Issue: April 2020
Source/Disclosures
Source: Healio Interviews
Disclosures: Ungaro reports he served as an advisory board member or consultant for Eli Lilly, Janssen, Pfizer, and Takeda; research grants from AbbVie, Boehringer Ingelheim, and Pfizer. The other experts report no relevant financial disclosures.
April 29, 2020
11 min read
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‘We’re in This Together’: COVID-19 and Gastroenterology

Issue: April 2020
Source/Disclosures
Source: Healio Interviews
Disclosures: Ungaro reports he served as an advisory board member or consultant for Eli Lilly, Janssen, Pfizer, and Takeda; research grants from AbbVie, Boehringer Ingelheim, and Pfizer. The other experts report no relevant financial disclosures.
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The COVID-19 pandemic has been an unprecedented crisis unlike anything seen in many decades. While infectious disease specialists have been on the front lines since the first outbreak of the disease, as more information comes out, the world is beginning to understand the role the gastrointestinal tract plays in the disease.

According to the CDC, there are now more than 300,000 confirmed cases of COVID-19 in the United States with the number growing every day. States like New York, New Jersey, California and Washington are bearing the greatest burden, but coronavirus has reached nearly every corner of the country and contributed to more than 7,500 deaths nationwide.

Concern about COVID-19 has led to the cancelation of more than three dozen medical conferences, including the leading GI conference, Digestive Disease Week. Event organizers are currently exploring virtual education options for the event.

“Given the logistics that go into organizing a meeting of this size, it will be unlikely that DDW will be able to reschedule the 2020 meeting,” according to a statement on the conference website. “However, in the coming weeks we intend to tap into the innovative spirit of our specialty and share the science and education from our meeting as we are able.”

Mark B. Pochapin, MD, director of the department of gastroenterology and hepatology at NYU Langone Health and president of the ACG, dons PPE to help out with the COVID-19 pandemic.
Source: Photo courtesy of Mark B. Pochapin, MD.

Healio Gastroenterology and Liver Disease has been in contact with GI experts as the data and understanding around the virus have evolved to find out how it impacts patients as well as daily clinical practice.

Role of GI Symptoms

Among the first indications of the involvement of the GI-tract in the transmission of coronavirus were two studies published in Gastroenterology out of labs in China that reported that patients with COVID-19 may experience GI symptoms, as well as the potential for fecal-oral transmission of the virus.

“[Mounting] evidence from former studies of SARS indicated that the gastrointestinal tract (intestine) tropism of SARS coronavirus (SARS-CoV) was verified by the viral detection in biopsy specimens and stool, even in discharged patients, which may partially provide explanations for the gastrointestinal symptoms, potential recurrence and transmission of SARS from persistently shedding humans as well,” Jinyang Gu, MD, of the department of transplantation, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, and colleagues wrote in one of the studies.

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Fei Xiao, MD, PhD, of the department of infectious diseases at the Fifth Affiliated Hospital, Sun Yat-sen University, Guangdong, China, and colleagues found that of 73 hospitalized patients with SARS-CoV-2, 39 patients (25 males and 14 females) tested positive for SARS-CoV-2 RNA in stool. Patients who tested positive for SARS-CoV-2 RNA in stool ranged in age from 10 months to 78 years. Investigators noted the duration time of positive stool was between 1 and 12 days. There were 17 patients who remained positive in stool even after they demonstrated negative in respiratory samples.

In a discussion on the Healio podcast, Gut Talk, Mark B. Pochapin, MD, director of the department of gastroenterology and hepatology at NYU Langone Health and president of the ACG, said that patients with COVID-19 who had GI symptoms as their chief complaint had a longer disease onset but a worse outcome.

“In a study from Wuhan, 15% of patients presented with diarrhea as one of their main chief complaints,” he said. “This information is coming in in real time. It is something we need to know about. We talk a lot about the droplet precautions with coughing and sneezing, but there probably is a component of fecal-oral transmission. We know that virus is alive, and if people aren’t careful about washing their hands, it’s very possible they transmit it in that route.”

Among 204 patients with COVID-19 48.5% reported digestive symptoms.

In that study from The American Journal of Gastroenterology, researchers found that patients who experienced digestive symptoms presented for care later than those with respiratory symptoms (16 ± 7.7 days vs. 11.6 ± 5.1 days; P < .001). They also had a longer duration between symptom onset and viral clearance (P < .001) and were more likely to test fecal virus positive compared with patients who experienced respiratory symptoms (73.3% vs. 14.3%; P = .033).

