Management of Gastrointestinal Bleeding in Coronavirus Disease: Exploring the Options.

We read with interest the recent article by Martin et al. (1) on the profile and outcomes of gastrointestinal bleeding (GIB) in patients with coronavirus disease (COVID-19). The authors describe the etiologies of GIB and therapeutic interventions in patients with COVID-19 in a real-world scenario. We want to highlight a few important points.

Approximately 63% of patients developed GIB while hospitalized for more than 24 hours, suggesting a cause of bleeding more likely to be related to factors other than a primary disease per se. A larger fraction of patients with GIB had received therapeutic anticoagulation compared with those without GIB (39% vs 27%, although statistically insignificant). Unlike those presenting with GIB, the use of anticoagulation was more common in inpatient GIB (7% vs 42%, P = 0.001). It would be interesting to compare these 2 subsets because GIB in hospitalized patients has a different profile and outcomes than those presenting with GIB.

The overall prevalence of GIB among all COVID-19-admitted patients was 4% (1). By contrast, the reported prevalence of GIB in another study was 0.4% (2). Importantly, the history of GIB was the only significant factor associated with upper GIB in this study. This suggests that inherent risk combined with iatrogenic factors could have played a role, rather than the virus itself. The higher age, comorbidities, use of aspirin and nonsteroidal anti-inflammatory drugs, and mechanical ventilation might have predisposed to the development of upper GIB. Careful use of anticoagulation is warranted in patients with COVID-19 with a history of GIB. Other studies have reported esophagitis, hemorrhagic gastritis, bleeding from varices, Dieulafoy lesion, segmental colitis, colonic ischemia, and diffuse hemorrhagic colitis as causes of GIB (2–4). The etiological spectrum of GIB in the current study seemed to reflect the local epidemiological pattern rather than a relation with the COVID-19 infection.

High viral loads in the upper aerodigestive tract make gastrointestinal endoscopy a high-risk procedure for COVID-19 transmission. Therefore, a major concern while dealing with patients with COVID-19 with GIB is to determine the need for urgent endoscopy and to rationalize the allocation of resources. COVID-19 is usually associated with hypercoagulability, so the risk of uncontrolled bleeding is expected to be low. Even in this study, although the criteria for performing endoscopy were not uniform across the centers, only 12.9% (4 of 31) patients with upper GIB required therapeutic intervention after an average delay of 2.4 days. Thus, most patients responded to conservative therapy, and a delay might minimize the number of emergency endoscopies. In a study from a tertiary care center in India, 24 (1.7%) of 1,382 patients with COVID-19 had GIB at presentation, with majority (91.6%) presumed to be having variceal bleeding (4). Importantly, GIB resolved in all patients with conservative management (use of vasoactive drugs, proton pump inhibitors, and restricted transfusion strategy), and none required emergency endoscopy.

Finally, the authors included patients with COVID-19 free of GIB as controls. It would be interesting to compare the COVID-19 with GIB with matched historical non-COVID-19 patients with GIB to evaluate the impact of COVID-19 infection.

CONFLICTS OF INTEREST

Guarantor of the article: Shalimar, MD, DM.

Specific author contributions: S.S.: Writing of draft. R.K.: Critical revision of draft. Shalimar: Writing of draft and critical revision of draft.

Financial support: None to report.

Potential competing interests: None to report.