key: cord-0873061-ro66qxwx
authors: Mao, Ren; Liang, Jie; Wu, Kai-Chun; Chen, Min-Hu
title: Responding to COVID-19: Perspectives from the Chinese Society of Gastroenterology
date: 2020-03-27
journal: Gastroenterology
DOI: 10.1053/j.gastro.2020.03.046
sha: f7c4413c57a8fb9977e6c841d832ee5e5d32e9f5
doc_id: 873061
cord_uid: ro66qxwx

nan

The pandemic of coronavirus disease 2019 has been tremendously impacting the entire world since December 2019. COVID-19 was first reported to affect the respiratory tract and spread from person to person by respiratory droplets; therefore, pulmonologists as well as critical care physicians have been the leading force to counteract this public health crisis. The evidence of digestive system involvement in COVID-19 was first reported by a group in China [1] .

There are increasing data showing that the gastrointestinal (GI) tract and liver might also represent target organs of severe acute respiratory syndrome corona virus 2 (SARS-CoV-2), and that infected patients could have corresponding organ damage and symptoms. More importantly, the evidence of SARS-CoV-2 detection in patient stool and the tentative fecal-oral route transmission have raised great concern and posed a challenge for control and prevention of COVID-19 [2] . It is the indispensable duty for our gastroenterologists, as we did in the history of other epidemics, to be armed with knowledge, facts and skills, and united in the battle against . In this concise review, we aim to:

 provide perspectives about how to respond to COVID-19 from the Chinese Society of Gastroenterology (CSG),  summarize disease manifestations or complications relevant to GI and liver involvement, and  propose recommendations for next steps regarding our future GI practice and care.

We expect that our response might be instructive for other GI communities to counteract the current unprecedented situation.

As the authorized academic association of gastroenterologists in China, we follow the guidance and recommendations of relevant government authorities. Several actions have been taken in response to COVID-19 outbreak. According to a survey of 2216 GI doctors from all over China early in the outbreak of COVID-19, the awareness of digestive system damage and involvement in COVID-19 was low, ranging from 31% to 35% [3] . To counteract this, the CSG rapidly organized a group of experts including gastroenterologists working in the forefront of COVID-19 patient care to discuss and reach a consensus on management of digestive disorders involved in COVID-19 (Table 1 ) [4] .This consensus includes recommendations regarding transmission route, clinical manifestation spectrum of digestive system involvement, practical guidelines on treatment based on the latest publications, and precautions regarding endoscopic procedure. In addition, cautions for GI outpatient clinic have been proposed [4] . The CSG is comprised of 25 committees of sub-specialty depending on the disease spectrum. As a response to the increasing concern and inquiry about COVID-19 risk from the community of inflammatory bowel disease (IBD) in China, the Chinese IBD Committee affiliated to CSG has issued timely recommendations for managing IBD patients in early February 2020, which is probably the first guideline regarding IBD and COVID-19 in the global community [5] . The guideline includes practical recommendations regarding immunosuppressive agent and biologics use, diet, Epidemics and public health crises pose great challenges to health care delivery. To minimize the risk of SARS-CoV-2 infection by avoiding close contact with infected patients in public areas such as hospitals, telemedicine has also been widely applied in our non-COVID-19 patient care including virtual clinic visits online clinic consultancy and nurse-led care support based on interactive social care app such as WeChat. These strategies have greatly facilitated care delivery to patients with chronic GI diseases such as inflammatory bowel disease.

While respiratory tract manifestations such as fever and cough are the most common reported symptoms in patients with COVID-19, symptoms within the gastrointestinal tract have also been reported. A study of 138 confirmed patients with COVID-19 showed that the major symptoms included fever (98.6%), fatigue (69.6%), cough (59.4%), myalgia (34.8%) and dyspnea (31.2%), while gastrointestinal symptoms included abdominal pain (3.6%), diarrhea (10.1%) and vomiting (3.6%). It is worth noting that 14 cases (10.1%) had initial symptoms of diarrhea and nausea, then fever and dyspnea [7] . This is important for gastroenterologists for screening and identifying COVID-19 cases. However, the disease course and outcomes in these subgroups of patients need further investigation. Another retrospective analysis of 1099 patients with COVID-19 showed that the main symptoms were fever (87.9%) and cough (67.7%), while diarrhea (3.7%) and vomiting (5.0%) were less frequent. Among GI symptoms, the incidence of diarrhea and abdominal pain in patients with severe COVID-19 was higher than that in patients with mild COVID-19 [8] .

Recent studies of single cell RNA sequencing of human tissues demonstrated that the cell receptor angiotensin covering enzyme II (ACE2) is expressed in epithelial cells of the digestive system as well as liver cells [9] . Liver abnormalities of COVID-19 patients may be due to liver cell dysfunction or other causes such as drug toxicity and systemic inflammation. In a cohort of 1099 patients with COVID-19, abnormal liver function tests including elevated aspartate aminotransferase (AST), alanine aminotransferase (ALT) and total bilirubin (TBIL) were found in 168 (168/757, 22.2%), 158 (158/741, 21.3%) and 76 (76/722, 10.5%) of patients [8] . Data about alkaline phosphatase (ALP) and gamma-glutamyl transpeptidase (GGT) were not provided in this study [8] . Another study that included 333 COVID-19 cases with liver function tests was recently reported in a Wuhan medical center. The incidence of liver injury was 39.6% (132/333) with the majority (71.2%, 94/132) being mild elevation in liver enzyme tests. TBIL were elevated in only13 patients (13/333, 3.9%). Regarding underlying liver conditions, 12 patients had a history of chronic hepatitis B and 2 patients had a history of chronic hepatitis C, but the detection of viral nucleic acid showed no active hepatitis [10] .There was no significant difference in the ratio of liver injury between patients in an ICU (45.6%, 26/57) or the general ward (38.4%, 106/276) (P > 0.05). However, in another study including 305 confirmed COVID-19 cases, the incidence of liver injury in ICU patients (67.4%, 31/46) was significantly higher than that on general wards (34.1%, 88/258) (P < 0.05) [11] . Currently there is only one published autopsy report in an 85-year-old man with COVID-19, which showed segmental dilatation and stenosis in the small intestine [12] . Further studies are needed to clarify whether this finding is secondary to COVID-19 or a pre-existing GI comorbidity.

