Gastrointestinal Bleeding in Patients With Coronavirus Disease 2019: A Matched Case-Control Study

Abstract

INTRODUCTION: Although current literature has addressed gastrointestinal presentations including nausea, vomiting, diarrhea, abnormal liver chemistries, and hyperlipasemia as possible coronavirus disease 2019 (COVID-19) manifestations, the risk and type of gastrointestinal bleeding (GIB) in this population is not well characterized. METHODS: This is a matched case-control (1:2) study with 41 cases of GIB (31 upper and 10 lower) in patients with COVID-19 and 82 matched controls of patients with COVID-19 without GIB. The primary objective was to characterize bleeding etiologies, and our secondary aim was to discuss outcomes and therapeutic approaches. RESULTS: There was no difference in the presenting symptoms of the cases and controls, and no difference in severity of COVID-19 manifestations ( P > 0.05) was observed. Ten (32%) patients with upper GIB underwent esophagogastroduodenoscopy and 5 (50%) patients with lower GIBs underwent flexible sigmoidoscopy or colonoscopy. The most common upper and lower GIB etiologies were gastric or duodenal ulcers (80%) and rectal ulcers related to rectal tubes (60%), respectively. Four of the esophagogastroduodenoscopies resulted in therapeutic interventions, and the 3 patients with rectal ulcers were referred to colorectal surgery for rectal packing. Successful hemostasis was achieved in all 7 cases that required interventions. Transfusion requirements between patients who underwent endoscopic therapy and those who were conservatively managed were not significantly different. Anticoagulation and rectal tube usage trended toward being a risk factor for GIB, although it did not reach statistical significance. DISCUSSION: In COVID-19 patients with GIB, compared with matched controls of COVID-19 patients without GIB, there seemed to be no difference in initial presenting symptoms. Of those with upper and lower GIB, the most common etiology was peptic ulcer disease and rectal ulcers from rectal tubes, respectively. Conservative management seems to be a reasonable initial approach in managing these complex cases, but larger studies are needed to guide management.

American Society of Hematology 2021 guidelines on the use of anticoagulation for thromboprophylaxis in patients with COVID-19

“…One cohort study showed that therapeutic-intensity anticoagulation may increase the risk of major bleeding (adjusted hazard ratio, 3.89; 95% CI, 1.90-7.97), 83 and 1 matched case-control study reported a higher use of therapeutic-intensity anticoagulation in the groups with upper gastrointestinal bleeding (OR, 1.84; 95% CI, 0.49-6.98) and lower gastrointestinal bleeding (OR, 1.42; 95% CI, 0.14-15.02), 82 but the evidence from both studies was very uncertain. Taking the range of point estimates, this translates into 7 to 46 more major bleeding events per 1000 patients (very low certainty due to risk of bias and imprecision).…”

“…Altogether, there were 5 observational studies that provided evidence related to this question. 69 , 70 , 82 , 83 , 84 Three studies exclusively or largely included patients with laboratory-confirmed COVID-19 who were categorized as severely or moderately ill or hospitalized in a ward other than the ICU. Two studies included patients with laboratory-confirmed COVID-19 who were categorized as critically ill or admitted to the ICU, as no reliable evidence was identified for PE and DVT in acutely ill patients.…”

“…One study reported the effect of therapeutic-intensity anticoagulation on all-cause mortality, 84 1 study reported the effect of intermediate-intensity anticoagulation on the development of PE in critically ill patients, 70 1 study reported the effect of intermediate-intensity anticoagulation on the development of DVT in critically ill patients, 69 and 2 studies reported the effect of therapeutic-intensity anticoagulation on major bleeding. 82 , 83 No studies reported the effect of therapeutic- or intermediate-intensity anticoagulation on multiple organ failure, severe ischemic stroke, intracranial hemorrhage, invasive ventilation, limb amputation, or ST-elevation myocardial infarction.…”

Gastrointestinal manifestations in COVID-19

“…Martin et al. 45 found gastric or duodenal ulcers in 80% of endoscopies for upper GI bleeding and rectal ulcers in 60% of endoscopies when there was lower GI bleeding. Mauro et al.…”

GI-COVID: Are There COVID-19 Patients with Primary Gastrointestinal SARS-CoV-2 Infection and Symptoms?

“…The varying expression and distribution of ACE2 within the GI tract may explain to a degree the GI symptoms experienced by COVID-19 patients. For example, a recent study reported that GI hemorrhage in COVID-19 patients resulted mainly from ulcers in areas of high ACE2 expression within the GI tract, in particular the stomach and the duodenum [ 7 ]. The presence of the SARS-CoV-2 virus in gastric, duodenal, and rectal tissue in the context of GI bleeding has previously been reported [ 6 ].…”