key: cord-0777755-nkzbtcfw
authors: Barrett, Lisa F.; Lo, Kevin Bryan; Stanek, Steven R.; Walter, James W.
title: Self-Limited Gastrointestinal Bleeding in COVID-19
date: 2020-07-15
journal: Clin Res Hepatol Gastroenterol
DOI: 10.1016/j.clinre.2020.06.015
sha: 50ca7ef8d8cc93ab9076b0beb9f410cf36a4157f
doc_id: 777755
cord_uid: nkzbtcfw

Abstract The most commonly reported gastrointestinal (GI) manifestations of COVID-19 include abdominal pain, diarrhea, nausea and vomiting. There is limited data regarding GI bleeding in patients with COVID-19, however, patients have been documented to present with hematochezia or melena at the onset of COVID-19 symptoms. The presence of GI bleeding in the setting of COVID-19 complicates the patient's clinical course and management of sequelae including coagulopathy. Clinicians should be aware of a possible increased risk of GI bleeding and its complications when managing critically ill COVID-19 patients.

Over 3.5 million people worldwide have been infected with SARS-CoV-2 [1] . SARS-CoV-2, a single-stranded RNA virus of the beta coronavirus genus, enters the body via the angiotensin converting enzyme 2 (ACE2) receptor [2] [3] . ACE2 is expressed in gastrointestinal (GI) epithelial cells suggesting that SARS-CoV-2 can infect and replicate in the GI tract [4] . Studies have identified viral RNA in stool specimens of infected patients [3] . The most prevalent GI features of COVID-19 include abdominal pain, nausea, vomiting, and diarrhea. There is limited data regarding GI bleeding in patients with COVID-19. We present a case series of six patients, most without a known source of GI bleeding, who tested positive for SARS-CoV-2 and concurrently suffered from hematochezia or melena.

This single-centered, retrospective case series was conducted at Albert Einstein Medical Center in Philadelphia and was approved by the institutional review board. We recorded cases of SARS-CoV-2 infection and concurrent GI bleeding from March 1, 2020 to April 24, 2020. SARS-CoV-2 was confirmed with a polymerase chain reaction test on sputum or nasopharyngeal swab samples. Our case series describes six patients (Table 1) Endoscopy is a virus-aerosolizing procedure that has been used judiciously during the pandemic.

Diagnostic studies implicating the virus in GI pathology have been infrequent. It is possible that the bleeding observed in the above cases is not related to COVID-19, and rather due to unknown pre-J o u r n a l P r e -p r o o f existing GI pathology. Patient #6 underwent upper endoscopy, which did not show any abnormalities.

Because the onset of typical COVID-19 symptoms was accompanied by self-limited GI bleeding in five of the six cases, a correlation should be considered.

Coagulopathy is associated with SARS-CoV-2 infection. Studies have suggested a mortality benefit in anticoagulating patients with elevated D-dimer [7] . Because of the increased risk of thrombi and disseminated intravascular coagulation, hospitalized patients have been placed on therapeutic anticoagulation [8] . Among our patients, patients #4 and #6 were on anticoagulation prior to experiencing bleeding. Patient #4 had no history of bleeding and was taking apixaban for two weeks due to HIT. Patient #6 had bleeding after starting prophylactic rivaroxaban. Given the possible increased risk of bleeding in COVID-19, therapeutic anticoagulation in infected patients should be used cautiously. This case series shows a possible increased risk of bleeding among patients with COVID-19. Further study of how SARS-CoV-2 affects the GI tract is warranted. Areas of research may include assessing for mucosal damage, evaluating a correlation with inflammatory markers and reviewing additional cases of bleeding in COVID-19 patients.

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