Reduced survival after upper gastrointestinal bleed endoscopy in the COVID-19 era is a secondary effect of the response to the global pandemic: a retrospective cohort study

Abstract

ObjectiveThe COVID-19 pandemic has placed increased strain on healthcare systems worldwide with enormous reorganisation undertaken to support ‘COVID-centric’ services. Non-COVID-19 admissions reduced secondary to public health measures to halt viral transmission. We aimed to understand the impact of the response to COVID-19 on the outcomes of upper gastrointestinal (UGI) bleeds.Design/methodsA retrospective observational multicentre study comparing outcomes following endoscopy for UGI bleeds from 24 March 2020 to 20 April 2020 to the corresponding dates in 2019. The primary outcome was in-hospital survival at 30 days with secondary outcomes of major rebleeding within 30 days postprocedure and intervention at the time of endoscopy.Results224 endoscopies for 203 patients with UGI bleeds were included within this study. 19 patients were diagnosed with COVID-19. There was a 44.4% reduction in the number of procedures performed between 2019 and 2020. Endoscopies performed for UGI bleeds in the COVID-19 era were associated with an adjusted reduced 30-day survival (OR 0.25, 95% CI 0.08–0.67). There was no increased risk of major rebleeding or interventions during this era. Patients with COVID-19 did not have reduced survival or increased complication rates.ConclusionEndoscopy for UGI bleeds in the COVID-19 era is associated with reduced survival. No clear cause has been identified but we suspect that this is a secondary effect of the response to the COVID-19 pandemic. Urgent work is required to encourage the public to seek medical help if required and to optimise patient pathways to ensure that the best possible care is provided.

Systematic review and meta-analysis of clinical outcomes of COVID-19 patients undergoing gastrointestinal endoscopy

“…Five studies 21 , 24 – 27 with a total of 183 COVID-positive subjects reported the case fatality rate in confirmed COVID-19 patients undergoing GI endoscopy ( Figure 3(a) ). Random-effects meta-analysis demonstrates that the total case fatality rate is 0.17 (95% CI = 0.02–0.38).…”

“…Four studies 13 , 24 – 27 with a total of 68 COVID-positive patients pointed out the complication rate in confirmed COVID-19 patients who have undergone GI endoscopy ( Figure 3(b) ). The pooled complication rate is 0.00 (95% CI = 0.00–0.02), and there is no statistically significant difference between the European group and the North American Group ( p -value = 0.90) using a fixed analysis.…”

“…Several studies also revealed that most cases did not die of endoscopy-related incidents but due to SARS-CoV2 infections. 21 , 25 – 27 Hence, we believe the high CFR of COVID-19 patients within GI endoscopy units is dependent of the characteristic baseline of included population. Hence, we strongly believe that the endoscopy-related CFR of COVID-19 patients who receive GI endoscopy is significantly low.…”

“…In regard to endoscopic intervention, only the data involving endoscopic hemostasis can be obtained; the success rate of endoscopic hemostasis was therefore analyzed based on three studies. 13 , 25 , 27 The endoscopic hemostasis procedure shows a high success rate with a pooled value of 89% (95% CI = 50%–100%). The main interventions for hemostasis are endoscopic clipping, hemostatic injection, rectal packing, cautery, and so on.…”

Gastroenterology 2021: from the heart of the COVID-19 pandemic

“…16 To stop the spread of the virus, many patients stayed at home. Secondary effects attributed to a reduction of service provision and the avoidance of healthcare have been sadly observed, including increased mortality from upper gastrointestinal bleeding in London 17 and a reduction in endoscopic gastrointestinal cancer diagnoses at a large UK centre. 18 Furthermore, nationwide lockdowns have led to both an increase in sedentary behaviour and alcohol consumption 19 with a subsequent increase in the number of patients with severe alcohol-related liver disease observed in a London teaching hospital…”