Our response is evolving as our knowledge about COVID-19 evolves. To fight against this public health crisis with numerous uncertainties, it is imperative for the entire healthcare community to respond in a collaborative fashion, and even establish a response mechanism for enabling rapid actions for the next crisis. Several action items about GI practice, care and research should be implemented.

Gastroenterologists serve patients who are potentially more vulnerable to COVID-19 because of underlying digestive disorders. The presence and number of comorbidities was reported to be associated with poorer clinical outcome in patients with COVID-19 [8] . In China, we have a large population of patients with digestive disorders including chronic liver disease and GI cancer, and an increasing number of patients with inflammatory bowel disease (IBD). However, whether these underlying conditions could increase the risk of COVID-19, and their impact on prognosis of COVID-19 remain unknown [13] .

Coronavirus Under Research Exclusion (SECURE-IBD) in the USA, are ongoing to evaluate these questions. This will greatly facilitate our GI practice and care for our patients.

Importantly, SARS-CoV-2 virus RNA was detected in the stool specimen from patients with COVID-19 and could persist throughout the course of illness resolution [1, 14] . Though viral detection in the stool does not necessarily equate to virus infectivity and direct evidence of fecal transmission of COVID-19 has yet to be identified, the implementation of high-level disinfection for surfaces potentially contaminated by feces is strongly recommended. Emerging evidence shows persistence of SARS-COV-2 virus RNA in stool samples or rectal swabs even after respiratory specimens tested negative [6, 16] . In a recent landmark clinical investigation on ten pediatric COVID-19 cases in China, eight persistently tested positive on rectal swabs even after nasopharyngeal testing was negative, suggesting that the gastrointestinal tract may continue to shed virus [6] . The updates criteria for hospital discharge of COVID-19 patients includes resolution of fever and respiratory symptoms, improvement in acute exudative lesions on chest CT, as well as 2 consecutively negative RT-PCR test results of respiratory samples with interval of at least 24 hours [15] . Whether fecal or rectal swab RT-PCR result should also be included in future discharge criteria needs to be further investigated.  Antibiotic-associated Seen with elderly and co-morbidity of chronic illness, particularly in patients with ventilation in ICU.  Liver injury Majority of the COVID-19 associated liver injury is mild with less 2 times of abnormal liver function test and need no treatment.  Diet and nutrition Enteral nutrition by oral feeding is preferred. Nutritional risk assessment is recommended for severe patients. Nasogastric tube can be inserted for enteral nutrition for those who are unable to take food by mouth (such as receiving mechanical ventilation).

Only emergency endoscopy is indicated during the outbreak such as treatment of acute gastrointestinal hemorrhage, removal of foreign bodies in the digestive tract, suppurative obstructive cholangitis and biliary pancreatitis. Screen for COVID-19 before procedure and provide appropriate protection for the endoscopists in an isolated and preferably a negative pressure room for procedure.  Suspend other examinations such as esophageal acid test, gastrointestinal motility test, hydrogen breath test, Helicobacter pylori test, fecal antigen test, etc. *adapted from The Chinese Society of Gastroenterology. Consensus on diagnosis and treatment of digestive system involvement in COVID-19. Chinese Journal of Medicine 2020 DOI: 10.3760/cma.j.cn112137-20200308-00645

Evidence for gastrointestinal infection of SARS-CoV-2

Enteric involvement of coronaviruses: is faecal oral transmission of SARS-CoV-2 possible?

A survey study on gastroenterologists' knowledge about COVID-19

The Chinese Society of Gastroenterology. Consensus on diagnosis and treatment of digestive system involvement in COVID-19

Managing IBD patients during the outbreak of COVID-19

Characteristics of pediatric SARS-CoV-2 infection and potential evidence for persistent fecal viral shedding

Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China

Clinical characteristics of coronavirus disease 2019 in China

Single cell RNA sequencing of 13 human tissues identify cell types and receptors of human coronaviruses

Manifestations of liver injury in 333 hospitalized patients with coronavirus disease 2019

Digestive manifestations in hospitalized patients with COVID-19: A single-center descriptive study

Macroscopic autopsy findings in a patient with COVID-19

Implications of COVID-19 for patients with pre-existing digestive diseases

First case of 2019 novel coronavirus in the United States

National Health Commission of the People's Republic of China. Diagnosis and Treatment Program of New Coronary Pneumonia (the seventh edition)

Prolonged presence of SARS-CoV-2 viral RNA in faecal samples

We thank all the gastroenterologists in China who are fighting against this public crisis.We thank all the members of Chinese Society of Gastroenterology for their collaborative efforts.

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