COVID-19:Gastrointestinal manifestations,liver injury and recommendations

Coronavirus disease 2019(COVID-19)has caused a pandemic that affected all countries with nearly 270 million patients and 5 million deaths,as of as of December,2021.The severe acute respiratory syndrome coronavirus 2 virus targets the receptor,angiotensin-converting enzyme 2,which is frequently found in human intestinal epithelial cells,bile duct epithelial cells,and liver cells,and all gastrointestinal system organs are affected by COVID-19 infection.The aim of this study is to review the gastrointestinal manifestations and liver damage of COVID-19 infection and investigate the severe COVID-19 infection risk in patients that have chronic gastrointestinal disease,along with current treatment guidelines.A literature search was conducted on electronic databases of PubMed,Scopus,and Cochran Library,consisting of COVID-19,liver injury,gastrointestinal system findings,and treatment.Liver and intestinal involvements are the most common manifestations.Diarrhea,anorexia,nausea/vomiting,abdominal pain are the most frequent symptoms seen in intestinal involvement.Mild hepatitis occurs with elevated levels of transaminases.Gastrointestinal involvement is associated with long hospital stay,severity of the disease,and intensive care unit necessity.Treatments and follow-up of patients with inflammatory bowel diseases,cirrhosis,hepatocellular carcinoma,or liver transplant have been negatively affected during the pandemic.Patients with cirrhosis,hepatocellular carcinoma,auto-immune diseases,or liver transplantation may have a greater risk for severe COVID-19.Diagnostic or therapeutic procedures should be restricted with specific conditions.Telemedicine should be used in non-urgent periodic patient follow up.COVID-19 treatment should not be delayed in patients at the risk group.COVID-19 vaccination should be prioritized in this group.

Gastrointestinal manifestations,risk factors,and management in patients with post-transplant lymphoproliferative disorder:A systematic review

BACKGROUND Patients with a history of solid organ transplantation(SOT)or hematopoietic stem cell transplantation(HSCT)are at an increased risk of developing post-transplant lymphoproliferative disorder(PTLD).The gastrointestinal(GI)tract is commonly affected as it has an abundance of B and T cells.AIM To determine typical GI-manifestations,risk factors for developing PTLD,and management.METHODS Major databases were searched until November 2021.RESULTS Non-case report studies that described GI manifestations of PTLD,risk factors for developing PTLD,and management of PTLD were included.Nine articles written within the last 20 years were included in the review.All articles found that patients with a history of SOT,regardless of transplanted organ,have a propensity to develop GI-PTLD.CONCLUSION GI tract manifestations may be nonspecific;therefore,consideration of risk factors is crucial for identifying GI-PTLD.Like other lymphoma variants,PTLD is very aggressive making early diagnosis key to prognosis.Initial treatment is reduction of immunosuppression which is effective in more than 50%of cases;however,additional therapy including rituximab,chemotherapy,and surgery may also be required.

Gastrointestinal manifestations of systemic mastocytosis

Systemic mastocytosis (SM) is a rare disease with abnormal proliferation and infiltration of mast cells in the skin, bone marrow, and viscera including the mucosal surfaces of the digestive tract. Gastrointestinal (GI) symptoms occur in 14%-85% of patients with systemic mastocytosis. The GI symptoms may be as frequent as the better known pruritis, urticaria pigmentosa, and flushing. In fact most recent studies show that the GI symptoms are especially important clinically due to the severity and chronicity of the effects that they produce. GI symptoms may include abdominal pain, diarrhea, nausea, vomiting, and bloating. A case of predominantly GI systemic mastocytosis with unique endoscopic images and pathologic confirmation is herein presented, as well as a current review of the GI manifestations of this disease including endoscopic appearances. Issues such as treatment and prognosis will not be discussed for the purposes of this paper.

Clinical characteristics,gastrointestinal manifestations and outcomes of COVID-19 patients in Iran;does the location matters?

