key: cord-0867281-usmov3xq
authors: Cavaliere, Kimberly; Levine, Calley; Wander, Praneet; Sejpal, Divyesh V.; Trindade, Arvind J.
title: Management of upper GI bleeding in patients with COVID-19 pneumonia
date: 2020-04-20
journal: Gastrointest Endosc
DOI: 10.1016/j.gie.2020.04.028
sha: 32f9a54447863a0f6f8daae6f2e7e737935ab2a7
doc_id: 867281
cord_uid: usmov3xq

nan

Kimberly Cavaliere, 1 Calley Levine, 1 Praneet Wander, 1 Divyesh V Sejpal, 1 Cornoavirus disease 2019 (COVID-19) has become a worldwide pandemic. The typical presentation is a respiratory illness with fever, cough, and shortness of breath. Gastrointestinal symptoms are being increasingly recognized and include abdominal pain, vomiting, diarrhea, and nausea. 1 We present a case series of 6 patients who presented to our hospital with COVID-19-associated pneumonia (fever, shortness of breath requiring oxygen, positive COVID-19 polymerase chain reaction [PCR] test, and infiltrates showing on chest radiograph), and upper GI bleeding. The patient and clinical characteristics can be found in Table 1 . The GI manifestations were hematemesis or melena.

Guidelines advise that patients who present with acute upper gastrointestinal bleeding undergo endoscopy within 24 hours of presentation 2 . Endoscopy can not only provide therapy but can also allow for risk stratification for re-bleeding that can dictate management. However, the discussion for endoscopy in patients with COVID-19 pneumonia brings about unique management decisions. Although endoscopy can provide therapy if a discrete visible vessel is seen, the risk of the procedure may outweigh the benefit in patients with COVID-19 pneumonia.

First, five of the six patients in this series were on supplemental oxygen while one had an endotracheal tube. Performing upper endoscopy would have likely required general anesthesia with an endotracheal tube in the 5 patients given the patient's oxygen requirements and/or procedure indication (hematemesis). Extubation after the procedure becomes challenging in the setting of pneumonia. In addition, a recent study from China demonstrated an increased mortality rate once a patient with COVID-19 pneumonia is intubated 3 . Although the data for this was in emergent intubation for respiratory failure (and not a elective procedure), the data is compelling. Second, there is a real concern for transmission of the virus to the anesthesiologist, staff, and endoscopist; given aerosolization of respiratory droplets during endoscopy 4 .

Given the risks of endoscopy may outweigh the benefits we decided to manage these patients conservatively with a proton pump inhibitor drip, blood transfusion as needed, and frequent monitoring of vital signs/GI symptoms /hemoglobin value. Endoscopy was reserved if the patient did not respond to conservative management by 24 hours (lack of hemodynamic stability and if the hemoglobin was not stable). Delaying the endoscopy for 24 hours has recently been shown to not affect 30-day mortality compared to earlier endoscopy 5 . All 6 of our patients responded to conservative management. Cessation of clinical symptoms of acute upper gastrointestinal bleeding was seen in all of our patients in combination with stabilization of hemoglobin. None of the patients required upper endoscopy during their clinical course.

The exact cause of GI bleeding in this cohort is unknown, as endoscopy was not performed. The most likely cause is ulcer related. Another etiology being recognized is COVID related coagulopathy 6 . Given the patients responded to conservative management, the former is more likely.

In conclusion, the management of patients admitted with COVID-19 pneumonia who develop upper GI bleeding is challenging. It can possibly be managed conservatively without endoscopy because all of our patients responded by 24 hours. Lack of response in 24 hours may indicate a need for endoscopy with personal protective equipment.

Effect of gastrointestinal symptoms on patients infected with COVID-19

Management of patients with ulcer bleeding

Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a singlecentered, retrospective, observational study

Use of a modified ventilation mask to avoid aerosolizing spread of droplets for short endoscopic procedures during coronavirus COVID-19 outbreak

Timing of endoscopy for acute upper gastrointestinal bleeding

ISTH interim guidance on recognition and management of coagulopathy in COVID-19