The mortality and morbidity associated with COVID-19 have raised increasing concerns around the world. Although efforts to recognize and manage COVID-19 have been focused on evaluating the respiratory complications, it has now become aware that COVID-19 infection occasionally involves atypical presentations, such as gastrointestinal manifestations and thrombotic complications [1]. Many Studies have reported that patients infected with COVID 19 are prone to coagulopathy, however, the exact mechanism for the thrombosis is yet to be clarified [2]. Acute mesenteric ischemia, especially superior mesenteric artery (SMA) occlusion, is a critical condition with a high mortality rate of 60–80% which requires urgent diagnosis and treatment [1]. Despite growing concerns about these life-threatening thrombotic complications, early diagnosis is challenging because of variable symptoms, non-specific laboratory investigations, and nonspecific radiological findings. Early diagnosis is necessary to commence appropriate treatment, whereas diagnostic delay contributes to increased morbidity and mortality. In this case, we depict the abdominal CT findings of an 82- year-old female patient with COVID-19 who developed severe abdominal pain and was diagnosed with severe life-threatening complications secondary to superior mesenteric artery thrombosis. The main objective of this case to emphasize treating physicians and surgeons about the high clinical suspicion of acute mesenteric ischemia in COVID-19 patients with acute abdominal pain and start early treatment without delay.

A 82-year-old female patient was admitted to the emergency department (ED) with shortness of breath and increasing severe epigastric and central abdominal pain accompanied by vomiting and diarrhea. She was tested positive for SARS -CoV-2 19 by real-time polymerase chain reaction (RT-PCR) in the community. Apart from Bronchial asthma, hypertension, hypothyroidism there were no past medical history of thromboembolic events. On physical examination, the patient was afebrile, had increased respiratory rate (24 breaths per minute) with oxygen saturation of 90 % on room air. Her saturation improved to 96% with 2 liters of oxygen, heart rate was at 85 beats per minute and blood pressure was 155/85.There was an epigastric tenderness without guarding or rigidity. Laboratory examination revealed neutrophilic leukocytosis (21,500/ul white cells with absolute neutrophils 19,700/ul), normal platelets, elevated C-reactive protein (CRP) at 291 mg/l (standard value: < 8 mg/l) and increased creatinine 299 micromol/l with a glomerular filtration rate of 33 ml/min. The liver enzymes and the lipase levels were normal. Following admission, her white cell count (WCC) and CRP continued to rise in which the results were 34,900 /ul and 388 mg/l respectively. However, her blood lactate levels were continued to be less than 2 mmol/l. Her coagulation profile on admission was INR 1.3, PT 13, APTT 43. No acute pathology was detected on Computed Tomography (CT) of the abdomen, which was performed without intravenous contrast (given the global contrast shortage at the time). She was managed with intravenous remdesivir and dexamethasone for her moderate COVID infection. Her abdominal pain was gradually settled in the initial 2 days following admission, however it started to get worsen on the third day of admission with associated worsening shortness of breath and constipation. Examination revealed evidence of severe epigastric and periumbilical tenderness with significant guarding and rigidity. Repeat multiphase CT performed with iodinated contrast demonstrated superior mesenteric artery (SMA) clot, which was non- occlusive proximally, becoming occlusive in the distal branches. Interval development of a long segment of mild small bowel dilatation with a segment of hyperdense mural thickening, mesenteric oedema and a small volume of free fluid raised concern for ischaemic enteritis. There were no features of advanced small bowel ischemia or infarction. Furthermore, CT of the chest revealed evidence of bilateral pulmonary emboli, which were appeared moderate in volume suggested significant coagulopathy. Urgent medical treatment with unfractionated heparin infusion started for anticoagulation. Given her CT abdominal finding on the time of clinical deterioration was not characteristic of bowel wall necrosis and the lactate was remained in the lower levels the surgeons decided to continue close monitoring for the next 24 hours. Unfortunately, she was rapidly deteriorated overnight, and she was taken to the theater on the following day where she underwent a 1.2 meters of small bowel resection. She also underwent a thrombo-embolectomy of the SMA thrombus during the surgery. A relook laparotomy on the following day revealed further ischemic segments and another 70 cm of her bowel was resected. Post operatively she had significant hematemesis and was performed an urgent gastroscopy. This revealed widespread gastric ulceration that unfortunately was not amenable to any endoscopic intervention. Given her significant deterioration, the decision was made to change the direction of care to a comfort base approach. She passed away peacefully following end of life care treatment.