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Vol. 99. Issue 6.
Pages 477-478 (June - July 2021)
Vol. 99. Issue 6.
Pages 477-478 (June - July 2021)
Letter to the Editor
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Reply to the Letter to the Editor “Pathogenesis of pneumoperitoneum in COVID-19 patients”
Réplica a la Carta al Director «Etiopatogenia de neumoperitoneo en pacientes COVID-19»
Ignacio Antonio Gemio del Reya,
Corresponding author

Corresponding author.
, Roberto de la Plaza Llamasa, José Manuel Ramiab,c, Aníbal Armando Medina Velascoa
a Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Guadalajara, Guadalajara, Spain
b Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario de Alicante, Alicante, Spain
c Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
Related content
Cir Esp. 2021;99:476-710.1016/j.cireng.2021.03.012
Javier A. Cienfuegos, Ana Almeida, Daniel Aliseda, Fernando Rotellar
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To the Editor,

As stated by Cienfuegos et al.,1 the incidence of non-surgical spontaneous pneumoperitoneum in positive COVID-19 patients is becoming more frequent as the incidence of infection grows exponentially,2,3 in addition to other types of gastrointestinal manifestations. Inflammatory bowel processes are being described related with direct damage to the mucosa mediated by receptors as well as ischemic processes secondary to splanchnic thrombosis.4,5

In our patient,6 the evolution of fibrinogen ranged from 370 mg/dL upon admission to the ICU and 180 mg/dL upon discharge. As for d-dimer levels, these peaked at 35.05 mg/L and had dropped to 2.83 mg/L at discharge.

Based on these parameters, we cannot categorically rule out that spontaneous pneumoperitoneum was caused by direct damage to the mucosa or by intestinal ischemia secondary to splanchnic thrombosis, especially due to the limited number of cases published to date. Even so, this seems unlikely, since the CT scan in our case did not show intestinal pneumatosis, and tomography is a very sensitive test.

In the original publication by Cienfuegos et al.,2 it is striking that the patient initiated enteral nutrition (EN) on day 2 of the ICU stay. On day 8, with no signs of ischemia, such as elevated lactic acid, the patient had diarrhea, abdominal distension, foul-smelling discharge from the nasogastric (NG) tube, and a CT scan detected intestinal pneumatosis (IP). This required the cessation of enteral nutrition, after which the symptoms were resolved. Several cases of IP associated with EN7,8 have been published in the literature, with complete resolution of symptoms after its withdrawal, so the direct association with COVID-19 infection is not guaranteed in this case.

The same occurred in the second published case report.3 The finding of spontaneous pneumoperitoneum occurred in the context of a positive COVID-19 patient with no associated respiratory symptoms. It cannot be ruled out that the pneumoperitoneum and intestinal pneumatosis were due to viral infection, but it would be interesting for the authors of the article to rule out other common causes of spontaneous pneumoperitoneum, such as cystic intestinal pneumatosis.9–11 In fact, the authors of the article acknowledge that more case series are required to support this statement.

Thus, it is clear that COVID-19 infection involves intestinal manifestations,12 which requires further study in large series. Even so, we must bear in mind that many of these manifestations may be due to prevalent diseases and not related to the viral infection. In short: not everything that happens in COVID-19–positive patients is due to the infection itself.

J.A. Cienfuegos, A. Almeida, D. Aliseda, F. Rotellar.
Etiopatogenia de neumoperitoneo en pacientes COVID-19.
J. Kielty, W.P. Duggan, M. O’Dwyer.
Extensive pneumatosis intestinalis and portal venous gas mimicking mesenteric ischaemia in a patient with SARS-CoV-2.
Ann R Coll Surg Engl, 102 (2020), pp. E145-E147
A.J. Láinez Ramos-Bossini, M. del C. Pérez García, M.Á. Pérez Rosillo, R. Gálvez López.
Spontaneous pneumoperitoneum and pneumatosis intestinalis as sole manifestations of a COVID-19 infection. An extremely rare complication.
Rev Esp Enferm Dig, 113 (2021), pp. 141-142
K. Mönkemüller, L.C. Fry, S. Rickes.
COVID-19, coronavirus, SARS-CoV-2 and the small bowel.
Rev Esp Enferm Dig, 112 (2020), pp. 383-388
F. Xiao, M. Tang, X. Zheng, Y. Liu, X. Li, H. Shan.
Evidence for gastrointestinal infection of SARS-CoV-2.
Gastroenterology, 158 (2020), pp. 1831e3-1833e3
I.A. Gemio del Rey, R. de la Plaza Llamas, J.M. Ramia, A.A. Medina Velasco, D.A. Díaz Candelas.
Non-surgical spontaneous pneumoperitoneum in a COVID-19 positive patient with severe bilateral pneumonia.
T. Matsuoka, K. Kobayashi, A.K. Lefor, J. Sasaki, H. Shinozaki.
Mesenteric ischemia with pneumatosis intestinalis and portal vein gas associated with enteral nutrition: a series of three patients.
Clin J Gastroenterol, 13 (2020), pp. 1160-1164
N. Brandi, A. Parmeggiani, S. Brocchi, C. Balacchi, C. Gaudiano, R. Golfieri.
Conservative treatment and radiological follow-up in a case of pneumatosis intestinalis associated with enteral tube feeding.
Minerva Gastroenterol Dietol, (2020),
D. Gomez de Antonio, P. Gámez, J. Garijo, A. Varela.
Causa intratorácica poco frecuente de neumoperitoneo espontáneo.
F.J. Frías Ugarte, F. Aranda Lozano, M.L. Almendral López, J.M. Bordas Rivas, J.T. Lejarcegui Achicallende, F.J. Ibáñez Aguirre.
Neumoperitoneo espontáneo asociado a neumonía.
F.J. González Rodríguez, J.A. Puñal-Rodríguez, J. Paredes-Gotoré, A. Beiras.
Neumoperitoneo espontáneo secundario a neumatosis quística intestinal.
Cir Esp, 86 (2009), pp. 111-121
K. Lui, M.P. Wilson, G. Low.
Abdominal imaging findings in patients with SARS-CoV-2 infection: a scoping review.
Abdom Radiol (NY), 14 (2020), pp. 1-7

Please cite this article as: Gemio del Rey IA, de la Plaza Llamas R, Ramia JM, Medina Velasco AA. Réplica a la Carta al Director «Etiopatogenia de neumoperitoneo en pacientes COVID-19». Cir Esp. 2021;99:477–478.

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