Acute lower gastrointestinal bleeding during the COVID-19 pandemic – less is more!

The COVID-19 pandemic has presented physicians with unique challenges worldwide. In the USA, in an attempt to reduce the spread of infection, elective procedures were deferred nationwide during the pandemic [1], yet urgent and emergent procedures continued to be performed. The American Gastroenterological Association recommends that colonoscopy for lower gastrointestinal bleeding (LGIB) is considered urgent [2]. However, many factors affect this decision, including the availability of staff and personal protective equipment (PPE), and the surge of COVID-19 cases in the region. Further, active respiratory infection (such as COVID-19) increases the risk of procedures requiring sedation. A recent report demonstrated successful conservative management in six patients with upper GI bleeding (UGIB) [3]; however, to our knowledge there are no reports on COVID-19 patients with LGIB.

A total of 11 COVID-19 patients who developed LGIB from two tertiary care hospitals in Boston were evaluated. Of these, 10 were managed in the intensive care unit. No patient underwent an endoscopic procedure, but one underwent interventional radiology-guided embolization. In 10 patients, no re-bleeding occurred within 48 hours. Eight patients were on anticoagulation; in seven of these, anticoagulation was resumed during hospitalization without evidence of re-bleeding. Antiplatelet agents were not discontinued in any patients. None of the 11 patients required a subsequent blood transfusion after their initial bleed. Three patients died from complications that were related to COVID-19 and not due to LGIB ([Table 1]).

Table 1 Characteristics and outcomes of the 11 patients with COVID-19 and lower gastrointestinal bleeding (LGIB).

Demographics
Sex, male, n (%)	6 (55 %)
Age, median, years	64
GI bleed characteristics, n (%)
Hematochezia	11 (100 %)
Prior GI bleed	1 (9 %)
History of cirrhosis	0
Risk factors for colonic ischemia	10 (91 %)
History of colonic ischemia	1 (9 %)
Need for blood transfusion	7 (64 %)
CT abdominal imaging done	8 (73 %)
CT positive for bleeding	1 (13 %)
Endoscopic procedure performed	0
Interventional radiology embolization performed	1 (9 %)
Anticoagulant/antiplatelet agent use, n (%)
Total on anticoagulant medication	8 (73 %)
Enoxaparin	2 (25 %)
Heparin infusion	3 (38 %)
Apixaban	3 (38 %)
Total on anticoagulation prior to hospitalization	6 (75 %)
Restarted on anticoagulation	7 (88 %)
Total on antiplatelet agent	4 (36 %)
Aspirin	3 (75 %)
Clopidogrel	1 (25 %)
Total on both anticoagulant and antiplatelet agent	2 (18 %)
COVID-19 characteristics
Initial oxygen saturation on room air, median	87 %
Multifocal pneumonia on chest x-ray, n (%)	11 (100 %)
Intubated, n (%)	8 (73 %)
Subsequently extubated, n (%)	2 (25 %)
Vasopressors for septic shock, n (%)	9 (82 %)
Laboratory data
Hemoglobin, median (range), g/dL; normal 11 – 15	10.7 (6.6 – 13.8)
Hematocrit, median (range), %; normal 32 – 45	33.6 (21.1 – 44.9)
Platelets, median (range), K/μL; normal 150 – 400	211 (86 – 361)
INR, median; normal 0.9 – 1.3	1.2
D-dimer, median, ng/mL; normal 0 – 243	405
CRP, median, mg/L; normal 0 – 7.48	38.6
Ferritin, median, ng/mL; normal 22 – 277	1063
LDH, median, IU/L; normal 120 – 220	551
Outcomes, (n%)
Re-bleed within 48 hours	1 (9 %)
Further transfusion required for LGIB after first episode	0
Death from septic shock	3 (27 %)
Death from hemorrhagic shock	0

CT, computed tomography; INR, international normalized ratio; CRP, C-reactive protein; LDH, lactate dehydrogenase.

There is no widely accepted risk stratifying score for LGIB, unlike for UGIB [4] [5]. Therefore, there is greater ambiguity in deciding when to intervene for LGIB. This becomes especially important in a pandemic setting. The timing of colonoscopy in LGIB has previously been shown to have no impact on mortality [6]. The focus during the pandemic should be on patient-important outcomes [7]. While LGIB might create significant apprehension for the patient and physician, for patients who remain hemodynamically stable without active bleeding, colonoscopy is unlikely to positively impact patient-important outcomes.

The mortality risk in COVID-19 patients relates more to the severity of their respiratory failure than to their LGIB. The pulmonary fragility of these patients, their increased risk of intra-procedural complications, the limited availability of PPE, and the need to reduce unnecessary exposure for the endoscopy team are all factors that should be taken into account while making the decision to pursue colonoscopy versus conservative management in this patient subset. Our report suggests that conservative management in COVID-19 patients with LGIB may be a reasonable strategy in the majority of cases.

Publication History

Article published online:
26 August 2020

• References

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