Outcome of Conservative Therapy in Coronavirus disease-2019 Patients Presenting With Gastrointestinal Bleeding

J Clin Exp Hepatol. 2021 May-Jun;11(3):327-333. doi: 10.1016/j.jceh.2020.09.007. Epub 2020 Oct 3.

Abstract

Background/objective: There is a paucity of data on the management of gastrointestinal (GI) bleeding in patients with Coronavirus disease -2019 (COVID-19) amid concerns about the risk of transmission during endoscopic procedures. We aimed to study the outcomes of conservative treatment for GI bleeding in patients with COVID-19.

Methods: In this retrospective analysis, 24 of 1342 (1.8%) patients with COVID-19, presenting with GI bleeding from 22nd April to 22nd July 2020, were included.

Results: The mean age of patients was 45.8 ± 12.7 years; 17 (70.8%) were males; upper GI (UGI) bleeding: lower GI (LGI) 23:1. Twenty-two (91.6%) patients had evidence of cirrhosis- 21 presented with UGI bleeding while one had bleeding from hemorrhoids. Two patients without cirrhosis were presumed to have non-variceal bleeding. The medical therapy for UGI bleeding included vasoconstrictors-somatostatin in 17 (73.9%) and terlipressin in 4 (17.4%) patients. All patients with UGI bleeding received proton pump inhibitors and antibiotics. Packed red blood cells (PRBCs), fresh frozen plasma (FFPs) and platelets were transfused in 14 (60.9%), 3 (13.0%) and 3 (13.0%), respectively. The median PRBCs transfused was 1 (0-3) unit(s). The initial control of UGI bleeding was achieved in all 23 patients and none required an emergency endoscopy. At 5-day follow-up, none rebled or died. Two patients later rebled, one had intermittent bleed due to gastric antral vascular ectasia, while another had rebleed 19 days after discharge. Three (12.5%) cirrhosis patients succumbed to acute hypoxemic respiratory failure during hospital stay.

Conclusion: Conservative management strategies including pharmacotherapy, restrictive transfusion strategy, and close hemodynamic monitoring can successfully manage GI bleeding in COVID-19 patients and reduce need for urgent endoscopy. The decision for proceeding with endoscopy should be taken by a multidisciplinary team after consideration of the patient's condition, response to treatment, resources and the risks involved, on a case to case basis.

Keywords: AD, Acute decompensation; AIH, Autoimmune hepatitis; AIMS65, Albumin, international normalized ratio, mental status, systolic blood pressure, age > 65; CLD, Chronic liver disease; COVID-19, Coronavirus disease −2019; CRS, Clinical Rockall Score; Carvedilol; Endoscopy; FFP, Fresh frozen plasma; GAVE, Gastric antral vascular ectasia; GBS, Glasgow-Blatchford bleeding score; GI, Gastrointestinal; HE, Hepatic encephalopathy; HVPG, Hepatic venous pressure gradient; INR, International normalized ratio; LGI, Lower gastrointestinal; Liver transplant; MOHFW, Ministry of Health and Family Welfare; NSAIDs, Non-steroidal anti-inflammatory drugs; PPE, Personal protective equipment; PRBC, Packed red blood cells; Prognosis; Proton pump inhibitors; RR, Respiratory rate; RT-PCR, Reverse transcriptase polymerase chain reaction; SARS-CoV2, Severe acute respiratory syndrome Coronavirus 2; UGI, Upper gastrointestinal; Variceal bleeding; mGBS, Modified Glasgow-Blatchford bleeding score.