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The coronavirus disease (COVID-19) pandemic presents hardships and challenges for patients and healthcare providers. Physicians, nurses, and staff involved in every field of medicine, including gastroenterology (GI), will likely encounter patients already sick with the virus and patients under investigation (PUI) for COVID-19. To prevent the spread of the virus, and to protect themselves, healthcare workers will have to change how they interact with patients. COVID-19 may be especially impactful for GI doctors in that there is potential for coronavirus transmission through droplets and perhaps even fecal shedding. These could pose risks to patients and personnel during endoscopy and colonoscopy.

The virus behind COVID-19, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), typically causes fever, cough, sore throat and fatigue. However, it can also cause gastrointestinal illnesses. In fact, up to 50 percent of patients with COVID-19 report nausea, diarrhea, and other GI symptoms, according to the American College of Gastroenterology.

The GI Tract – A Potential Route of Coronavirus Infection

SARS-CoV-2 may be present in gastrointestinal secretions and viral RNA is detectable in stool, according to the American College of Gastroenterology. The results of a study published in the journal Gastroenterology March 3, 2020, show the GI tract is a welcoming environment for SARS-CoV-2. A team of researchers in China enrolled 73 patients hospitalized for possible COVID-19. They were then tested from February 1 to 14, 2020, into the study. The team collected and tested serum, oropharyngeal and nasopharyngeal swabs, tissue, urine, and stool samples. Thirty-nine patients (53.4 percent) tested positive for fecal SARS-CoV-2 RNA.

“Our immunofluorescence data showed that the ACE2 protein, which has been proved to be a cell receptor for SARS-CoV-2, is abundantly expressed in the glandular cells of gastric, duodenal, and rectal epithelia, supporting the entry of SARS-CoV-2 into the host cell,” wrote the team. “Our results of SARS-CoV-2 RNA detection and intracellular staining of viral nucleocapsid protein in gastric, duodenal and rectal epithelia demonstrate that SARS-CoV-2 infects these gastrointestinal glandular epithelial cells. Although viral RNA was also detected in esophageal mucous tissue, absence of viral nucleocapsid protein staining in esophageal mucosa indicates low viral infection in esophageal mucosa.”

Another paper published in the journal that same day suggests the novel coronavirus has the potential to be transmitted by the fecal-oral route. The SARS coronavirus showed up in stool, even in some patients discharged from the hospital.

The authors of that paper noted that the first confirmed case in the United States reported nausea and vomiting upon admission and a loose bowel movement on the second day of hospitalization. Furthermore, the team noted recent reports of mild to moderate liver injury in COVID-19 patients, as evidenced by elevated aminotransferases, hypoproteinemia, and prothrombin time prolongation.

How GI Doctors and Patients Can Help Stop the Spread of COVID-19

Gastroenterologists can help flatten the curve of COVID-19 spread between patients, themselves and staff members.

Reschedule non-urgent endoscopic procedures

Consider rescheduling colon cancer screening and standard polyp removal for patients at average risk. Take extra precautions when performing non-urgent procedures of higher priority. These include cancer evaluations, evaluation of significant symptoms, and prosthetic removals.

Be aware that COVID-19 may present GI symptoms first

COVID-19 patients may complain of gastrointestinal symptoms such as nausea or diarrhea. Laboratory findings described in COVID-19 patients include liver function test abnormalities.

Pre-screen all patients for symptoms and risk exposure

Ask patients about history of fever or respiratory symptoms. Inquire about the patient’s family members or close contacts with similar symptoms. This also includes contact with someone with COVID-19, or travel to a high-risk area.

Avoid bringing older adults into the clinic or hospital setting

People who are 65 and older are more likely to develop serious COVID-19 disease, according to the U.S. Department of Health and Human Services’ Administration for Community Living.

Implement telemedicine visits whenever possible

Physicians should consider implementing telemedicine visits into their practice or look for ways to reduce the number of older adults coming into their clinics.

Identify high-risk patients

Identify older patients that are at higher risk for complications from infection due to chronic medical conditions. Among these are heart and lung disease, diabetes, decompensated cirrhosis, and HIV with low CD4 counts. Immunosuppressive therapies, such as those used in liver and solid organ transplant recipients and treatment for inflammatory bowel disease (IBD), can increase patient risk for complications from infections, including coronavirus infections.

Screen patients arriving for endoscopy

Check the body temperature of all patients arriving for GI procedures. Ask for updates in personal and family health status and symptoms.

Use PPE during endoscopy

Use personal protective equipment (PPE) during endoscopy, as the GI tract may be a potential route of coronavirus infection. PPE includes gloves, mask, face shields, eye shield/goggles, and gown. Use the sequence for putting on PPE as outlined by the CDC. To conserve the supply of PPE, allow only essential personnel to be present during cases. Consider extending the use or reuse of surgical masks and eye protection in accordance with hospital or clinic policies.

Use isolation procedures for Covid-19 positive patients

For COVID-19 positive patients and for those awaiting test results, use isolation procedures. You should also perform their procedures in a negative pressure room.

Provide patient guidance about corona and GI

Patients who take immunosuppressive drugs for IBD and autoimmune hepatitis should continue taking their medications. This is because the risk of untreated disease outweighs the chance of contracting coronavirus. These patients should avoid crowds, limit travel, and adhere to other CDC guidelines for at-risk groups.

Anticipate supply chain disruptions

The Centers for Disease Control and Prevention (CDC) suggests patients keep a 30-day supply of non-prescription medications on hand, and talk to their doctors, insurers and pharmacists about creating an emergency supply of prescription drugs. This might be easier said than done, though, because about 80 percent of active pharmaceutical ingredients (APIs) come from China and India; both were hard hit by the pandemic, so shortages of prescription drugs in the United States are possible.

Above all, wash hands frequently and require patients and staff to practice social distancing. Together, GI doctors, healthcare providers and patients can slow the spread of COVID-19.

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