key: cord-0904198-st8wyybq authors: Koh, Christopher; Liang, T. Jake title: Covid-19 Has Come Home to Roost in Gastroenterology date: 2020-06-12 journal: Gastroenterology DOI: 10.1053/j.gastro.2020.06.013 sha: 5ed29c6303a369a75fd8549923fa829c34a91429 doc_id: 904198 cord_uid: st8wyybq nan The greatest current threat to global health involves the pandemic outbreak of the novel coronavirus (CoV) that is structurally related to the virus that causes Severe Acute Respiratory Syndrome (SARS-CoV) or Middle East Respiratory Syndrome (MERS-CoV), and is known as SARS-CoV-2. 1 Human infection with SARS-CoV-2 was initially recognized in December 2019 in Wuhan, China and has since been named Coronavirus Disease 2019 (Covid-19). 2, 3 SARS-CoV-2 is highly contagious and containment has been a challenge given its high rate of transmissibility through respiratory droplets. 4 Covid-19 infection results in a spectrum of clinical presentations, but in its more severe form, it predominantly results in severe respiratory disease. The increased pathogenicity of SARS-CoV-2 may be partly a result of the SARS-CoV-2 surface spike protein binding at least 10 times more tightly than SARS-CoV to the angiotensinconverting enzyme 2 (ACE2) receptor, which is highly expressed in pneumocytes in the lung. 5 Early reports have described luminal gastrointestinal manifestations in up to 10% of patients, extended detection of viral RNA in stool beyond symptom resolution, and nonspecific mild liver test abnormalities in up to 60% of patients. 6, 7 While the etiologies of GI manifestations have yet to be fully understood, the robust presence of ACE2 receptors within the GI tract and the liver may play a role. [8] [9] [10] Additionally, there is concern for increased susceptibility to Covid-19 in patients on immunosuppressant medications, including those with inflammatory bowel disease (IBD) and autoimmune hepatitis (AIH). Finally, gastroenterologists have had to reconsider how and under what conditions invasive endoscopic procedures should occur. In this issue of Gastroenterology, four separate manuscripts from known global Covid-19 hotspots report on a spectrum of GI issues ranging from potential pancreatic involvement in Covid-19, the impact of Covid-19 on IBD patients, GI manifestations in a large cohort of Covid-19 patients in the US, and finally the risk and implementation of endoscopic practices during this pandemic period. [11] [12] [13] [14] In a cohort of 52 patients admitted over a period of 6 weeks, Fan and colleagues from Wuhan, China describe 9 patients that developed serum amylase or lipase abnormalities which they defined as pancreatic injury. 11 Notably, the overall median time to SARS-CoV-2 seronegativity was 22 days from symptom onset and 29% of patients developed liver test abnormalities. In the 9 subjects, amylase/lipase elevations were mostly mild, and no patients had clinically severe pancreatitis. Although the authors suggest that pancreatic involvement occurred more frequently in those with serious viral illness, only one patient required mechanical ventilation. Alternatively, 6 of the 9 patients had blood glucose abnormalities; however, all but one patient was on corticosteroid therapy as a part of the Covid-19 published study from Hubei, China now suggest that GI symptoms can occur in up to 35% of cases. 16 Interestingly, those with GI symptoms had a seemingly longer duration of illnesses, lower death rates, and a trend toward lower ICU admission rates. While this may suggest that GI involvement of Covid-19 may result in less severe disease, a separate report has described the opposite. 17 Given that the follow-up period in this report is shorter than what has been described for other Covid-19 articles, additional experiences with longer follow-up is needed. In the third manuscript, Norsa and colleagues from Bergamo, Italy studied a cohort of 552 patients with ongoing management for IBD and described that no IBD patients were diagnosed with SARS-CoV-2 infection over a 5-week period. 13 Notably, the ACE2 receptor is known to be highly expressed in ileal and colonic tissue and intestinal ACE2 levels are induced in patients with IBD. 8, 18 This report, along with another report on an IBD cohort from China is certainly thought-provoking and contrary to the global concern of susceptibility to Covid-19 in IBD patients on immunosuppressive regimens. 