Araujo AK, Carrillo FJC, et al. (2021) COVID 19 and its Repercussions
on Vascular and Abdominal Medical Emergency Scenario. Interinstitutional, Multidisciplinary Approach. J Surg Open Access 7(3): dx.doi.
org/10.16966/2470-0991.243
Copyright: © 2021 Torrejón-Hernández CA, et al. This is an open-access article distributed under the terms of the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source
are credited.
Abstract
Objective: To identify the causes related to a rise in morbidity and mortality due to COVID in the most frequent events of acute abdomen and
vascular disease.
Introduction: SARS-CoV-2 disease is a syndrome which includes respiratory, digestive, hepatic, and cardiovascular and nervous systems. 20% of
positive cases present gastrointestinal symptoms whereas vascular manifestations appear up to 15%.
We are facing a new scenario, where well known practices involving the most common abdominal and/or vascular diseases approaches must change
remarking a thorough anamnesis on all medical attention levels. Uncomplicated surgical diseases have increased morbidity and mortality rates due
to fear and disinformation in both, patients and medical staff.
Methods: An ambispective, observational, descriptive, multicentric and multidisciplinary study was carried out with the most frequent abdominal
and vascular pathologies, since pandemic establishment. Identifying delaying factors in surgical management, evaluating predominant symptoms
and postoperative complications.
Results: Fifty-seven patients, 22 form vascular surgery service (Group I) and 35 from general surgery (Group II) were included.
Group I: Average age 60.7 years; 16 men, 6 women; PCR positive 55%; 7 deaths, 18% PCR positives; 8 with delayed treatment due to administrative
issues; without apparent cause: embolism to mesenteric root, aorta, vena cava, pulmonary artery, lower limbs, coronary and carotid vessels.
Diabetics 35%, hypertensive disease 30%.
Group II: 20 men, 15 women; average age 62.5 years; 12 deaths, 7 men, 5 women; diabetics and hypertensive 30%; 3 hemicolectomies due to acute
appendicitis; 2 cholecystectomies with acute abdomen management. 1 intestinal resection due to incarcerated hernia with fistulae. 4 amputations.
Conclusion: We have a long road ahead to deal with this new pandemic scenario; medicine teaching should focus on prophylaxis and a preventive
approach instead only therapeutic, simulating real life scenarios to be better prepared.

Keywords: COVID-19; Acute abdomen; Arterial insufficiency; Complications

Abbreviations: M: Patient’s fear to medical environment due to the pandemic; DE: Wrong diagnostic approach which lead to sing in patients
into COVID areas; MPMP: Medical staff fear to treat COVID-19 patients; PPST: Prioritizing COVID-19 diagnosis over other life-threatening illness
the patient presented; SARS-CoV-2: Type 2 Coronavirus Severe Acute Respiratory Syndrome; COVID: Corona Virus Disease; ACE2: Angiotensin
Converting Enzyme 2; MERS: Middle East Respiratory Syndrome

