key: cord-0769306-atd2i1mj authors: Agarwal, Ashish; Chowdhury, Sudipta Dhar; Sachdeva, Sanjeev; Saraswat, Vivek; Kochhar, Rakesh; Saraya, Anoop title: Low Risk of Transmission of SARS-CoV2 and Effective Endotherapy for Gastrointestinal Bleeding Despite Challenges Supports Resuming Optimum Endoscopic Services date: 2020-10-14 journal: Dig Liver Dis DOI: 10.1016/j.dld.2020.10.009 sha: c630c9de5b5140d03ff98332192e4fe6fb52da84 doc_id: 769306 cord_uid: atd2i1mj nan emergencies, major hardship and possible neglect of patients with acute non-COVID medical emergencies ensued. Acute Gastrointestinal (GI) bleeding, the most common GI emergency, is associated with a mortality of around 10% 1 , which may be higher especially in patients with variceal bleeding depending on the severity of the underlying liver disease. The cornerstone for achieving hemostasis and subsequent reduction in mortality in patients with GI bleeding is endoscopic therapy within 12-24 hours of presentation which is effective in >90% of cases. 2, 3 Upper GI endoscopy however, is an aerosolgenerating procedure with possibility of transmission of SARS-CoV-2 to healthcare workers (HCWs) during the procedure. 4 Therefore, concerns have been raised about endoscopic procedures in patients with GI diseases who are potentially infected with COVID-19, with a few societies issuing consensus guidelines regarding the indications, precautions such as the use of personal protective equipment (PPE), and procedure-related technical issues for effective and safe endoscopy procedures. 5 In view of the concerns about spread of infection, reallocation of resources, use of PPE, and restricted access to medical care, we conducted an ambispective observational study in five tertiary care academic institutions in India to examine the efficacy and safety of therapeutic GI endoscopic procedures in patients with acute GI bleeding during the COVID-19 pandemic that led to the We included all patients >12 years of age undergoing GI endoscopic procedures for overt or occult GI bleeding from 1 st April to 31 st May 2020 during the COVID-19 pandemic and nationwide lockdown. There was no universal policy of testing for SARS-COV2 prior to the endoscopy in view of urgency of the procedure except in one of the five centres. Patients and HCWs were tested by RT-PCR for SARS-CoV2 infection only if they were symptomatic or had history suggestive of exposure to a COVID-19 positive patient. Details of measures for prevention of cross infection and protocol for the management of GI bleeding are summarized in supplementary document 1. Ethical approval for the study was obtained from the Institute Ethics Committee. Informed consent was waived by the ethics committee and only anonymized data are being reported. Efficacy and safety of endoscopic therapy for GI bleeding was the primary outcome. Efficacy was defined as successful endoscopic therapy for the underlying cause of bleeding. Safety was defined in terms of complication of the endoscopic procedure and transmission of COVID-19 infection to HCWs and/or patients during endoscopic procedures. Secondary outcomes were rebleeding rate and mortality during hospital stay and within 28 days of index bleed. All the centers reported 85%-95% reduction in number of endoscopic procedures performed during the nationwide lockdown because only urgent endoscopies were being undertaken. A total of 1294 endoscopic procedures [Esophagogastroduodenoscopy (EGD)-1064, colonoscopy-230] were performed across 5 centers from April 1 to May 31, 2020 (Table 1) . Of these, 638 (49.3%) procedures (EGD-500 and colonoscopy-138) were done for GI bleeding, which was the most common indication for performing an endoscopic procedure. Of the 500 patients who underwent an EGD, 177 (35.4%) patients had non-variceal bleeding ( Table 2 and Supplementary Table 1 ) and 323 (64.6%) patients had variceal bleeding (Table 2 and Supplementary Table 2 patients. Therapeutic intervention was required in 256 (51.2%) patients and was successful in 250 patients but not in 6 (1.2%) patients; Twenty (4.0%) patients with variceal bleeding had rebleeding during the hospital stay. In-hospital mortality was 4.4% (22/497) and the 28-day mortality was 6.7%. A total of 138 colonoscopies were performed for lower GI bleeding (Table 2 and Supplementary table 3 ). Thirty (21.7%) patients had inflammatory bowel