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Am J Surg Pathol ; 46(1): 89-96, 2022 01 01.
Article in English | MEDLINE | ID: covidwho-1254925


Approximately 20% of patients with symptomatic syndrome-associated coronavirus-2 (SARS-CoV-2) infection have gastrointestinal bleeding and/or diarrhea. Most are managed without endoscopic evaluation because the risk of practitioner infection outweighs the value of biopsy analysis unless symptoms are life-threatening. As a result, much of what is known about the gastrointestinal manifestations of coronavirus disease-2019 (COVID-19) has been gleaned from surgical and autopsy cases that suffer from extensive ischemic injury and/or poor preservation. There are no detailed reports describing any other gastrointestinal effects of SARS-CoV-2 even though >3,000,000 people have died from COVID-19 worldwide. The purpose of this study is to report the intestinal findings related to SARS-CoV-2 infection by way of a small case series including one with evidence of direct viral cytopathic effect and 2 with secondary injury attributed to viral infection. Infection can be confirmed by immunohistochemical stains directed against SARS-CoV-2 spike protein, in situ hybridization for spike protein-encoding RNA, and ultrastructural visualization of viruses within the epithelium. It induces cytoplasmic blebs and tufted epithelial cells without inflammation and may not cause symptoms. In contrast, SARS-CoV-2 infection can cause gastrointestinal symptoms after the virus is no longer detected, reflecting systemic activation of cytokine and complement cascades rather than direct viral injury. Reversible mucosal ischemia features microvascular injury with hemorrhage, small vessel thrombosis, and platelet-rich thrombi. Systemic cytokine elaboration and dysbiosis likely explain epithelial cell injury that accompanies diarrheal symptoms. These observations are consistent with clinical and in vitro data and contribute to our understanding of the protean manifestations of COVID-19.

COVID-19/pathology , Intestinal Diseases/pathology , Intestinal Diseases/virology , Intestines/pathology , Intestines/virology , Adult , Aged , Aged, 80 and over , Biomarkers/metabolism , Biopsy , COVID-19/diagnosis , COVID-19/immunology , Cytokines/metabolism , Gastrointestinal Hemorrhage/diagnosis , Gastrointestinal Hemorrhage/immunology , Gastrointestinal Hemorrhage/pathology , Gastrointestinal Hemorrhage/virology , Humans , Intestinal Diseases/diagnosis , Intestinal Diseases/immunology , Intestines/immunology , Ischemia/diagnosis , Ischemia/immunology , Ischemia/pathology , Ischemia/virology , Male , Thrombosis/diagnosis , Thrombosis/immunology , Thrombosis/pathology , Thrombosis/virology
Gastroenterol Hepatol ; 45(1): 9-17, 2022 Jan.
Article in English, Spanish | MEDLINE | ID: covidwho-1111615


INTRODUCTION: The pandemic caused by the SARS-CoV-2 virus has had a serious impact on the functioning of gastrointestinal endoscopy Units. The Asociación Española de Gastroenterología (AEG) and the Sociedad Española de Endoscopia Digestiva (SEED) have proposed the EPAGE guidelines for managing postponed colonoscopies. OBJECTIVE: To evaluate the EPAGE guidelines as a management tool compared to the immunologic faecal occult blood test (iFOBT) and compared to risk score (RS) that combines age, sex and the iFOBT for the detection of colorectal cancer (CRC) and significant bowel disease (SBD). METHODS: A prospective, single-centre study enrolling 743 symptomatic patients referred for a diagnostic colonoscopy. Each order was classified according to the EPAGE guidelines as appropriate, indeterminate or inappropriate. Patients underwent an iFOBT and had their RS calculated. RESULTS: The iFOBT (p<0.001), but not the EPAGE guidelines (p = 0.742), was an independent predictive factor of risk of CRC. The ROC AUCs for the EPAGE guidelines, the iFOBT and the RS were 0.61 (95% CI 0.49-0.75), 0.95 (0.93-0.97) and 0.90 (0.87-0.93) for CRC, and 0.55 (0.49-0.61), 0.75 (0.69-0.813) and 0.78 (0.73-0.83) for SBD, respectively. The numbers of colonoscopies needed to detect a case of CRC and a case of SBD were 38 and seven for the EPAGE guidelines, seven and two for the iFOBT, and 19 and four for a RS ≥5 points, respectively. CONCLUSION: The EPAGE guidelines, unlike the iFOBT, is not suitable for screening candidate patients for a diagnostic colonoscopy to detect CRC. The iFOBT, in combination with age and sex, is the most suitable strategy for managing demand for endoscopy in a restricted-access situation.

COVID-19/epidemiology , Colonoscopy/standards , Colorectal Neoplasms/diagnosis , Occult Blood , Pandemics , Practice Guidelines as Topic , Adult , Age Factors , Aged , Analysis of Variance , COVID-19/prevention & control , Colonoscopy/statistics & numerical data , Endoscopy, Gastrointestinal/standards , Female , Gastroenterology/standards , Humans , Intestinal Diseases/diagnosis , Male , Middle Aged , Predictive Value of Tests , Prospective Studies , Risk Factors , Sex Factors , Societies, Medical