J Surg Open Access | JSOA 1

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Introduction tissue. Time and elevated D Dimer counted in day 10-14 of patients
who did not survive. It has been reported that a high D-Dimer level
World Health Organization (WHO) baptized the new disease as
(>0.5 mcg/ml) is associated to a higher death risk (59.6%). An initial
“disease by coronavirus 2019” (COVID-19) and the taxonomy virus
rise in fibrinogen levels have also been reported with a subsequent
committee as SARS-CoV-2 (Severe Acute Respiratory Syndrome)
decrease in patients with high mortality [8,9].
The disease by SARS-CoV-2 virus is a constellation of symptoms
with manifestations on the respiratory, gastrointestinal, hepatic, COVID-19 could induce arterial and venous thrombosis, with
cardiovascular and nervous systems. With more than two hundred a higher incidence on severe illness [9]. Arterial thrombosis is
thousand deaths in Mexico [1,2]. occasionally observed due to the higher velocity and pressure
compared to the venous system. Cases with high mortality sequels
We are upon a new health scenario created by the pandemic.
have reported myocardial infarction or intestinal ischemia. Acute
Traditional view around acute abdomen approach should be changed,
with a remark on a thorough medical history in all attention levels. thrombosis of extremities requiring surgical treatment, have also been
Due to lack of information and fear, there has been a delay on optimal detected [10,11].
care windows in surgical cases. Leading to the presentation of advance Some other reports state that 31% of critical SARS COV 2 patients
and more complicated cases, hence, rising morbidity and mortality present a vascular complication, with pulmonary thrombosis in 81%
rates. of them [9].
Up to date, Dr. Felipe Martinez Lomakin from Andres Bello Up to 10% COVID-19 positive patients begin their illness with
University, has reported the infection caused by the new coronavirus digestive symptoms such as diarrhea, nausea and abdominal pain.
strains, as an acute respiratory distress syndrome; leading with a Abdominal pain could be confused with pancreatitis or abdominal
massive inflammatory response due to immune reply against the virus. sepsis etiologies. 80% of the patient’s present lymphopenia and mild
COVID-19 is a single chained enveloped ARN. The complete thrombocytopenia in worst prognostic scenarios; reporting also a
sequence of its genome has classified it on the Betacoronavirus genre, non-specific increase in D dimer. Procalciton in has been reported to
and Coronavirinae subfamily. A similar genome to bat and pangolin increase in up to 5% of the cases, whereas C reactive protein has a
coronavirus has suggested them as the virus main and intermediate direct relationship with prognosis and disease severity.
hosts in nature [3,4]. It seems to interact through the trimeric S Mild to moderate abdominal pain is probably related to the
glycoprotein with the Angiotensin-Converting Enzyme 2 (ACE2) with diminished oxygen concentration in blood which could lead to
a structural rearrange which allows viral fusion to human host cells intestinal ischemia, digestive bleeding, pain, ileum, pancreatitis, and
[4]. other non-specific manifestations [10].
The virus has been found in nostrils, saliva, sputum, throat, Moreover, other reports have shown alleged COVID related
blood, bile and feces. It has also been reported within respiratory appendicitis, treated with medical management and confirmed with
and gastrointestinal tract cells. There are many hypothesis about virus detection on feces.
transmission mechanisms [3].
The mortality overall index has been reported in 24.5%; where
The coronavirus S protein acts like a key in the cell’s receptor
thrombotic events (43.2%) were in the higher category: pulmonary
allowing it to enter its host and start replication. The more receptor a
embolism in 3.2%, arterial thrombosis in 11.1% (1.6% ischemic stroke,
cell has, the more likely it is to generate infection.
8.9% MI, and 1% systemic thromboembolic event). With a consequent
There have been hypothesis about why the male population is more rise on ICU patients with 29.4% (venous 13.6, arterial 18.6%) [12].
vulnerable to COVID-19. Recent studies reveal that higher blood Some other patients got worse very fast (within minutes).
levels of ACE2 could increase COVID-19 activity the host’s cells [5].
Approaching strategies are different among institutions and may
The virus adheres to the alveolar epithelial cells through its spike probably change as long as we learn more about this disease.
surface protein which engages to the ACE2 over the cell membrane
In ICU units of the Cleveland Clinics, DVT was detected on 25-30%
[5]. ACE2 works as a receptor after the spike protein activation by the
while Cui et al reported a 25% incidence in sever COVID pneumonia
transmembrane protease serine [2]. Once inside the cell, the virus
cases [13]. Maatman reported up to a 25% of prophylaxis failure
presents fast replication leading to a high viral load [5,6].
against DVT [14,15].
The disease has a higher morbidity and mortality in advanced age
and patients with comorbidities such as diabetes, hypertension and Other key factors for thrombosis presentation are a sedentary
vascular disease. lifestyle, age above 70 years, overweight, oncologic disease and
coagulopathies.
Severe cases have shown an elevated cytokine release and activation
characterized by higher levels of IL-1, IL-6, tumor necrosis factor, The most frequent vascular manifestation on COVID-19 patients
and other minor cytokines; this activity creates cellular reaction is deep vein thrombosis. Pathologic reports of COVID-19 patients
on endothelium, platelets, monocytes and other tissues. A rise on have found disseminated clots and micro hemorrhages mainly on the
thrombin generation and a decrease on anticoagulant factor leads to respiratory system [14].
a prothrombotic state. Methods
Coagulopathy associated with COVID-19 is related to severe An ambispective, observational, descriptive study was carried out
disease and increased mortality [7].
since the official COVID-19 pandemic establishment with patients
Complement activation contributes to pulmonary damage and treated in the angiology and general surgery units in the hospitals
other organic failures [8]. Microvascular thrombosis could be specific Dr. Antonio Fraga Mouret (IMSS) and Dr. Dario Fernandez Fierro
to COVID-19 by its affinity for ACE2 in respiratory and vascular (ISSSTE).