BACKGROUND Coronavirus disease 2019(COVID-19)started in Asia,and Iran was one of its first epicenters.AIM To study the gastrointestinal(GI)symptoms and comorbidities associated with this pandemic in four different regions of Iran.METHODS We analyzed data from severe acute respiratory syndrome coronavirus 2 positive patients evaluated at four hospitals of Iran(n=91),including South(Shiraz),Southeast(Dezful),Rasht(North),and Northwest(Mashhad)between April and September 2020.Demographics,comorbidities and clinical findings including GI symptoms were collected.Statistical descriptive analysis and correlation analyses of symptoms,comorbidities,and mortality were performed.RESULTS The average age of COVID-19 patients was 51.1 years,and 56%were male.Mortality rate was 17%.Cough with 84.6%,shortness of breath with 71.4%,fever with 52.7%,and loss of appetite with 43.9%were the main symptoms.Overall cardiac disease was the most common comorbidity with an average of 28.5%followed by hypertension(28.5%)and diabetes(25.2%).The highest comorbidity in North(Rasht)was diabetes(30%)and in South(Dezful)hypertension(37%).Shiraz leads cardiac disease with 43.4%.The most reported GI symptoms included nausea,diarrhea,vomiting,and abdominal pain,with 42.8%,31.8%,26.8%,and 12%prevalence,respectively.In addition,albumin,alkaline phosphatase,aspartate aminotransferase,and alanine aminotransferase were elevated in 26.3%.CONCLUSION Our results show hypertension and diabetes as the most common comorbidities,but their distribution was different in COVID-19 patients in the four studied regions of Iran.Nausea,diarrhea,and elevated liver enzymes were the most common GI symptoms.There was also a high mortality rate that was associated with high infection rates in Iran at the beginning of the pandemic.

COVID-19 pandemic:Pathophysiology and manifestations from the gastrointestinal tract

The pandemic of coronavirus disease 2019(COVID-19),caused by a newly identifiedβ-coronavirus(SARS-CoV-2)has emerged as a dire health problem,causing a massive crisis for global health.Primary method of transmission was firstly thought to be animal to human transmission.However,it has been observed that the virus is transmitted from human to human via respiratory droplets.Interestingly,SARS-CoV-2 ribonucleic acid(RNA)has been isolated from patient stools,suggesting a possible gastrointestinal(GI)involvement.Most commonly reported clinical manifestations are fever,fatigue and dry cough.Interestingly,a small percentage of patients experience GI symptoms with the most common being anorexia,diarrhea,nausea and vomiting.The presence of viral RNA in stools is also common and fecal tests can be positive even after negative respiratory samples.The exact incidence of digestive symptoms is a matter of debate.The distribution of Angiotensin converting enzyme type 2 receptors in multiple organs in the body provides a possible explanation for the digestive symptoms’mechanism.Cases with solely GI symptoms have been reported in both adults and children.Viral RNA has also been detected in stool and blood samples,indicating the possibility of liver damage,which has been reported in COVID-19 patients.The presence of chronic liver disease appears to be a risk factor for severe complications and a poorer prognosis,however data from these cases is lacking.The aim of this review is firstly,to briefly update what is known about the origin and the transmission of SARS-CoV-2,but mainly to focus on the manifestations of the GI tract and their pathophysiological background,so that physicians on the one hand,not to underestimate or disregard digestive symptoms due to the small number of patients exhibiting exclusively this symptomatology and on the other,to have SARS-CoV-2 on their mind when the“gastroenteritis”type symptoms predominate.

COVID-19 status quo:Emphasis on gastrointestinal and liver manifestations

The coronavirus disease 2019(COVID-19)has caused one of the worst public health crises in modern history.Even though severe acute respiratory syndrome coronavirus 2 primarily affects the respiratory tract,gastrointestinal manifestations are well described in literature.This review will discuss the epidemiology,virology,manifestations,immunosuppressant states,and lessons learned from COVID-19.Observations:At the time of writing,COVID-19 had infected more than 111 million people and caused over 2.5 million deaths worldwide.Multiple medical comorbidities including obesity,pre-existing liver condition and the use of proton pump inhibitor have been described as risk factor for severe COVID-19.COVID-19 most frequently causes diarrhea(12.4%),nausea/vomiting(9%)and elevation in liver enzymes(15%-20%).The current data does not suggest that patients on immunomodulators have a significantly increased risk of mortality from COVID-19.The current guidelines from American Gastroenterological Association and American Association for the Study of Liver Diseases do not recommend pre-emptive changes in patients on immunosuppression if the patients have not been infected with COVID-19.Conclusions and relevance:The COVID-19 pandemic has prompted a change in structure and shape of gastroenterology departmental activities.Endoscopy should be performed only when necessary and with strict protective measures.Online consultations in the form of telehealth services and home drug deliveries have revolutionized the field.

