key: cord-331703-4hwmajt3
authors: Occhipinti, Vincenzo; Saibeni, Simone; Sampietro, Gianluca M.; Pastorelli, Luca
title: Impact of COVID-19 outbreak on the management of patients with severe IBD: a domino effect
date: 2020-05-12
journal: Gastroenterology
DOI: 10.1053/j.gastro.2020.05.027
sha: 
doc_id: 331703
cord_uid: 4hwmajt3

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The International Organization for the study of Inflammatory Bowel Diseases (IOIBD) recently published on Gastroenterology a consensus 1 about the management of IBD patients during the coronavirus disease 19 (COVID-19) pandemic, addressing several topics of interest such as the risk of infection in IBD patients, how to manage therapies and how to safely provide continuity of biological therapy. We read it with great interest and we highly appreciated the effort to provide a guidance to IBD care in these difficult days, even in the absence of evidence-based data.

Indeed, as IBD physicians working in one of the most severely affected regions of the world (Lombardia region, in northern Italy 2 ), we had to face additional and unexpected difficulties, while managing severe IBD during the SARS-CoV-2 outbreak.

Here, we report the emblematic case of a 38-year-old man. Because of episodes of bloody diarrhea, the patient underwent colonoscopy in January 2020 with evidence of mild proctosigmoiditis, with histology compatible with ulcerative colitis (UC). A gastroenterological consult was scheduled for the end of February, but not performed due to the COVID-related limitations to non-urgent consultations and procedures. A short course of oral mesalamine therapy given by the general practitioner provided clinical remission, but no maintenance therapy was initiated. After two months the patient developed severe bloody diarrhea (>10 episodes/day), malaise and diffuse abdominal pain. For these symptoms, he called twice the Emergency Service who telephonically suggested to avoid access to the hospitals because of the COVID-19 outbreak. After two weeks at home clinical conditions further deteriorated, and he was finally transported to the emergency room of our hospital (Policlinico San Donato, a University Hospital in the Southeastern region of Milan metropolitan area). He appeared severely ill, tachycardic, with mild fever (37.8 °C) and a diffuse abdominal pain. Laboratory tests showed markedly elevated C reactive protein (24 mg/dl, normal values < 0.5), neutrophilic leukocytosis and hypoalbuminemia (2.7 g/dl). Chest X-ray was normal, nasopharyngeal swab for novel coronavirus was negative. An urgent CT scan excluded significative colonic dilatation but showed markedly thickened and enhanced colonic walls. A rectosigmoidoscopy showed severely inflamed mucosa with multiple, deep ulcers; histology confirmed severely active ulcerative colitis. Broad spectrum antibiotics, intra-venous corticosteroids and anti-thrombotic prophylaxis were promptly started. Despite the absence of urgent surgical indications, we thoroughly pondered the potential risk of performing urgent colectomy with post-surgical ICUs converted into critical COVID-19 units. Thus, we decided to transfer the patient to a COVID-free hospital with IBD-specialized gastroenterologists and surgeons (Rho Hospital, in the Northern area of Milan) for further management. In the end, the patient only partially responded to i.v. steroids, with dramatic fall in CRP levels (0.95 mg/dl) but persistent bloody diarrhea with up to 10 bowel movements. Then, salvage therapy with infliximab 5 mg/kg was started with satisfying clinical efficacy, thus avoiding urgent colectomy.

This case clearly highlights some unanticipated difficulties in providing adequate care to patients with severe IBD in a high-prevalence area of COVID-19. The limitation to all non-urgent consultations and the extreme pressure on the emergency system may lead to wide diagnostic and therapeutic delays. Moreover, many patients themselves may try to avoid access to hospitals even in presence of severe symptoms, because of the fear of getting infected. Severe IBD flares require admission, tight monitoring and may require urgent surgery. All of these measures may become problematic during the pandemic. In our region, after the identification of the first COVID-19 clusters at the end of February, in few days, several hospitals (included ours) were almost completely converted in COVID-19 clinics with consequent deranging of physicians' organization chart and limitations of specialistic activities. As a third level IBD center we struggled to guarantee essential care to our patients, such as infusional therapies and urgent consultations, and to protect them from the risk of infection by instituting telephonic screening and 24/7 availability 3 . However, with our gastroenterological ward closed and all gastroenterologists but one reassigned in newborn COVID units, we turned unable to adequately manage patients with IBD flares.

Management of Patients with Crohn's Disease and Ulcerative Colitis During the COVID-19 Pandemic: Results of an International Meeting

Coronavirus Disease 2019 (COVID-19) in Italy

Challenges in the Care of IBD Patients During the CoViD-19 Pandemic: Report From a "Red Zone" Area in Northern Italy