Citation: Torrejón-Hernández CA, Bizueto-Rosas H, Galván MAP, Trujillo-Araujo AK, Carrillo FJC, et al. (2021) COVID 19 and its Repercussions
on Vascular and Abdominal Medical Emergency Scenario. Interinstitutional, Multidisciplinary Approach. J Surg Open Access 7(3): dx.doi. 2
org/10.16966/2470-0991.243
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Journal of Surgery: Open Access
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Medical attention delaying causes were assorted among most without apparent risk factors. One death without risk factors, neither
frequent vascular and abdominal consultation diagnosis. These confirmed COVID 19 diagnosis (Image 1). 2 MI, one pulmonary
causes were divided in: Patient discomfort/fear to assist a medical embolism, one common carotid thrombosis, and 2 DVT.
consultation (M), misdiagnosis that classified a patient into a COVID 8 patients presented lower extremity advanced arterial disease,
area (DE), Medical personnel discomfort/fear to do diagnostic work 3 were amputated and 5 surgically explored. Later reporting 100%
up (MPMP), and focusing on COVID-19 diagnosis disregarding main mortality due to systemic complications. 4 patients presented with
pathology for which the patient needed medical attention (PPST). arterial disease in upper extremity from which 2 were amputated and
Predominant symptoms and complications were evaluated in each 2 treated with anticoagulation with good recovery.
pathology. Most frequent comorbidities were: Type 2 Diabetes Mellitus (34.7%),
Essential hypertension (30.4%), type 2 diabetes and hypertension
Results (27.1%), obesity (1%). Associated risk factors in deceased were type 2
A total of 57 patients were included, 22 of vascular etiology (Group diabetes (13%), diabetes and hypertension (8.6%), liver failure (4.5%),
1, Table 1) and 35 from surgical etiology (Group 2, Table 2). with hematologic comorbidities (4.5%); any comorbid disease (21.7%).
In group 1, 16 men (average age 60.7, ranging from 16 to 87 years) Group 2 analysis included 35 patients, 20 males and 15 females
and 6 women (average age 56.6, ranging from 52 to 67 years) (Table 3) ranging from 35 to 88 years. Reporting 7 male and 5 female deceased,
with 54.5% COVID-19-positive PCR. 7 deaths (6 men and 1 woman), 45.5% between 40 and 59 years. 30% of the mortality rate presented
4 of them COVID19-positive. type 2 diabetes and hypertension while 60% had essential hypertension.

During group 1 analysis, 8 patients were admitted with COVID-19 Five patients were diagnosed with COVID-19 in group 1. Whereas
from which PCR test confirmed 7 of them. 3 patients presented SARS in group 2; 21 patients resulted positive, 5 unspecified, 8 negative and
COV 2 so their vascular diagnosis came in second term. 8 had a one was pending to this article’s publication.
delayed attention to COVID-19 symptoms, by administrative reasons. Seven appendectomies were performed, none diagnosed at
One patient received delayed medical attention due to fear/discomfort the beginning; two required hemicolectomies and ileo-transverse
of going to a hospital. Initial vascular diagnosis was performed in 17 anastomosis, three were managed with primary closure, and one
patients: 2 mesenteric thrombosis, 2 aortic and vena cava thrombosis presented enteroatmospheric fistula which later required ileostomy

Group 1: Percentage of patients who were seen on time and of those who were seen late for various causes secondary to the COVID pandemic.

Group 2: Percentage of patients who were seen on time and of those who were seen late for various causes secondary to the COVID pandemic. 

Citation: Torrejón-Hernández CA, Bizueto-Rosas H, Galván MAP, Trujillo-Araujo AK, Carrillo FJC, et al. (2021) COVID 19 and its Repercussions
on Vascular and Abdominal Medical Emergency Scenario. Interinstitutional, Multidisciplinary Approach. J Surg Open Access 7(3): dx.doi. 3
org/10.16966/2470-0991.243
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Table 1: COVID 19 effects on medical/surgical treatment in group 1.

