FIT Update: COVID-19: Gut Feeling, It’s Time to Prepare Catherine Bartnik MD, MPH, University of Pittsburgh Medical Center, Gastroenterology Hepatology Fellowship FIT Board Member
@CatBartnik
The outbreak of Severe Acute
Respiratory Corona Virus 2 (SARSCoV-2), also known as COVID-19 is coming to a community near you. Is your healthcare system and endoscopy suite prepared to handle this rapidly spreading pathogen? As of March 13, 2020, the World Health Organization (WHO) reported 132, 758 confirmed cases worldwide among one hundred twenty-four countries1. Within the United States, the Centers of Disease Control (CDC) reported a total of 1,629 cases in forty-seven states, with the highest concentration of cases in California and Washington state. Presently, the mortality of this virus is estimated to be roughly 2-3% in the general population although the elderly that are greater than age 80 years old may have an estimated 10-15% mortality risk. Additional at risk populations are those who are chronically ill and also younger immunocompetent individuals have succumb to respiratory failure and have died as a result of this infection. Our immunosuppressed IBD patients have also been a concern. Fortunately, as of March 8,
2020, there were no reported cases of COVID-19 from China’s IBD Elite Union patient registry of >20,000 IBD patients2. That said, there is much that remains unknown about this infectious agent and nonspecific symptoms and suboptimal detection remain a grave concern. As healthcare professionals, we must stay ahead of this outbreak and prepare ourselves and our health care delivery systems as this virus continues to spread rapidly within the United States. Within this article, I plan to highlight a summary of this novel pathogen with respect to clinical symptoms and spread, as well as to provide a protocol tailored to gastroenterologists to decrease the risk of transmission to themselves as well as their staff and patients. As a reminder, in order for us to provide quality healthcare, we too must protect ourselves from exposure. Recently, Guan et al. published a study in the New England Journal of Medicine describing the clinical symptoms of COVID-19, identified among hospitalized patients in Wuhan, China3. The most common symptoms included fever (defined as a temperature greater than 37.5C, 88.7% of 1099 cases), cough (67.8%), and shortness of breath (18.7%). Roughly 20% of individuals develop serious illness with pneumonia and acute respiratory distress syndrome requiring mechanical ventilation. While the Wuhan group reported gastrointestinal symptoms to be less common (nausea and/or vomiting at 5% and diarrhea at 3.8% of 1099 cases), the initial presentations of some patients with COVID-19 are primarily gastrointestinal. Hence, a
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fecal-oral route of transmission is also thought possible in addition to respiratory droplet transmission. COVID-19 has also been implicated to play a role in liver toxicity with 2-11% of patients developing liver comorbidities4. Abnormal AST values identified on presentation correlated with the need of ICU care, whereas those who presented with normal aminotransferase levels were less likely to be cared for in the ICU4. The possible mechanism involves viral entry into cholangiocytes mediated by ACE2 receptors found throughout the gastrointestinal tract. An unpublished post mortem analysis of a patient who died from COVID-19 did not have viral inclusion bodies on liver histology in the setting of high viral titers. It is unclear if AST elevations could alternatively be explained by ischemia, hypoxia due to respiratory failure, or drug induced injury. No reported liver transplantation for acute liver failure has occurred in a COVID-19 positive patient thus far. With respect to spread, we understand that having close contact (within 6 ft) with an infected patient or when handling their secretions increases the likelihood of transmission1. Therefore, infection control and prevention remain the cornerstones in curbing further disease spread. As this coronavirus has been found in stool samples of infected patients, endoscopy poses a significant risk of transmission6. Likewise, the sterilization and reprocessing of endoscopic equipment presents its own challenges as more frequent sterilization, in the midst of a pandemic, may place greater demand on cleansing solutions and filters depleting