In another study, published in The American Journal of Gastroenterology, Lei Pan, MD, PhD, from the department of Respiratory and Critical Care Medicine at Binzhou Medical University Hospital and the Second Medical Center & National Clinical Research Center for Geriatric Diseases at the Chinese PLA General Hospital, and colleagues performed a cross-sectional study of 204 patients with COVID-19 by analyzing their laboratory, imaging and historical data.

They found that 48.5% of patients reported digestive symptoms as their main complaint. Compared with patients without digestive symptoms, patients with symptoms had a significantly longer time from onset to hospital admission (7.3 days vs. 9 days). Manifestations in patients with digestive symptoms included anorexia (83 cases), diarrhea (29 cases), vomiting (8 cases) and abdominal pain (4 cases). There were digestive symptoms, but no respiratory symptoms seen in seven cases. Digestive symptoms became more pronounced as the disease severity increased. Patients without digestive symptoms compared with those with symptoms were more likely to be cured and discharged (60% vs. 34.3%).

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“Clinicians should recognize that digestive symptoms, such as diarrhea, may be a presenting feature of COVID-19, and that the index of suspicion may need to be raised earlier in at-risk patients presenting with digestive symptoms rather than waiting for respiratory symptoms to emerge,” Pan and colleagues wrote. “However, further large sample studies are needed to confirm these findings.”

Endoscopy

COVID-19 is disrupting daily life around the world, and common practices of patient care in gastroenterology are no different. In addition to taking extra care to screen patients for the virus, the GI societies joined together to make recommendations about what changes needed to be made for clinical practice.

On March 15, The American Association for the Study of Liver Diseases, The American College of Gastroenterology, The American Gastroenterological Association and the American Society for Gastrointestinal Endoscopy made the “strong recommendation” to reschedule elective, non-urgent endoscopic procedures during the pandemic. They also urged proper use of personal protective equipment for endoscopists who have to go on with urgent and emergent procedures.

“For all endoscopies, we should be using universal precautions, as we’ve always been expected to do,” David Greenwald, MD, director of clinical GI and endoscopy at Mount Sinai and president-elect of ACG, said on Gut Talk. “That includes, gowns, gloves, face mask and a shield. That predates the coronavirus, but it’s even more important than ever because of the concern of droplet spread.”

David Greenwald, MD
David Greenwald

Greenwald said special considerations for endoscopy should be made, including whether or not the endoscopist should wear additional respiratory equipment.

“It’s an open question right now about whether that is required for all endoscopies, but there is growing evidence that it should be recommended,” he said. “For any patients diagnosed with COVID-19 or are under investigation and endoscopy is necessary, an N95 mask should be used in addition to the other gear.”

Mark B. Pochapin, MD
Mark B. Pochapin

Another question is which procedures should continue as normal. Pochapin said on Gut Talk that there are some nuances to this question, but there are some cases where the need for endoscopy is clear.

“If you’re worried about cancer, we’re all in agreement that you should go forward with that,” he said. “But it would be nice if we could come up with consensus guidelines to take it to the next phase. As this wears on, it’s easy to reschedule a week maybe 2 weeks, but if it continues, we need to make sure we’re getting important procedures done, and there isn’t a delay in important diagnoses like colon cancer or others.”

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In a guest commentary, Farhan Quader, MD, of Washington University School of Medicine, and Zachary Smith, DO, of Case Western Reserve School of Medicine, wrote that procedures in the middle ground of semi-urgency take significant vetting.

“Factors including patient age and comorbidities, symptom severity, and risk for disease/symptom progression all are considered when making these decisions, and this review process is labor-intensive,” they wrote.

On Gut Talk, Greenwald provided a relatively simple method of determining whether or not to go on with a procedure.

“Anything that’s going to change management in a significant way in short order is something that should be pursued,” he said. “We’re gastroenterologists and we need to keep doing the things that we’re doing for the patients who have those problems, whether or not there’s a coronavirus pandemic. Some of these emergent and urgent problems are going to continue, and we need to make sure our patients, ourselves and our staff are fully equipped to not become infected while doing those procedures.”

Patient Impact

One of the main concerns about COVID-19 was its impact on immunosuppressed patients, and for many in gastroenterology, that brought to mind patients with inflammatory bowel disease who might be on immunomodulators or other therapies. How would these medications impact them? Would they be more susceptible to the virus?