Total 22 22
Covid-19 related 20 20
Fear 1 9
Deferred by COVID severity 3 3
Administrative related delay 8
Adequate approach
2 2
and treatment
COVID 19 related delay 20 20
Patient´s COVID concern delay 9
Deferred by severity COVID 3
Administrative issues: fear of medical and
paramedical personnel 8

Table 2: Group 2 COVID 19 effects on medical/surgical treatment in

group 1.
Total 35
COVID related delay 19 19 100
Patient´s COVID concerns delay 16 13 68.4
Deferred by COVID
1 5.2
severity
Administrative related delay 5 26.3
Adequate approach
16 Image 2: Incarcerated hernia with intestinal perforation.
and treatment

Four acute perforations; 3 subjects showed intestinal perforation

and two of them were initially treated for severe COVID-19 symptoms.
One patient reported a perforated gastric ulcer who in spite of marked
abdominal symptoms, came to delayed treatment due to pandemic
concerns and died during hospital stay.
A patient with incarcerated hernia presented advanced stages of
necrosis and perforation due to pandemic concerns, undergoing
intestinal resection and anastomosis. Later, anenteroatmospheric
fistula was observed and a second intervention and ileostomy was
required (Image 2).

Discussion
Thrombosis has been reported as one of the main complications in
COVID-19 patients.
The patients have been stigmatized due to the lack of information
Image 1: Angiotomography, 40-year-old male with aortic cava available.
thrombosis. Without risk factors. Probable COVID 19, deceased. Even when the main COVID-19 symptoms focus on respiratory
system; a fifth of the patients present gastrointestinal and/or vascular
manifestations.
and open abdomen treatment. Five patients were self-medicated in
order to avoid hospitals due to the pandemic while 2 presented initial Surgical acute abdomen requires a fast and accurate approach
diagnosis of COVID-19 taking abdominal symptoms to secondary which was delayed because health system is focused on the pandemic.
term. Vascular thrombosis cases, representing a functional risk, require
Two patients with gallbladder etiology were admitted for delayed an immediate response which was also delayed for pandemic
treatment due to concerns about the pandemic, being later diagnosed concern.
with COVID-19. One of them required an exploratory laparotomy due
Appendicitis mortality
to biliary peritonitis, and died later due to septic complication. The
second patient presented an infected gallbladder which was removed Present mortality: the probability of dying due to a non-complicated
laparoscopically. appendicitis is lower than 0.1% [16].

Citation: Torrejón-Hernández CA, Bizueto-Rosas H, Galván MAP, Trujillo-Araujo AK, Carrillo FJC, et al. (2021) COVID 19 and its Repercussions
on Vascular and Abdominal Medical Emergency Scenario. Interinstitutional, Multidisciplinary Approach. J Surg Open Access 7(3): dx.doi. 4
org/10.16966/2470-0991.243
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Table 3: Risk Factors, Affected Sites, and Treatment.

Age Average Most affected age group Range Total

Male 60.7 50-69 16-87 16
Female 56.6 52-67 20-82 6
HAS 0.3
DM2 34-7%
Obesity 0.7
Smoking 0.3
Positive PCR 0.55
Risk Factors
None 7(31.8%)
less than 2 0.35
3 or more 0.3
Sites
Arterial MsIs 17
Venous MsIs 2
Carotid 1
Coronary Disease 2
Pulmonar 1
Abdomen 2
Sings/symptoms of Covid
8
Arterial and Venous Thrombosis
Cava/aorta 2
Treatment
Delayed COVID severity (PSST)
3
Administrative delay (DE/MPMP)
8
Fear related delay (M)
9
Amputations Early Delayed deferred Expectant Mortality
3 3
Arterial exploration 5 5
Arterial disease
Upper limbs 2 2 0

Appendicitis could be a severe disease if it is not resolved in early Gallbladder resection mortality
stages, presenting a morbidity of 37% and mortality of 1% [17].
In an emergency scenario, death rate in cholecystectomy for
Mortality in open appendectomy is reported between 0.3 and 11% acute gallbladder disease is reported between 0.8 to 2% [21]. Biliary
[18]. peritonitis is a rare complication reported in 11% of acute disease with
Perforation rate in delayed treatment of appendicitis is reported a 70% mortality rate [22].
about 34% with a mortality of 0.5% [19]. Mortality in embolectomy
Mortality in hemicolectomy secondary to complicated Embolectomy death rate ranges from 20 to 25% ending in
appendicitis amputation in up to 20% of the cases [23]. Other authors as Pérez-
Approximately 1.7% of complicated appendicitis requires right Prada KJ, et al. Torres have reported late embolectomy (10 to 14 hours
hemicolectomy with primary anastomosis. Presenting complications after clotting event) with an amputation rate of 32.3% and a 10%
in 70% of the cases, with a mortality 0f 5% [20]. mortality rate; the Sierra Juarez group reported a 16% amputation rate

