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IntroductionDuring the coronavirus 2019 (COVID-19) pandemic, it is clear this novel coronavirus generates a markedly hypercoagulable state Thrombotic events are driven by a severe pro-inflammatory response to COVID-19 as well as hypoxia manifested in severe illness Whilst the commonest thrombotic events associated with COVID-19 remain pulmonary embolism, myocardial infarction and deep vein thrombosis, intra-abdominal thromboses are less well characterised, but are illustrated in this case Case PresentationA 42 year-old Eastern European man with chronic hepatitis B (undetectable viral load on Entecavir;eAg negative;sAg positive;alanine transaminase (ALT) 34 IU/l;FibroScan 7 4kPa Nov 2019), and prior trauma-related splenectomy (1998), developed pyrexia and cough on the 23rd March 2020 His fever resolved on symptom-day 10, following a course of Amoxicillin, then Doxycycline, for presumed bronchitis from his GP On symptom day 14, he woke with constant non-radiating right hypochondrial pain The following day he presented to his local hospital and was managed conservatively for suspected biliary colic (no imaging) His bilirubin was 23µmol/l, ALT 55 IU/l, alkaline phosphatase (ALP) 66 IU/l and albumin 31 g/l Having been discharged with analgesia, he re-presented to his GP with ongoing worsening pain on symptom-day 25 His bilirubin was now 33µmol/l, ALT 31 IU/l, ALP 74 IU/l and albumin 35 g/l Abdominal ultrasound suggested portal vein thrombosis (PVT) with collateralisation He was subsequently admitted by the general surgeons and a CT-abdomen demonstrated loss of enhancement of the entire length of the portal vein and proximal superior mesenteric vein, with expansion and surrounding inflammatory stranding consistent with thrombosis Concurrent CT-chest demonstrated bilateral patchy ill-defined ground glass opacities with basal predominance, worse on the right, consistent with COVID-19 infection Whilst his RT-PCR was negative, subsequent SARS-CoV-2 antibody serology was positive His thrombophilia screen excluded inherited and acquired thrombophilia such as antiphospholipid syndrome His repeat triple phase CT-abdomen 6 weeks later, confirmed an established PVT with collateralisation extending into the upper abdomen Having been commenced on Apixaban 5 mg BD in April 2020, he is currently asymptomatic DiscussionThis is one of the first cases of likely COVID-19-related porto-mesenteric thrombosis to be described in the UK Similar cases have been described in France and Italy in non-cirrhotic patients With almost a fifth of COVID-19 infections presenting with gastrointestinal symptoms, and a recent meta-analysis suggesting 9 2% developing abdominal pain, our threshold for performing liver ultrasound with doppler assessment must be lower to avoid missing this reversible complication of COVID-19
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