Remarkable gastrointestinal and liver manifestations of COVID-19: A clinical and radiologic overview

The coronavirus disease 2019(COVID-19)raging around the world still has not been effectively controlled in most countries and regions.As a severe acute respiratory syndrome coronavirus,in addition to the most common infectious pneumonia,it can also cause digestive system disease such as diarrhea,nausea,vomiting,liver function damage,etc.In medical imaging,it manifests as thickening of the intestinal wall,intestinal perforation,pneumoperitoneum,ascites and decreased liver density.Angiotensin-converting enzyme 2 has great significance in COVID-19-related digestive tract diseases.In this review,we summarized the data on the clinical and imaging manifestations of gastrointestinal and liver injury caused by COVID-19 so far and explored its possible pathogenesis.

Mucosal lesions of the upper gastrointestinal tract in patients with ulcerative colitis:A review

Ulcerative colitis(UC)is a chronic,nonspecific,relapsing inflammatory bowel disease.The colorectum is considered the chief target organ of UC,whereas upper gastrointestinal(UGI)tract manifestations are infrequent.Recently,emerging evidence has suggested that UC presents complications in esophageal,stomachic,and duodenal mucosal injuries.However,UC-related UGI tract manifestations are varied and frequently silenced or concealed.Moreover,the endoscopic and microscopic characteristics of UGI tract complicated with UC are nonspecific.Therefore,UGI involvement may be ignored by many clinicians.In addition,no standard criteria have been established for patients with UC who should undergo fibrogastroduodenoscopy.Furthermore,specific treatment recommendations may be needed for patients with UC-associated UGI lesions.Herein,we review the esophageal,gastric,and duodenal mucosal lesions of the UC-associated UGI tract,as well as the potential pathogenesis and therapy.

COVID-19 among African Americans and Hispanics:Does gastrointestinal symptoms impact the outcome?

BACKGROUND The coronavirus disease 2019(COVID-19)disproportionately affected African Americans(AA)and Hispanics(HSP).AIM To analyze the significant effectors of outcome in African American patient population and make special emphasis on gastrointestinal(GI)symptoms,laboratory values and comorbidities METHODS We retrospectively evaluated the medical records of 386 COVID-19 positive patients admitted at Howard University Hospital between March and May 2020.We assessed the symptoms,including the GI manifestations,comorbidities,and mortality,using logistic regression analysis.RESULTS Of these 386 COVID-19 positive patients,257(63.7%)were AAs,102(25.3%)HSP,and 26(6.45%)Whites.There were 257(63.7%)AA,102(25.3%)HSP,26(6.45%)Whites.The mean age was 55.6 years(SD=18.5).However,the mean age of HSP was the lowest(43.7 years vs 61.2 for Whites vs 60 for AAs).The mortality rate was highest among the AAs(20.6%)and lowest among HSP(6.9%).Patients with shortness of breath(SOB)(OR2=3.64,CI=1.73-7.65)and elevated AST(OR2=8.01,CI=3.79-16.9)elevated Procalcitonin(OR2=8.27,CI=3.95-17.3),AST(OR2=8.01,CI=3.79-16.9),ferritin(OR2=2.69,CI=1.24-5.82),and Lymphopenia(OR2=2.77,CI=1.41-5.45)had a high mortality rate.Cough and fever were common but unrelated to the outcome.Hypertension and diabetes mellitus were the most common comorbidities.Glucocorticoid treatment was associated with higher mortality(OR2=5.40,CI=2.72-10.7).Diarrhea was prevalent(18.8%),and GI symptoms did not affect the outcome.CONCLUSION African Americans in our study had the highest mortality as they consisted of an older population and comorbidities.Age is the most important factor along with SOB in determining the mortality rate.Overall,elevated liver enzymes,ferritin,procalcitonin and C-reactive protein were associated with poor prognosis.GI symptoms did not affect the outcome.Glucocorticoids should be used judiciously,considering the poor outcomes associated with it.Attention should also be paid to monitor liver function during COVID-19,especially in AA and HSP patients with higher disease severity.