Citation: Torrejón-Hernández CA, Bizueto-Rosas H, Galván MAP, Trujillo-Araujo AK, Carrillo FJC, et al. (2021) COVID 19 and its Repercussions
on Vascular and Abdominal Medical Emergency Scenario. Interinstitutional, Multidisciplinary Approach. J Surg Open Access 7(3): dx.doi. 5
org/10.16966/2470-0991.243
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with only 6% mortality rates. They demonstrated an average time of 12 2. A relatively young and productive country with a main
days between clotting event and treatment [24,25]. working activity outside an office environment
Moreover, pneumonia has been reported as the main post 3. Concurrence of other pandemics, such as obesity and diabetes
amputation complication [30 to 40%], with a 20% mortality rate. In
4. Smoking rate is among the highest worldwide
patients with arterial disease along with COVID-19 symptoms and
positive test, the mortality rate was 87.5%. COVID-19 most affected population ranged between 50 and 60
years in group 1, with average age: 60.7 mean: 54, average age at
Some of the socio-demographic variables to consider were
death: 52.1 years (Graph 1) similar to national statistics (Graph 2).
1. Education Whereas, in group 2 the average age was 59 years with a mean age

Table 4: Risk factors, affected sites, and treatment.

Age Average Most affected age group Range Total

Male 62.5 70-88 35-88 20
Female 45.4 40-59 22-82 15
HAS 0.6
DM2 0.3
Obesity 0.7
Smoking 0.6
Positive PCR 0.6
Risk Factors
None 9
less than 2 2
3 or more 23
Sites
Arterial MsIs 6
Venous MsIs 1
Carotid
Coronary Disease
Pulmonar
Abdomen
Sings/symptoms of Covid
Arterial and Venous Thrombosis
Cava/aorta 2
Treatment
Delayed COVID severity (PSST) 1
Administrative delay (DE/MPMP) 5
Fear related delay (M) 13
Procedure Early Delayed Deferred Expectant Mortalilty
Amputations 2 4 1
Appendectomy 7
Hemicolectomy 2
Cholecistectomy 2
Cholecistectomy+additional
1 1
procedures
Laparotomy 4
Intestinal Tract Perforation
Intestinal 3
Gastric 1 1
Incarcerated hernia 1

Citation: Torrejón-Hernández CA, Bizueto-Rosas H, Galván MAP, Trujillo-Araujo AK, Carrillo FJC, et al. (2021) COVID 19 and its Repercussions
on Vascular and Abdominal Medical Emergency Scenario. Interinstitutional, Multidisciplinary Approach. J Surg Open Access 7(3): dx.doi. 6
org/10.16966/2470-0991.243
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Conclusions
“Management strategies vary a lot among institutions and it is
highly probable to keep changing as we learn more about this disease”
[17].
We have a long road ahead of us before we can say we are fully
ready to keep up with this new medical scenario. We should not forget
that state of the art and high quality medicine practice must focus on
prophylaxis and prevention of as many complications as we can foresee.
A disease treatment only philosophy has to be considered obsolete so
we have to see the big picture, create educational simulations and have
backup plans to deal with the improbable, become anti fragile.

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Citation: Torrejón-Hernández CA, Bizueto-Rosas H, Galván MAP, Trujillo-Araujo AK, Carrillo FJC, et al. (2021) COVID 19 and its Repercussions
on Vascular and Abdominal Medical Emergency Scenario. Interinstitutional, Multidisciplinary Approach. J Surg Open Access 7(3): dx.doi. 7
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Citation: Torrejón-Hernández CA, Bizueto-Rosas H, Galván MAP, Trujillo-Araujo AK, Carrillo FJC, et al. (2021) COVID 19 and its Repercussions
on Vascular and Abdominal Medical Emergency Scenario. Interinstitutional, Multidisciplinary Approach. J Surg Open Access 7(3): dx.doi. 8
org/10.16966/2470-0991.243