Gastrointestinal Bleeding in COVID-19 Patients


The ongoing COVID-19 pandemic has led to a surge of research aiming to better understand the various clinical manifestations and complications associated with the virus.

Among the diverse range of symptoms reported in COVID-19 patients, gastrointestinal (GI) symptoms have emerged as a notable component.

In this systematic review, the focus is on a specific subset of GI symptoms: gastrointestinal bleeding (GIB) in COVID-19 patients. This review synthesizes the findings from 33 studies that collectively investigated the risk, prevalence, management, and outcomes of GIB in individuals with COVID-19.

Prevalence and Factors Influencing GIB

The studies included in this review collectively examined a substantial cohort of 134,905 COVID-19 patients, among whom 1458 cases of GIB were documented.

The prevalence of GIB, however, exhibited variability across studies, with estimates ranging from as low as 0.47% to as high as 19%.

Several factors were identified as influencing the prevalence of GIB in COVID-19 patients. Notably, GIB appeared to be more common in individuals with COVID-19 who were receiving anticoagulation treatment or exhibited gastrointestinal disturbances. Conversely, studies involving larger samples of COVID-19 patients without apparent GI involvement reported lower prevalence rates, ranging up to 5%. Even at this lower threshold, the clinical significance of GIB remains substantial, especially when considering the potential severity of this complication.

Meta-Analysis Results and Implications

A meta-analysis was conducted to aggregate the available data on GIB prevalence in COVID-19 patients, revealing a pooled prevalence of 3.05%.

The confidence interval for this prevalence ranged from 2.58 to 3.52, with a strikingly high level of heterogeneity at 96%. This indicates that while GIB is not the most common complication of COVID-19, its impact is significant enough to warrant careful consideration. Moreover, the prevalence of GIB substantially increased to 6.2% among patients under anticoagulant or antiplatelet treatment.

Given the common use of such treatments due to COVID-19-associated coagulopathy, any symptoms indicative of GIB in treated patients should prompt investigation and differential diagnosis.

Challenges in Diagnosis and Management

The recommended approach to diagnosing and managing GIB in non-COVID-19 patients involves early endoscopy, ideally within 24 hours of presentation. However, COVID-19 patients pose unique challenges due to their increased vulnerability to pneumonia and the risk of viral transmission during invasive procedures.

While endoscopy remains a valuable tool, its implementation should be approached cautiously and in line with infection control protocols. In cases where endoscopy is not feasible, conservative treatments such as proton pump inhibitors, antibiotics, somatostatin, and terlipressin can be considered, supplemented by interventions like fresh frozen plasma, packed red blood cells, and intravenous fluids.

Endoscopic Procedures and Treatment

Among the cases of GIB in COVID-19 patients, 286 underwent endoscopic procedures. These procedures predominantly involved esophagogastroduodenoscopy due to the prevalence of upper GI bleeding. Various therapeutic techniques were employed during endoscopy, including injectable solutions, hemostatic substances, mechanical methods, elastic rings, hemostatic knots, stapling mechanisms, and cauterization. Surgical intervention was considered if these methods failed. Success rates varied based on patient characteristics and accompanying conditions.

Altered Laboratory Values and Clinical Outcomes

COVID-19 patients with GIB demonstrated altered laboratory values, including a drop in hemoglobin levels, slightly reduced platelet counts, and elevated d-dimer levels. These changes reflect a combination of bleeding, COVID-19 infection, and anticoagulant treatments. Mortality outcomes in COVID-19 patients with GIB were often linked to the severity of COVID-19 infection itself, with only a small proportion of deaths directly attributed to GIB. Factors such as the use of corticosteroids, anticoagulants, and patient comorbidities contributed to the complex interplay between COVID-19 severity and GIB.

Clinical Implications and Future Research

This systematic review underscores the importance of recognizing GIB as a potential and significant complication in COVID-19 patients. While not the most common manifestation of the disease, GIB holds clinical significance due to its potential for urgent treatment requirements and adverse outcomes.

The prevalence of GIB is influenced by factors such as anticoagulant treatment, and caution is advised in COVID-19 patients receiving such therapies. Further research is warranted to explore the safety of endoscopic interventions in COVID-19 patients and to elucidate the direct mechanisms underlying GIB in this population. As the pandemic continues to evolve, understanding and managing the diverse complications of COVID-19 remain crucial for optimal patient care.

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