Acute acalculous cholecystitis during severe COVID-19 hospitalizations

ABSTRACT

INTRODUCTION: Reported gastrointestinal manifestations from COVID-19 include transaminitis, acute hepatitis, and mild pancreatic injury;but biliary manifestations have not been reported. In this case report, we describe two cases of acute acalculous cholecystitis (AAC) in patients with prolonged hospitalizations for COVID-19. CASE DESCRIPTION/METHODS: A 60-year-old woman with hypertension, type 2 diabetes and hypothyroidism and separately, a 68-year-old man with hypertension, hyperlipidemia, asthma, and obstructive sleep apnea were both admitted during the peak of the SARS-CoV2 pandemic in New York City for acute hypoxic respiratory failure secondary to acute respiratory distress syndrome (ARDS) from COVID-19 pneumonia. Both patients were diagnosed with acute acalculous cholecystitis on a general medicine service after a prolonged hospital course including mechanical ventilation (Table 1). Both patients improved clinically after placement of a cholecystostomy tube and antibiotics. DISCUSSION: Acute acalculous cholecystitis accounts for 2-15% of all cases of acute cholecystitis and results from ischemia and stasis of the gallbladder, often from critical illness. Whereas AAC has been described in a variety of clinical settings including trauma, recent surgery, sepsis and enteral fasting, it has not been described in the context of severe COVID-19 infection requiring prolonged hospitalization. It is unclear whether AAC is a direct manifestation of the SARS-CoV2 virus directly or a consequence of prolonged illness from the virus. Notably, both of our patients had long ICU stays for COVID-19 but were diagnosed with AAC when they were more clinically stable on a non- ICU medicine service, suggesting that this manifestation may not be merely from severe critical illness alone. In patients with a strong clinical suspicion, including new leukocytosis and right upper quadrant pain or bacteremia with gastrointestinal pathogens, providers should not be reassured by non-diagnostic CT or ultrasound imaging because none of these imaging modalities have good sensitivity for AAC. COVID-19 is proving to have multiorgan manifestations during its disease course and providers should not fail to recognize biliary complications such as acute acalculous cholecystitis. Further studies are necessary to assess the incidence of AAC in patients with prolonged hospitalization from COVID-19. (Figure Presented).