What Should Gastroenterologists and Patients Know About COVID-19?
Physicians need to consider that gastrointestinal (GI) symptoms, such as nausea, vomiting, and diarrhea could be early signs of COVID-19 infection, especially in those GI patients who also present with upper respiratory complaints. Meanwhile, patients with digestive diseases should closely monitor the news and stay in touch with their doctors if they experience new or unusual GI symptoms.
These were among the insights summarized recently by clinical researchers at the Icahn School of Medicine at Mount in New York City. They also provided renewed guidance to physicians for those patients who have inflammatory bowel disease (IBD) and are being treated with immunosuppressive agents. Research suggests, they said, these patients may be considered at high risk for COVID-19, which is caused by the SARS-CoV-2 virus.
“This is a rapidly evolving area with new information emerging on a daily basis,” said Ryan Ungaro, MD, MS, Assistant Professor of Medicine (Gastroenterology). “We strongly urge our patients to closely monitor the news and to stay in touch with their doctors if they experience new or unusual GI symptoms.”
For physicians seeing a patient with predominant GI symptoms, and some respiratory symptoms, “COVID-19 should be part of a differential diagnosis,” he added.
Dr. Ungaro and world-renowned physician-scientist Jean-Frederic Colombel, MD, published an overview of COVID-19 research findings for the gastroenterology community to help them address their patients’ questions and concerns. It was published on March 17, 2020, in Clinical Gastroenterology and Hepatology, a journal of the American Gastroenterological Association. Dr. Colombel is Director of the Susan and Leonard Feinstein Inflammatory Bowel Disease Clinical Center at Mount Sinai, and Professor of Medicine (Gastroenterology). Also contributing were Mount Sinai’s Timothy Sullivan, MD, Assistant Professor of Medicine (Infectious Diseases), and Gopi Patel, MD, Associate Professor of Medicine (Infectious Diseases).
In their overview, the researchers recounted what has been learned to date:
— The SARS-CoV-2 virus shares 79.5 percent of the genetic sequence of SARS, a respiratory illness caused by a coronavirus that appeared in 2002.
— In that outbreak, diarrhea was reported in up to 25 percent of SARS patients.
— The reported frequency of diarrhea among COVID-19 patients has varied from 2 percent to 33 percent, however, it was one of the prominent symptoms reported in the first U.S. COVID-19 case.
— SARS-CoV-2 has been detected in the stool of COVID-19 patients.
— Common laboratory findings described in COVID-19 patients also include liver function test abnormalities.
“While COVID-19 appears to primarily spread through respiratory droplets and secretions,” the authors wrote, “the gastrointestinal tract may be another potential route of infection.” With this possibility, they reinforced the importance that gastroenterologists use personal protective equipment during endoscopy.
They acknowledged that there are no data currently about the impact of immunosuppressive agents. “At the current time, we should not advise IBD patients, or others on immunosuppressive agents, such as those with autoimmune hepatitis, for example, to hold or stop medications,” they wrote, as the risk of disease flare is still a larger concern at this time. They further suggested that physicians advise their patients on immunosuppression to follow the Centers for Disease Control and Prevention (CDC) guidelines for at-risk populations.
They additionally highlighted new evidence on the cell entry receptor ACE2. “Interestingly,” they wrote, “the cell entry receptor ACE2 appears to mediate entry of SARS-CoV-2,” a similar phenomenon observed with SARS, “and has been demonstrated to be highly expressed in small intestinal enterocytes,” the intestinal absorptive cells that line the inner surface of the small and large intestines. ACE2 is important in regulating nutrient absorption, in particular basic amino acids such as tryptophan, and its disruption may lead to diarrhea.
Mount Sinai is actively studying ACE2 expression in intestinal tissue, said Dr. Ungaro, referring to the work of Saurabh Mehandru, MD, Associate Professor of Medicine (Gastroenterology). “We are particularly interested in determining if the ACE2 inhibitor is differentially expressed in patients with inflammatory conditions of the GI tract to better understand this patient population’s susceptibility to SARS-CoV-2.”