19 Alternatively, given the current state of SARS-CoV-2 testing availability, the story may be incomplete as only those who are symptomatic would likely be tested, thus leaving out individuals that may be Covid-19 positive and asymptomatic or minimally symptomatic. While the course of COVID-19 in IBD patients may be relatively benign, further long-term reporting and more global testing will be important to develop evidence-based strategies to manage IBD patients regarding biologic and immunomodulator therapies. Finally, in a regional survey of 41 endoscopy units, Repici and colleagues from Northern Italy report endoscopic outcomes and evolving practice changes implemented from the beginning of the Covid-19 outbreak in February to mid-March 2020. 14 While nearly all units described a mandatory reduction in endoscopic activities, 34% performed a total of 75 endoscopic procedures in Covid-19 positive patients with no cases resulting in direct transmission of SARS-CoV-2 to healthcare personnel. Notably, the types of endoscopic procedures (upper versus lower endoscopy) was not described. While upper endoscopy almost certainly confers a higher risk of viral exposure given the aerosolization of SARS-CoV-2, the possibility it may be an enteric virus capable of shedding in the stool is a concern for lower endoscopy. 10 During the study period, infection control and mitigation practices separately evolved in over 75% of endoscopy units, trending towards more stringent practices, with adequate PPE (including N95/FFP2-3) available in almost all units. This piece highlights the need for major gastroenterology organizations, working with infectious disease experts, to provide guidance for endoscopic practice in the Covid-19 era for the foreseeable future. Several recent publications outlining such guidance are an important step to mitigate transmission to healthcare professionals, who are on the frontlines of the Covid-19 crisis and have the highest risk of infection. 20 The Covid-19 pandemic has been a searing reminder of how delicate and interwoven our medical ecosystem is and how science is intimately related to our practice of medicine. The Covid-19, while predominantly an infectious and respiratory disease, has an inexorable relevance to the practices of gastroenterology and other medical specialties in many unexpected and yet practical ways. As the scientific community fervently labors to gain fundamental knowledge about this novel virus with the ultimate goals of developing vaccines A Novel Coronavirus from Patients with Pneumonia in China Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study Visualizing Speech-Generated Oral Fluid Droplets with Laser Light Scattering Cryo-EM structure of the 2019-nCoV spike in the prefusion conformation Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China Virological assessment of hospitalized patients with COVID-2019 Quantitative mRNA expression profiling of ACE 2, a novel homologue of angiotensin converting enzyme Recapitulation of SARS-CoV-2 infection and cholangiocyte damage with human liver ductal organoids Is SARS-CoV-2 Also an Enteric Pathogen with Potential Fecal-Oral Transmission: A COVID-19 Virological and Clinical Review Pancreatic injury patterns in patients with COVID-19 pneumonia Gastrointestinal Symptoms and COVID-19: Case-Control Study from the United States Uneventful course in IBD patients during SARS-CoV-2 outbreak in northern Italy Endoscopy units and the COVID-19 Outbreak: A Multi-Center Experience from Italy Binding of SARS coronavirus to its receptor damages islets and causes acute diabetes Clinical Characteristics of COVID-19 Patients With Digestive Symptoms in Hubei, China: A Descriptive, Cross-Sectional, Multicenter Study Epidemiological, clinical and virological characteristics of 74 cases of coronavirus-infected disease 2019 (COVID-19) with gastrointestinal symptoms Imbalance of the renin-angiotensin system may contribute to inflammation and fibrosis in IBD: a novel therapeutic target? Implications of COVID-19 for patients with pre-existing digestive diseases AGA Institute Rapid Recommendations for Gastrointestinal Procedures During the COVID-19 Pandemic and therapies to contain this pandemic, those of us in the gastroenterology and hepatology specialty can certainly play a central role in this fight and contribute to the healing of our world in the wake of this devastation.