disease, 12 (8.7%) patients had infective colitis, 12 (8.7%) patients had colonic malignancy, 3 (2.2%) patients had radiation proctitis, 3 (2.2%) patients had diverticular bleed, 24 (17.4%) patients had hemorrhoidal bleed, and 16 patients had other causes. Therapeutic intervention was needed only in 11 (8%) patients. Hemostasis was achieved in all patients with lower GI bleeding and there was no rebleeding. There was no mortality in patients with lower GI bleeding. As compared to upper GI bleeding, the need for therapeutic intervention was significantly less in lower GI bleeding (51.2% vs. 7.9%; p <0.001). Thus, our study has shown a marked reduction in the number of endoscopy procedures during the COVID-19 pandemic. However, the number of endoscopy procedures performed for GI bleeding was similar to those reported previously from one centre (130 over 2 months for UGI bleeding -43% nonvariceal and 57% variceal). 6 Primary hemostasis was achieved in 98.8% of patients with a 4.0% rebleeding rate and 6.7% 28-days mortality in patients with upper GI bleeding. In patients with lower GI bleeding, it was controlled in all patients with no mortality. The results of the present study are comparable to our published results in terms of hemostasis and mortality in both variceal and nonvariceal bleeding before COVID crisis. Previously published reports showed that most patients with GI bleeding during COVID-19 pandemic were managed with pharmacotherapy and the strategy was to avoid endoscopic procedures. 7, 8 This may be due to fear of increased risk of transmission of infection to endoscopy personnel as there is high aerosol generation during EGD and risk of contact with virus present in faeces during colonoscopy 9 . However, our study has demonstrated that endoscopy could be performed for urgent indications such as GI bleeding with a very low risk of transmission of COVID-19 (0.49% per 100 endoscopies per HCW) with the use of adequate PPE, even without a policy of universal preprocedure COVID-19 testing. The low rate of infection among endoscopy personnel during this period which suggests that proper PPE use, adherence to infection control practices and proper protocol in place are effective measures to contain this infection. Our findings thus validate the recommendations of various endoscopic societies guidelines in this regard. 10 There are several limitations of our study. Our was an ambispective study with data collected retrospectively for the first month but there was no significant difference between the 2 months. There was some difference in the incidence of COVID-19 across centres which could have affected the proportion of positive patients, the policy of testing for COVID-19 prior to endoscopic procedure varied between different centers, there were subtle differences between choice of treatment protocol e.g. somatostatin versus terlipressin and the selection of endoscopic procedures was usually decided by the institutional policy and at the discretion of the endoscopist. In summary, endoscopic therapy with adequate precautions is safe and effective for gastrointestinal bleeding with relatively low risk of cross-infection during COVID-19 pandemic. These observations call for and support resumption of optimum level of endoscopic services during the ongoing COVID-19 pandemic even without a policy of universal pre-procedure testing for SARS-CoV2 particularly in resource limited settings. This research received no specific grant from any funding agency in the public, commercial, or notfor-profit sectors The study protocol was approved by the Institute Ethics committee Patient consent was waived-off by ethics committee and only anonymized data are being reported Ashish We declare no competing interests Management of acute upper gastrointestinal bleeding Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group Considerations in performing endoscopy during the COVID-19 pandemic Gastrointestinal endoscopy during the COVID-19 pandemic: an updated review of guidelines and statements from international and national societies Comparison of various prognostic scores in variceal and non-variceal upper gastrointestinal bleeding: A prospective cohort study Effect of the COVID-19 Pandemic on Outcomes for Patients Admitted with Gastrointestinal Bleeding in New York City. 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