key: cord-0915902-ihjojwun authors: Goyal, Hemant; Sachdeva, Sonali; Perisetti, Abhilash; Mann, Rupinder; Chandan, Saurabh; Inamdar, Sumant; Tharian, Benjamin title: Management of gastrointestinal bleeding during COVID-19: less is more! date: 2021-07-28 journal: Eur J Gastroenterol Hepatol DOI: 10.1097/meg.0000000000002224 sha: ea15e916573c694828cc341ad15acd1f43820df7 doc_id: 915902 cord_uid: ihjojwun nan Coronavirus disease-2019 (COVID-19) is a global pandemic caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2). Although it is primarily a respiratory illness, gastrointestinal involvement is increasingly being observed, such as anorexia (26.8%), nausea/ vomiting (7.8%), diarrhea (5-10%) and abdominal pain (3.9-6.8%) [1, 2] . Despite limited evidence from literature about gastrointestinal bleed (GIB) management in COVID-19, stable patients are often managed conservatively because endoscopies are high-risk aerosol-generating procedures. Herein, we systematically reviewed published literature about the point prevalence of causes of GIB in COVID-19 patients and their outcomes. A systematic search of PubMed, Google Scholar, Embase and Scopus databases was undertaken to extract articles relevant to GIB in COVID-19 on 13 September 2020. The search strategy was implemented using various combinations of the following search terms: "gastrointestinal bleed," "melena," "hematochezia," "upper GI bleed," "lower GI bleed," "rectal bleeding," "hematemesis," "coffee-ground emesis," "black tarry stools," maroon-colored stools," "COVID-19", "SARS-COV-2", "coronavirus." Data about management and clinical outcomes such as rebleeding, mortality and length of hospital stay (LoS) was collected from available case reports, case series and observational studies and summarized using descriptive statistics. From the initial 400 articles retrieved, 21 studies were finally included after eliminating nonrelevant articles, reviews and duplicates. There were 13 case reports, 5 case series, 2 retrospective observational studies and 1 case-control study. The total sample size consisted of 123 patients with a positive SARS-CoV-2 reverse transcriptase-PCR. The mean age was 63.1 ± 16.4 years, with the majority being males (88/123, 71.5%). Endoscopic evaluation was performed only in 40% cases (49/123), esophagogastroduodenoscopy (EGD) in 40, colonoscopy in 5 and sigmoidoscopy in 4 patients ( Table 1) . The most common finding on EGD was gastroduodenal ulcers (42.5%, 17/40 patients), followed by esophagitis and esophageal ulcers in 15% (6/40) of individuals. Less common findings included esophageal varices and erosive/hemorrhagic gastritis in 10% (4/40) of patients. Most patients (108/123, 87.8%) were managed conservatively with proton pump inhibitors, somatostatin analogs, vasopressin analogs, intravenous fluid resuscitation and local hemostatic agents. Endoscopic interventions were performed in 12.2% of cases (15/123). Only half (62/123) patients received packed red blood cell transfusion, with a mean number of four transfusions. The GIB-related mortality rate was 1.6% (2/123). Rebleeding occurred in 12 patients (10%). The median LoS was 8 days (interquartile range: 7-28 days). Our study results show that less than half of the COVID-19 patients (40%) presenting with GIB underwent endoscopic evaluation. Low rates of endoscopy could be attributed to the fear of potential endoscopic transmission of SARS-CoV-2, a need for conserving personal protective equipment, or multiple GI societies' recommendations to defer nonurgent endoscopy [3, 4] . Peptic ulcer disease remains the most common finding, and mortality related to GIB in COVID-19 is low (2%), even with low rates of endoscopies during the pandemic. SARS-CoV-2 has also reported to cause acute hemorrhagic colitis; however, the exact role of the virus in causing GIB is still needed to be defined [5] . Furthermore, any case of GIB needs individualized attention, and clinical judgment should prevail, and the focus should be the patient outcome. 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What should the gastroenterologist keep in mind?