Untying the knot: Acute variceal bleeding in a COVID-19 patient. What should the gastroenterologist keep in mind?

Coronavirus disease 2019 (COVID-19) has rapidly spread throughout the world, affecting medical practice. Although it usually presents with respiratory symptoms, gastrointestinal and/or liver involvement might sometimes constitute basic manifestations [1–3]. A 40-year-old male with alcoholic Child–Pugh C cirrhosis presented fever, dyspnea and worsening of liver-function tests (LFTs). He tested positive for COVID-19 and was hospitalized. His temperature was 38.5°, he was disoriented and icteric with ascites. Laboratory values included bilirubin: 13.38 mg/dL, aspartate transaminase: 73 IU/L, gamma-glutamyl transpeptidase: 144 U/L, albumin: 1.8 g/dL. A computed tomography scan revealed mild lung involvement, ascites and varices in the hepatogastric space. The following day, the patient had episodes of hematemesis. Coagulation deteriorated (international normalized ratio from 1.02 to 3.56, fibrinogen from 443 to 152 mg/dL, activated-partial-thromboplastin time 82.1 s and D-dimers: 15 759 μg/L). He was intubated and transferred to our COVID-19- dedicated ICU, with negative-pressure chambers, for emergency endoscopy. An endoscopic tower was specially prepared for COVID-19 cases (Fig. 1). Upper gastrointestinal-endoscopy revealed esophageal varices actively bleeding; band ligation was performed, resulting in effective hemostasis. However, despite supportive care (including hydroxychloroquine and piperacillin-tazobactam), he remained febrile, LFTs and renal function deteriorated and he succumbed the next day.

Fig. 1.

Protection of the endoscopic tower. A surgical field covers the tower and a transparent cover protects the screen, in an attempt to minimize contact with contaminated material and reduce the infection risk for the cleaning personnel.

Our case is a rare combination of variceal bleeding in a COVID-19 patient. Recently, 95 COVID-19 patients were reviewed for gastrointestinal manifestations [4]. Fifty-eight (49.5%), had mostly nonspecific symptoms, including anorexia/nausea in 17.9% and diarrhea (3.2% at admission and 24.2% during hospitalization). Gastrointestinal-bleeding was rare, encountered in two patients (2.1%); these and four other patients underwent upper gastrointestinal-endoscopy; esophageal erosions and ulcers positive for the virus were found in one bleeding patient with severe COVID-19. No endoscopic interventions were undertaken. Hepatic manifestations also occur in COVID-19 [2,3]. Our patient had decompensated cirrhosis and, although evidence is scarce, COVID-19 could have affected his rapid hepatic deterioration. Hypoalbuminemia has been linked to COVID-19 severity. Could our patient’s hypoalbuminemia have been an “alarm” for his bad outcome? The association could have been via acute-on-chronic disease through direct viral hepatotoxicity, COVID-19-related disseminated intravascular coagulation or drug-hepatotoxicity [2,3]. Naturally, coexisting infection from other pathogens or random coexistence could also be the case.

Gastrointestinal-endoscopy in COVID-19 patients is a risky procedure for infection, requiring close contact with the patient, especially in active bleeding, where blood might splash on personnel and surfaces [5]. In our case, an advanced personal protective equipment was used, and endoscopy was performed in a negative-pressure room with the patient intubated, using a dedicated tower, which could ideally be stored in this room, minimizing unnecessary movements of contaminated material. A tip, which could apply for practical issues of this sort, is to plan on how these procedures will be undertaken and even to rehearse them in co-operation with hospital infectious control authorities. Such measures could guaranty the best possible outcomes for these complicated cases.

Acknowledgements

Conflicts of interest

There are no conflicts of interest.