Gastrointestinal bleeding in patients with COVID-19 appears to be uncommon, only occurring in 1.5% to 3.0% of patients hospitalized with the infection. However, it is still a contributing factor to the many disease complications, according to a new literature review.
“Although COVID-19 is primarily a respiratory disease with prominent respiratory symptoms and frequent respiratory compromise, GI manifestations play an important secondary role in the morbidity and even rarely in the mortality of this infection,” noted the authors of the review.
To assess the risk for GI bleeding in COVID-19 patients, the researchers conducted a semiquantitative review of the literature through September 2022 using PubMed and Ovid (Gastroenterol Clin North Am 2023;52[1]:77-102).
The researchers found GI bleeding to be generally mild to moderate in COVID-19?infected patients, rarely being severe enough to necessitate endoscopy. It generally was related to mild to moderate mucosal inflammation.
Severe or life-threatening GI bleeding was more common in patients who had peptic ulcer disease or stress gastritis associated with severe COVID-19 pneumonia.
The team reported several causes of upper GI bleeding in proximity to the ligament of Treitz in COVID-19 patients. Petechial/hemorrhagic lesions were a common finding, occurring in 9.2% of COVID-19 patients undergoing esophagogastroduodenoscopy (EGD) in a large study. There was increased reporting of esophageal variceal hemorrhages in COVID-19 patients with cirrhosis, chronic liver disease or advanced alcohol-associated liver disease.
Reported causes of jejunal and ileal bleeding with COVID-19 were jejunal ulcers, hemorrhagic enteritis, and in some cases, small and large intestinal mucosal sloughing, or gastrointestinal stromal tumor in the jejunum.
Lower GI bleeding associated with COVID-19 infection frequently was due to ischemic colitis.
Endoscopy in the COVID-19 Setting
Bleeding was seldom evaluated by GI endoscopy in COVID-19 patients at the onset of the pandemic, but more recently, the researchers found patients with moderate bleeding from COVID-19 are undergoing semi-elective GI endoscopy more often.
When deemed necessary, endoscopists can decrease the risk for disease spread with COVID-19 vaccination along with personal protective equipment (PPE) for endoscopic staff, they wrote. Staff should exercise caution when performing EGD on all patients, but especially on COVID-19 patients, the researchers noted. EGD procedures pose a high risk for transmitting SARS-CoV-2 virus from patient to endoscopy staff because of the presence of aerosolized infectious droplets, they noted. Endoscopy staff should strongly consider donning PPE, including an N95 mask.
The researchers noted that disparate results from different studies around the world reflect differences in criteria for GI bleeding, patient demographics, rates of infection and study design. The literature also was conflicting concerning predisposing factors and the relationship to outcomes, including mortality.
Despite these shortcomings, the authors wrote that they felt this work could help to guide gastroenterologists in treating these patients who develop GI bleeding during COVID-19 infection.
—Joe Morreale