Upper gi bleeding in COVID-19 patients: Characteristics and management in a multicenter experience from northern italy

Introduction: Outbreak of the novel SARS-CoV-2 infection, leading to coronavirus disease 2019 (COVID-19) has been declared an official pandemic by WHO on March 11, 2020 COVID-19 patients have an increased susceptibility to develop thrombotic complications, and therefore thromboprophylaxis is routinely administered The widespread of anticoagulant treatment and the exposure to stress ulcer risk may increase the occurrence of upper gastrointestinal bleeding (UGIB) Timing of upper GI endoscopy should be carefully evaluated given the risk of respiratory worsening in non-intensive care unit (ICU) patients Aims \u0026 Methods: To retrospectively evaluate the medical and endoscopic management of UGIB in non-ICU COVID-19 patients referred to eight COVID Hub Centers from Northern Italy COVID-19 inpatients (positive nasopharyngeal swab or bronchoalveolar lavage) older than 18 yrs with overt sign of UGIB were enrolled in the study in the period from March 5th to April 30th Demographic and clinical characteristics at admission were evaluated Type of anticoagulant and/or antiplatelet therapy were acquired Severity of COVID- 19 pneumonia was classified according to the type of oxygen support Glasgow Blatchford score was calculated at onset of signs of GI bleeding Timing between onset of signs of GI bleeding and execution, if performed, of upper GI endoscopy was evaluated Endoscopic characteristics and outcome of patients were evaluated overall or according to the execution or not of an upper GI endoscopy before and after 24 hr Chi-square test with Fisher test and Mann-Whitney test were used when appropriate Results: 23 patients (18 male;75 yrs;IQR 64-78) were included in the study Antiplatelet therapy was present in 7/23 patients whereas 18/23 (78%) were on anticoagulant therapy before or during hospital stay (35% on prophylactic therapy and 44% in full dose anticoagulant) and 65% of them had two or more comorbidities (78% hypertension or chronic heart disease, 48% diabetes and 9% cirrhosis) 69% of patients had a significant respiratory involvement (high flow oxygen or non-invasive positive pressure support) Signs of upper GI bleeding appeared in a median time of 4 days (0 6-7) during hospital stay being presence of tarry stool the most common finding (52%) In 11 patients (48%) upper GI endoscopy was performed within 24 hr (4 had haematemesis), whereas it was not performed because of complete resolution of bleeding with medical management in 4 patients, and because of severe respiratory worsening in one Peptic ulcer was the most common finding (8/18) followed by erosive or haemorragic gastritis (4/18), Mallory-Weiss or Dieulafoy lesion (4/18) and variceal bleeding (1/18) Endoscopic treatment (adrenaline injection + clips in 5 and cyanoacrylate injection in one) was necessary in 6/18 patients Mortality rate was 21 7% Mortality (2 vs 3 patients) and rebleeding (2 vs 1 episodes) were not different between patients having upper GI endoscopy before or after 24 hr/not performed Need of endoscopic treatment was more common in patients in which upper GI endoscopy was performed before 24 hr (6 vs 1 patients, p=0 02) although Glasgow Blatchford score was similar between the two groups (13;12-16 vs 12;9-15) Conclusion: Upper GI bleeding is not a common complication in COVID-19 patients although the widespread of thromboprophylactic therapy, and peptic ulcer disease is the most common finding Conservative management with optimization of medical therapy and delay of endoscopy could be an option in patients that are at risk of respiratory complications