Additionally, Mount Sinai, with collaborators from the University of North Carolina, has started a web-based registry for physicians to report any IBD patients who have a confirmed case of COVID-19. The goal is to better understand the impact of immunosuppressive medications and other risk factors to best guide clinical decisions, he said.
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These were among the insights summarized recently by clinical researchers at the Icahn School of Medicine at Mount in New York City. They also provided renewed guidance to physicians for those patients who have inflammatory bowel disease (IBD) and are being treated with immunosuppressive agents. Research suggests, they said, these patients may be considered at high risk for COVID-19, which is caused by the SARS-CoV-2 virus.
“This is a rapidly evolving area with new information emerging on a daily basis,” said Ryan Ungaro, MD, MS, Assistant Professor of Medicine (Gastroenterology). “We strongly urge our patients to closely monitor the news and to stay in touch with their doctors if they experience new or unusual GI symptoms.”
For physicians seeing a patient with predominant GI symptoms, and some respiratory symptoms, “COVID-19 should be part of a differential diagnosis,” he added.
Dr. Ungaro and world-renowned physician-scientist Jean-Frederic Colombel, MD, published an overview of COVID-19 research findings for the gastroenterology community to help them address their patients’ questions and concerns. It was published on March 17, 2020, in Clinical Gastroenterology and Hepatology, a journal of the American Gastroenterological Association. Dr. Colombel is Director of the Susan and Leonard Feinstein Inflammatory Bowel Disease Clinical Center at Mount Sinai, and Professor of Medicine (Gastroenterology). Also contributing were Mount Sinai’s Timothy Sullivan, MD, Assistant Professor of Medicine (Infectious Diseases), and Gopi Patel, MD, Associate Professor of Medicine (Infectious Diseases).
In their overview, the researchers recounted what has been learned to date:
— The SARS-CoV-2 virus shares 79.5 percent of the genetic sequence of SARS, a respiratory illness caused by a coronavirus that appeared in 2002.
— In that outbreak, diarrhea was reported in up to 25 percent of SARS patients.
— The reported frequency of diarrhea among COVID-19 patients has varied from 2 percent to 33 percent, however, it was one of the prominent symptoms reported in the first U.S. COVID-19 case.
— SARS-CoV-2 has been detected in the stool of COVID-19 patients.
— Common laboratory findings described in COVID-19 patients also include liver function test abnormalities.
“While COVID-19 appears to primarily spread through respiratory droplets and secretions,” the authors wrote, “the gastrointestinal tract may be another potential route of infection.” With this possibility, they reinforced the importance that gastroenterologists use personal protective equipment during endoscopy.
They acknowledged that there are no data currently about the impact of immunosuppressive agents. “At the current time, we should not advise IBD patients, or others on immunosuppressive agents, such as those with autoimmune hepatitis, for example, to hold or stop medications,” they wrote, as the risk of disease flare is still a larger concern at this time. They further suggested that physicians advise their patients on immunosuppression to follow the Centers for Disease Control and Prevention (CDC) guidelines for at-risk populations.
They additionally highlighted new evidence on the cell entry receptor ACE2. “Interestingly,” they wrote, “the cell entry receptor ACE2 appears to mediate entry of SARS-CoV-2,” a similar phenomenon observed with SARS, “and has been demonstrated to be highly expressed in small intestinal enterocytes,” the intestinal absorptive cells that line the inner surface of the small and large intestines. ACE2 is important in regulating nutrient absorption, in particular basic amino acids such as tryptophan, and its disruption may lead to diarrhea.
Mount Sinai is actively studying ACE2 expression in intestinal tissue, said Dr. Ungaro, referring to the work of Saurabh Mehandru, MD, Associate Professor of Medicine (Gastroenterology). “We are particularly interested in determining if the ACE2 inhibitor is differentially expressed in patients with inflammatory conditions of the GI tract to better understand this patient population’s susceptibility to SARS-CoV-2.”
Additionally, Mount Sinai, with collaborators from the University of North Carolina, has started a web-based registry for physicians to report any IBD patients who have a confirmed case of COVID-19. The goal is to better understand the impact of immunosuppressive medications and other risk factors to best guide clinical decisions, he said.
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