Authors’ response to: “About the scientific letter: Suspected acute abdomen as an extrapulmonary manifestation of Covid-19 infection”

To the Editor,

We have read with interest the comments made by Dr. F. Pardo Aranda in his Letter to the Editor. We appreciate the points made.

Firstly, we insist that our aim was to inform about the gastrointestinal involvement associated with COVID-19 in the context of patients requiring urgent surgery.

The original title of the accepted publication was Abdominal bloating and gastrointestinal symptoms as an extrapulmonary manifestation in a COVID-19+ patient, which was later replaced with Suspected Acute Abdomen (…), after review by the Editorial Committee.

In his letter, Dr. Pardo states that it does not conform to usual practice, but General Surgery specialists assess ​​abdominal pain and/or gastrointestinal symptoms.¹ The patient was referred to our hospital from Primary Care in order to rule out acute abdomen, at which time the patient was triaged to our General Surgery Emergency Unit. This could also be the case of inadequate protection against patients presenting in the emergency department with gastrointestinal symptoms associated with COVID-19 and mild or no pulmonary symptoms; some 10% present chest radiographs without pneumonia, as in the case reported.²

At that moment, we believed that triage and treatment protocols should be followed for patients referred from the emergency room. Given the epidemiological suspicion, the patient presented signs that led us to consider the possibility of COVID-19, and this immediately allowed us to pursue the diagnosis and isolate the patient. The presentation of lymphopenia and elevated PCR on the laboratory tests were signs to suspect a poor COVID-19 prognosis,³ requiring a differential diagnosis with other pathologies such as sepsis of abdominal origin.

Computed tomography (CT) scan of the abdomen ruled out urgent surgical pathology and showed sensitivity to rapidly identify pulmonary alterations due to COVID-19.^4,5 Based on the findings, the differential diagnosis needed to be confirmed. In this specific case, the abdominal radiograph showed dilation of the loops, so the possible causes of acute abdomen to be ruled out included volvulus, intestinal obstruction, and colitis. It is important to guarantee early treatment of patients who initially consult for gastrointestinal signs, since they may later present respiratory symptoms.⁶ In addition, another reason for the need to identify early suspicion is to avoid dissemination among other patients who come to the Surgical Emergency Unit for other reasons and to avoid infection of healthcare workers, who are the gateway to the healthcare system and who are often unprotected.

In coming months, we will surely see the results of international cohort studies and clinical trials that will enable better protocols to be proposed based on scientific evidence.⁷ We have adapted the protocols according to the experience described. Furthermore, it will be necessary to consider whether the current system functioning in the emergency services of many hospitals is adequate. Properly trained multidisciplinary groups may also be required for triage in potentially surgical pathologies.¹

Surely new challenges are ahead, such as the transformation not only of traditional departments but also of hospitals and our healthcare system. Currently, we are already working along this line in our hospital while we continue caring for our patients.