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

Am J Gastroenterol. 2020 Oct;115(10):1609-1616. doi: 10.14309/ajg.0000000000000805.


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.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Anticoagulants / adverse effects
  • Betacoronavirus / pathogenicity*
  • Blood Transfusion / statistics & numerical data
  • COVID-19
  • Case-Control Studies
  • Coronavirus Infections / complications*
  • Coronavirus Infections / epidemiology
  • Coronavirus Infections / therapy
  • Coronavirus Infections / virology
  • Endoscopy / statistics & numerical data
  • Enema / adverse effects
  • Enema / instrumentation
  • Female
  • Gastrointestinal Hemorrhage / epidemiology*
  • Gastrointestinal Hemorrhage / etiology
  • Gastrointestinal Hemorrhage / therapy
  • Hemostatic Techniques / statistics & numerical data
  • Humans
  • Male
  • Middle Aged
  • Pandemics
  • Peptic Ulcer / complications
  • Peptic Ulcer / epidemiology*
  • Pneumonia, Viral / complications*
  • Pneumonia, Viral / epidemiology
  • Pneumonia, Viral / therapy
  • Pneumonia, Viral / virology
  • Rectal Diseases / epidemiology*
  • Rectal Diseases / etiology
  • Rectal Diseases / therapy
  • Risk Factors
  • SARS-CoV-2


  • Anticoagulants