COVID‐19 and the digestive system: More than just a “flu”

Although initially considered another “flu” illness, the new Coronavirus Disease 2019 (COVID‐19) infection has morphed into a global pandemic, the likes of which we have not seen in recent times. Fundamentally regarded as a respiratory illness and caused by the coronavirus 2 (SARS‐CoV‐2), it is spread as an airborne infection. COVID‐19 has been shown to be a highly infectious disease. As a new virus and with the world's population lacking any immunity to the virus, COVID‐19 has now spread like wildfire throughout the world.

In this June issue, JGH Open has published two Leading Articles on the COVID‐19 infection: the first is the “Asian Pacific Association of Gastroenterology (APAGE) Inflammatory Bowel Disease (IBD) Working Party Guidelines on the IBD during the COVID‐19 pandemic ¹ and the second an excellent review article by Aguila et al. focusing on gastrointestinal and liver complications of COVID‐19 infection and endoscopy practice.” ²

Studies have shown that the virus enters cells of the body through ACE II receptors. ³ The gastrointestinal (GI) tract, with the exception of the esophagus and the biliary tract, contains an abundance of these receptors, and it is not surprising that GI complications occur in up to 20% of patients and liver involvement in up to 50% of patients infected with this virus. ⁴ , ⁵ GI complications mimic acute gastroenteritis with complaints of diarrhea and abdominal pain. In the present time, it would be important to exclude COVID‐19 infection in patients presenting with these complaints. Liver complications are usually mild but can be severe, especially if they are also part of a multisystem organ failure syndrome that many COVID‐19 patients suffer in the terminal stages of their illness. ⁵ , ⁶ Aguila et al. have provided a succinct review of the complications of GI and liver diseases in collaboration with COVID‐19 infection. ²

Detection of a high volume of viral RNA in the feces of patients was also reported in up to 50% of patients with COVID‐19, and these findings raise the possibility that SARS‐CoV‐2 can be transmitted via the fecal–oral route. ⁷ It is alarming that the virus' nucleic acid in feces can be detected even beyond the time of clearance of virus RNA from respiratory samples of patients. ⁴ Therefore, it is advisable for health‐care workers to practice caution in collecting stool samples and while performing colonoscopy.

Aguila et al. have also outlined practical steps that must be taken in the endoscopy room. ² As with other procedures, only urgent or emergency cases should be performed. A more detailed description of steps to be taken with GI endoscopy and precautions in the endoscopy suite in the Asia Pacific region is well described by Chiu et al. ⁸

The inflamed intestinal lining in IBD patients demonstrates an increase in ACE II receptors. ⁹ As such, there has been concern that SARS‐CoV‐2, which binds to target cells through ACE II receptors, may increase the risk of developing COVID‐19 in IBD patients. IBD patients who are on immunosuppressive agents and biological drugs have impaired immunity. The APAGE working party has focused on management issues with regard to COVID‐19 and IBD and mainly to maintain IBD disease control while ensuring patients safety at the same time. ¹ The working party recommended that, for IBD patients not infected with COVID‐19, 5‐aminioslciylates should be continued. If patients are in remission, they should continue with their prescribed immunosuppressive agents. Corticosteroid usage should be minimized, and if biologicals need to be started, newer agents, such as vedolizumab or ustekinumab, should be considered. In the meantime, IBD patients who are infected with COVID‐19 are recommended, where possible, to stop corticosteroids, immunomodulators, and biological agents until clearance of the virus. ¹

It is interesting to speculate, with the occurrence of a “cytokine storm” in COVID‐19 infections, whether biological agents that are used for severe cases of IBD may in fact help with the treatment of severe COVID‐19 infection. ¹⁰ , ¹¹

While the whole world is reeling from the monumental blow of the COVID 19 infection on our health, social, and economic well‐being and a near total lockdown on all our activities, this enforced respite has also forced us to focus and plan ahead for future pandemics that we may be confronted with. This “quiet time” has also given us the opportunity to reflect and recalibrate and to think on what is truly important in our lives.