Reply

We thank Aguila et al for their interest in our article and appreciate their perspective on the management of gastrointestinal bleeding during the coronavirus disease 2019 (COVID-19) pandemic.

We agree that the pandemic has caused significant dilemmas for risk-stratification of patients presenting with gastrointestinal (GI) bleeding. The risks of staff exposure and depletion of personal protective equipment need to be weighed against the benefits of endoscopy on a case-by-case basis using clinical judgement. As reported in our study, conservative medical management, including blood product transfusions and proton pump inhibitor use, was emphasized early in the pandemic and inpatient endoscopy volume significantly decreased.¹

A recent study by Blackett et al² found that, among patients undergoing endoscopic procedures in New York City hospitals during the first wave of the pandemic, COVID-positive patients were more likely to have an indication of GI bleeding at 41.7% compared with 29.8% of COVID-negative patients and 24.1% of untested patients. Endoscopies in COVID-positive patients were also more likely to have a hemostatic intervention compared with COVID negative patients (adjusted odds ratio, 2.90; P = .041). These findings likely reflect the higher clinical threshold to pursue endoscopy in COVID-positive patients.

A recent randomized trial found that delaying endoscopy for ≤24 hours does not affect 30-day mortality compared with earlier endoscopy,³ but it is difficult to adapt these guidelines during the pandemic because patients seem to be presenting later in their disease course. In another study from our institution by Laszkowska et al,⁴ the presence of GI symptoms in COVID-positive patients was associated with a longer time from symptom onset to presentation for admission compared with COVID-positive patients without GI symptoms (median, 7.4 days vs 5.4 days; log-rank P < .01). In our study, we found that patients with GI bleeding during the pandemic presented with more severe laboratory abnormalities, which may reflect patients’ reluctance to seek medical care unless symptoms worsen. The ongoing COVID-19 pandemic has presented new challenges in the management of GI bleeding, and future studies are needed to develop evidence-based guidelines relevant to this specific population.