Endoscopic examinations reveal abnormalities in a high proportion of COVID-19 cases, researchers report in Clinical Gastroenterology and Hepatology. Peptic ulcers and esophagitis were detected in most upper GI endoscopies, and colitis, ranging from mild to more severe ulcerative lesions, was the most common finding during colonoscopy. No endoscopists became infected after the procedures in this study.
The reported prevalence of digestive symptoms ranges in patients with COVID-19 ranges from 3% to 79%, depending on the study. However, there have been few data on GI endoscopic and histologic findings from patients with COVID-19.
Sara Massironi et al performed a retrospective study of patients with confirmed SARS-CoV-2 infection who underwent an endoscopic examination at 7 hospitals in Italy, from February 21 through April 20, 2020. Findings from 24 esophagogastroduodenoscopies (EGDs) and 20 colonoscopies, in 38 patients, were examined.
Endoscopic lesions were observed in 75% of EGDs and 70% of colonoscopies. Main findings from EGD were 5 cases of esophagitis (20.8%), 5 cases of bulbar ulcer 5 (20.8%), 4 cases of erosive gastritis (16.6%), 2 neoplasms (8.3%), and 1 Mallory-Weiss tear (4.1%).
The main findings from colonoscopy were segmental colitis associated with diverticulosis in 5 cases (25%), histologically confirmed colon ischemia in 4 cases (20%), diffuse hemorrhagic colitis in 1 case, and neoplasm in 1 case. In 3 patients the colonic mucosa appeared normal, but there was histologic evidence of microscopic (2 cases) and lymphocytic (1 case) colitis.
Most of the patients required endoscopy because of GI bleeding, possibly due to low molecular weight heparin therapy (76% of patients), bleeding predisposition in patients with severe infection, and/or disseminated intravascular coagulation.
Massironi et al propose that the high proportion of ulcerative colonic lesions observed, with pictures superimposed on either segmental colitis associated with diverticulosis or colonic ischemia, indicate ischemic injury—possibly due to a thrombotic dysfunction attributable to excessive inflammation, platelet activation, and endothelial dysfunction. The authors also point out that colonic ischemia can be caused by a hypoperfusion state, due to transient hypotension or shock related to sepsis itself. However, SARS-CoV-2 might also have a direct inflammatory effect on the GI mucosa.
This was a small, retrospective study—larger prospective studies are needed of these effects in patients with COVID-19. More research is also needed to elucidate the extent to which some of the endoscopic and histologic findings can be attributed to the virus.
Massironi et al state that the fact that none of the endoscopists became infected is reassuring.