Зважаючи на те, що інфекція спричинена вірусом COVID-19 може викликати шлункові та кишечні симптоми, гастроентерологи повинні пам’ятати про короновірусну інфекцію при веденні пацієнтів з поєднанням гастроентерологічних та респіраторних симптомів.
Крім того, пацієнти з запальними захворюваннями кишечника мають бути віднесені до високого ризику інфікування COVID-19 якщо лікуються із застосуванням імуносупресивної терапії, про що йдеться в останній публікації проф. Ryan Ungaro з колегами у Clinical Gastroenterology and Hepatology.
Нещодавно декілька гастроентерологічних асоціацій, включаючи Американську гастроентерологічну асоціацію, оприлюднили спільні рекомендації для гастроентерологів, наголошуючи на тому, що «останні докази припускають можливість поширення коронавірусу не лише повітряно-крапельним, але й фекально-оральним шляхом». Це означає, серед іншого, можливий ризик трансмісії під час виконання ендоскопічних досліджень.
Ungaro з колегами звертають увагу на те, що пацієнти інфіковані COVID-19 можуть скаржитись на гастроінтестинальні проблеми, зокрема, нудоту або діарею, подібно до того, що спостерігалось при спалаху SARS. Діарея була провідним симптомом у першому випадку COVID-19, який виник у США і новітній коронавірус SARS-CoV-2 був виявлений у фекаліях пацієнта.
«Важливо, що клітинні рецептори АСЕ2 ймовірно є відповідальними за потрапляння вірусу SARS-CoV-2 у клітини (аналогічно тому, що спостерігалось із вірусом SARS). Такі рецептори присутні у великій кількості в ентероцитах людини» - зазначають автори. «АСЕ2 – важливі рецептори у контролі кишкового запалення і порушення їх функції може бути асоційованим з появою діареї».
"Interestingly, the cell entry receptor ACE2 appears to mediate entry of (similar to SARS) and has been demonstrated to be highly expressed in small intestinal enterocytes," the authors wrote. "ACE2 is important in controlling intestinal inflammation and its disruption may lead to diarrhea."
Ungaro told MedPage Today that gastroenterologists should be aware they may be encountering cases with predominantly GI symptoms.
"If you're seeing a patient with GI symptoms and some degree of upper respiratory symptoms," COVID-19 should be part of a differential diagnosis, he said.
He also emphasized that medical personnel should protect themselves against infection during endoscopy procedures.
"Gastroenterologists and staff should be donning personal protective equipment [PPE] as recommended by their institution" such as surgical masks, face shields, and eye shields, he said.
Joint GI society guidelines include strongly considering rescheduling elective or non-urgent endoscopic procedures, pre-screening all patients for high risk exposure or symptoms, and making sure appropriate PPE is available and worn by all members of the endoscopy team, and more importantly, that PPE is put on and taken off correctly.
Beyond the procedures they perform, gastroenterologists need to be aware of their IBD patients on immunomodulators or biologics, as well as other GI patients on immunosuppressive therapies, Ungaro noted. Increased susceptibility to viral infection and reactivation is a hallmark of many agents used to treat autoimmune diseases.
"Until we know more about how this affects patients with IBD," Ungaro said, he recommends that patients be "aggressive about social distancing" and "particularly mindful about hand hygiene."
His group's paper cited research where viral infections were more likely among IBD patients on small-molecule immunomodulators than biologics, "but it is unclear if this can be extended to COVID-19." They emphasized that at this time they are not advising patients with IBD or other conditions such as autoimmune hepatitis to stop immunomodulator therapy, noting, "The risk of disease flare far outweighs the chance of contracting [COVID-19]."
Ungaro also highlighted research from China finding hepatic abnormalities in patients with COVID-19 infection including elevated liver enzymes and bilirubin.
The outbreak of novel coronavirus (2019-nCoV) pneumonia initially developed in one of the largest cities, Wuhan, Hubei province of China since early December 2019 has been declared the sixth public health emergency of international concern by the World Health Organization, and subsequently named coronavirus disease 2019 (COVID-19). As of February 20, 2020, a total of more than 75,000 cumulative confirmed cases and 2,130 death cases have been documented globally in 26 countries across 5 continents. Current studies reveal that respiratory symptoms of COVID-19 such as fever, dry cough, even dyspnea represent the most common manifestations at visit similar to severe acute respiratory syndrome (SARS) in 2003 and Middle East respiratory syndrome (MERS) in 2012, which is firmly indicative of droplet transmission and contact transmission. However, the incidence of less common features like diarrhea, nausea, vomiting and abdominal discomfort varies significantly among different study populations, along with an early and mild onset frequently followed by typical respiratory symptoms.1 Amounting evidence from former studies of SARS indicated that the gastrointestinal tract (intestine) tropism of SARS coronavirus (SARS-CoV) was verified by the viral detection in biopsy specimens and stool even in discharged patients, which may partially provide explanations for the gastrointestinal symptoms, potential recurrence and transmission of SARS from persistently shedding human as well.2 Notably, the first case of 2019-nCoV infection confirmed in the United States reported a 2-day history of nausea and vomiting on admission, and then passed a loose bowel movement on hospital day 2. The viral nucleic acids of loose stool and both respiratory specimens later tested positive.3 In addition, 2019-nCoV sequence could be also detected in the self-collected saliva of most infected patients even not in nasopharyngeal aspirate, and serial saliva specimens monitoring showed declines of salivary viral load after hospitalization.4 Given that extrapulmonary detection of viral RNA does not mean infectious virus is present, further positive viral culture suggests the possibility of salivary gland infection and possible transmission.4 More recently, two independent laboratories from China declared that they have successfully isolated live 2019-nCoV from the stool of patients (unpublished).