Edward V. Loftus Jr., MD
Edward V. Loftus Jr.

In a Q&A with Healio Gastroenterology and Liver Disease, our Chief Medical Editor, Edward V. Loftus Jr., MD, from Mayo Clinic in Rochester, Minnesota, made it clear that these patients should not stop taking their medications, in most cases, because the potential drawbacks could be worse than COVID-19 (Read more on this here).

“We don’t want people to stop their IBD meds, because exacerbation of Crohn’s or ulcerative colitis is a real risk,” he said. “The last thing a patient needs right now is to have a flare and end up in a hospital filled with patients with COVID-19. It’s better for that IBD patient to stay on their meds and do all the things that experts are recommending, like washing your hands frequently, avoiding touching your face, and practicing some social distancing.”

In guidance issued in March, the Crohn’s and Colitis Foundation recommended that patients stay on their IBD medications, such as mesalamine or other aminosalicylates. Additionally, they advised patients to check with health care providers if they are taking steroids because some may suppress the immune system. Patients should continue to take immunomodulators and the Jak inhibitor Xeljanz (tofacitinib, Pfizer). They advised patients not to stop taking biologics/biosimilars and to talk to their health care provider if adjustment to medications need to be made.

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To help find answers about how to manage patients with IBD during the pandemic, Mount Sinai and the University of North Carolina launched the Surveillance Epidemiology of Coronavirus Under Research Exclusion-IBD (SECURE-IBD) registry to monitor and report outcomes of COVID-19 in patients with IBD.

“We are trying to understand the impact of IBD medications on the course of the COVID-19, as well as the impact of other comorbidities and disease activity,” Ryan C. Ungaro, MD, a gastroenterologist with Mount Sinai Hospital’s Feinstein IBD Center, told Healio Gastroenterology and Liver Disease in a recent Q&A. “Are IBD patients at higher risk for getting the disease? Also, are they at higher risk for a more severe disease course similar to elderly people with cardiovascular disease or lung disease? This is all unknown currently.”

Ungaro is on the steering committee with Mount Sinai colleague Jean-Frederic Colombel, MD, as well as Mike Kappelman, MD, and Erica Brenner, MD, from UNC. He said researchers will use data from the registry to find out if bad outcomes, like hospitalization or death, are more or less likely in patients with IBD. In the first week of the registry, Ungaro said there were already more than 40 cases reported.

“The ultimate goal is to provide information to GIs and patients to know how to best manage IBD patients in this challenging time so that we are not flying blind,” he said. “It’s been great to see the international medical community, especially in the IBD world, to come together.”

As the rapidly evolving nature of the COVID-19 pandemic moves on, it has brought other dramatic changes to patient care in GI. Greenwald and other experts said that telehealth is becoming more common and more navigable as practices adapt to managing patients in the era of social distancing.

“We have shifted virtually every outpatient visit to a telehealth visit,” Greenwald said on Gut Talk, adding that it keeps people away from a potentially dangerous setting, and as a bonus, patients seem to love it.

William D. Chey, MD
William D. Chey

William D. Chey, MD, director of the GI Physiology Laboratory at University of Michigan Health System, and co-host of Gut Talk, said that improved telehealth services might come out of this pandemic as an overall benefit to the world of health care.

“We’re thinking not just about the ability to bring a GI to interface with their patients, but also bringing a whole suite of services to providers in the field, including nutritional health services and behavioral health services,” Chey said on the podcast. “This has the potential to be one of the great silver linings of this pandemic.”

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If the coronavirus pandemic has proven one thing, it is that a lot of things can change in a short period. The health care community has had to adapt to the rapid change, but Pochapin thinks that, so far, the community has been up to the task.

“This is something we’re all in together,” he said on Gut Talk. “We look toward each other to help. It’s not just about a single institution, or a city or a country. It’s about the world. It’s about all health care providers, all people interested in caring for others, are actually unified in our ability to try and learn from each other and get rid of this thing.” – by Alex Young

Editor’s note: Developments in the COVID-19 pandemic are quickly evolving. Information in this story was up to date at the time of publication. To access the latest updates for practicing clinicians, visit our COVID-19 Resource Center at www.Healio.com/coronavirus.

Disclosures: Ungaro reports he served as an advisory board member or consultant for Eli Lilly, Janssen, Pfizer, and Takeda; research grants from AbbVie, Boehringer Ingelheim, and Pfizer. The other experts report no relevant financial disclosures.