Enteropathy endoscopic findings in small intestine in patients with severe COVID-19

Background and aim: Small intestine study is a challenge in the field of clinical research. However, capsule endoscopy is a safe and minimally invasive alternative. During the COVID-19 pandemic, this endoscopic procedure acquires added value. Although SARS-CoV-2 has mainly respiratory manifestations, gastrointestinal symptoms are observed in 30% of cases. ACE-2 used by SARS-CoV-2 to infect cells is highly expressed in the brush border of enterocytes. This enzyme transports essential amino acids in the small intestine and regulates intestinal inflammation through antimicrobial peptides production. Here we describe the endoscopic changes in the mucosa of the small intestine secondary to severe SARS-CoV-2 infection in patients with and without gastrointestinal symptoms. Methods: We performed a prospective and observational study in hospitalized patients with severe COVID-19 disease. Capsule endoscopy and detection of SARS-CoV-2 RNA in feces were performed in each participant. Each capsule was reviewed separately by two trained endoscopists. Results: Twenty individuals were enrolled. Diarrhea was observed in 78% of participants. In 45% of capsule endoscopy studies, changes characterized by shortening of villi, atrophy or denuded areas accompanied by red spots or patches, hyperemia or edema were found. Individuals showing these changes in the intestinal mucosa were positive for SARS-CoV-2 in stool. Conclusions: Here we provide evidence of macroscopic changes along the small intestine in COVID-19 patients. We proposed the term of COVID-19 enteropathy to denote involvement of the mucosa and in the villi of the small intestine in SARS-CoV-2 infected individuals. Longitudinal follow-up will be valuable for a better understanding of COVID-19 enteropathy.