Changes to Normal Gastrointestinal Care During the COVID-19 Pandemic

The COVID-19 pandemic has caused physicians in the New York area to reevaluate how they care for patients with gastrointestinal (GI) diseases, including the utilization of more noninvasive procedures, reducing hospital stays, and avoiding surgery. A narrative review detailing this shift was published in Clinical Gastroenterology and Hepatology.

By the third week of the COVID-19 outbreak in New York City, the hospital system reached 40%-80% capacity. To address the rapid influx of patients, 400 GI faculty members and fellows from New York states were redeployed to hospitals in the city, and 1 or 2 GI clinicians continued to work in their specialty. As a result, GI consultations were reduced to 50% and procedures to 80%-90% of normal volume.

Patients experiencing mild to moderate dysphagia who were able to maintain weight and nutrition were deferred to home care. COVID-19 presents with dysphagia, nausea, vomiting, or diarrhea in up to 61% of patients. In many cases, these GI symptoms pre-date respiratory symptoms. Until proven otherwise, individuals experiencing GI distress were considered to be SARS-CoV-2 positive and required to self-quarantine.

During the pandemic, incidence of GI bleeding remained high (70% of consultations) in part due to the GI symptoms in patients with SARS-CoV-2 (Mallory-Weiss tears, profound diarrhea, and hypovolemic-induced ischemic colitis). However, emergency endoscopy evaluation was no longer possible. The review authors recommended deferral for these patients as SARS-CoV-2 symptoms may mimic the hemodynamic effects of a GI bleed. Furthermore, COVID-19 can cause a pro-thrombotic form of disseminated intravascular coagulation, so some patients in the study were treated with an anticoagulant, which exacerbated these symptoms.

Interventional endoscopy, if not needed urgently (within 48 hours), was deferred. The most common emergent interventional procedures were for cholangitis and obstructive jaundice. For these, the review authors recommended percutaneous transhepatic cholangiography as an alternative procedure.

There is no evidence of urgent need for chemoradiotherapy in patients with GI cancer. No guidelines exist for proper integration of lead protection with a thyroid shield with personal protective equipment. For this reason, the review authors recommended a short-term deferral of up to 4 weeks for patients with GI cancers.

The review authors emphasized treatment maintenance for the care of patients with inflammatory bowel disease. Patients who received immunosuppressive therapies at the hospital had their appointments moved to a center that did not treat patients with SARS-CoV-2 and that had a screening procedure in place. The review authors did not recommend therapy interruption or change due to the high risk of flares or recurrences in these patients. They did, however, recommend delaying the start of biologic treatment in patients with manageable symptoms. It was imperative for continuous monitoring of all patients with IBD during this time because it remains unclear what the long-term prognosis is for patients with continuous immunosuppressive treatment.

The review authors concluded that standard GI practices had to be adapted to the current needs of the pandemic and asserted that rapid response, open communication, and implementing strategies that minimized collateral damage were needed.

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Reference

Sethi A, Swaminath A, Latorre M, et al. Donning a new approach to the practice of gastroenterology: perspectives from the COVID-19 pandemic epicenter. [available online April 21, 2020]. Clin Gastroenterol Hepatol. doi:10.1016/j.cgh.2020.04.032