COVID-19 appears to have significant extrapulmonary complications affecting multiple organ systems. Critically ill patients with COVID-19 often
develop gastrointestinal complications during their hospital stay, including bowel ischemia, transaminitis, gastrointestinal bleeding, pancreatitis, Ogilvie syndrome, and severe ileus.

Whether the high incidence of gastrointestinal complications is a manifestation of critical illness in general or is specific to COVID-19 remains unclear. The authors compared the incidence of gastrointestinal complications of critically ill patients with COVID-19–induced acute respiratory distress syndrome (ARDS) vs comparably ill patients with non–
COVID-19 ARDS using propensity score analysis.

A total of 486 patients with ARDS met eligibility criteria, of which 244 had non–COVID-19 ARDS and 242 had COVID-19 ARDS. This report includes data from 141 patients with COVID-19 (58%) whose overall gastrointestinal
complications have been previously described.

The median age of patients was 60.5 years (interquartile range, 48-71) and 62 years (interquartile range, 53-73.5) for patients with and without COVID-19, respectively, and the percentage of males was 66.5% and 54.9%, respectively. Ninety-two patients with COVID-19 and ARDS were propensity score matched to 92 patients with non–COVID-19 ARDS (Table). The etiologies for ARDS among the non– COVID-19–matched cohort were bacterial pneumonia (60%), aspiration (27%), influenza (7%), respiratory syncytial virus infection (2%), and Pneumocystis jiroveci pneumonia (2%).

Patients with COVID-19 were more likely to develop gastrointestinal complications compared with those without COVID-19 (74% vs 37%; P < .001; incidence rate ratio, 2.33 [95% CI, 1.52-3.63]). The difference in incidence was more evident after the third day of critical illness (Figure). Specifically, patients with COVID-19 developed more transaminitis (55% vs 27%; P < .001), severe ileus (48% vs 22%; P < .001), and bowel ischemia (4% vs 0%; P = .04). Three of the 4 patients with COVID-19 and bowel ischemia were taken to the operating room and had intraoperative findings consistent with COVID-19 bowel as previously described in different patients.3 Pathology findings demonstrated fibrin thrombi in the microvasculature underlying areas of necrosis.