穴位刮痧联合中药热奄包对腹腔镜手术后胃肠功能紊乱患者排便功能的影响

目的探讨穴位刮痧联合中药热奄包在腹腔镜术后胃肠功能紊乱患者中的应用效果。方法回顾性分析2020年3月—2022年3月平邑县中医医院收治的84例腹腔镜术后胃肠功能紊乱患者的病历有关资料,按治疗方法的不同分为两组。其中行常规西医治疗的40例患者纳入对照组,而行穴位刮痧联合中药热奄包治疗的44例患者则纳入观察组,均进行2周的治疗。对比两组患者的临床疗效、中医证候积分、恢复情况。结果观察组患者治疗总有效率高于对照组,肠鸣音恢复时间、肛门排气时间、排便时间以及下床活动时间均短于对照组,差异有统计学意义(P<0.05)。治疗前,两组患者便秘、纳差、恶心呕吐、腹胀评分相比,差异无统计学意义(P>0.05);治疗后,观察组患者便秘、纳差、恶心呕吐、腹胀评分低于对照组,差异有统计学意义(P<0.05)。结论穴位刮痧联合中药热奄包治疗腹腔镜术后胃肠功能紊乱患者作用明显,能够明显的缓解其各项临床表现,加速排便功能改善,值得临床应用。

系统性红斑狼疮患者1034例及伴发消化系统受累的危险因素分析

目的了解伴消化系统受累的系统性红斑狼疮(systemic lupus erythematosus,SLE)住院患者的临床及实验室检查等的特征,为其诊断及治疗等提供参考依据。方法回顾性分析1 034例SLE住院患者的临床资料,对伴有消化系统损伤的181例患者的临床表现、实验室检查、影像学检查进行回顾性分析。结果 1 034例SLE患者中,181例(17.50%)伴有消化系统损害,表现为口腔及黏膜损害34例(18.78%)、胃部病变19例(10.50%)、肠道病变15例(8.29%)、腹水45例(24.86%)、肝脏病变61例(33.70%),余7例为消化道出血、吞咽困难、急性胰腺炎等。SLE住院患者消化系统受累者与非消化系统受累者的SLEDAI评分存在差异,且以SLEDAI评分活动时受累人数多。多因素Logistics回归分析显示:抗RNP/Sm抗体和有呼吸系统疾病为危险因素(OR>1),抗RNP/SM抗体阳性消化系统受累风险增高1.678倍,SLEDAI评分趋势可提示消化系统受累风险,即每下降4分,消化系统受累的风险降低0.692倍。结论 SLE住院患者伴发消化系统受累者发病率较高,临床表现及影像学表现多样,SLEDAI评分显示病情活动时常伴消化系统受累,呼吸系统、抗RNP/Sm抗体是其危险因素。

过敏性紫癜患者胃和十二指肠黏膜病变的观察

目的:观察过敏性紫癜患者胃和十二指肠黏膜的改变,探讨其与临床症状之间的关系。方法:对18例过敏性紫癜患者进行纤维胃镜检查、幽门螺杆菌(Hp)检测及胃和十二指肠病变黏膜组织病理学检查。结果:18例患者均有胃、十二指肠黏膜改变,1例食管受累。损害主要表现为黏膜呈花斑样充血、水肿及点状糜烂和多发性溃疡,且伴有胃肠道症状者的胃肠道黏膜病变程度更严重,但与皮损严重程度无关。15例患者Hp检测阳性。胃黏膜组织病理学改变为毛细血管和细小血管内皮细胞肿胀,血管壁纤维蛋白性坏死、出血、管腔缩小,血管周围大量淋巴细胞、中性粒细胞浸润,可见核碎裂。结论:临床各型过敏性紫癜均可出现胃和十二指肠黏膜改变,其严重程度与胃肠道症状密切相关,与皮损的严重程度无关;纤维胃镜及组织病理学检查有助于过敏性紫癜的早期诊断。

过敏性紫癜胃镜特征与临床分析

目的探讨胃镜检查在以腹痛为首发症状的过敏性紫癜(HSP)诊断中的意义。方法对HSP患儿37例通过胃镜检测胃及十二指肠黏膜病变,病变部位取活组织检查,并分析其病变特征与临床的关系。结果病变检出率为62.2%。其中单纯皮肤紫癜检出率为31.3%;伴急性腹痛症状者检出率为100%;单纯关节炎1例和紫癜性肾炎2例均未检出病变。病损以黏膜糜烂、充血、水肿及出血为主要特征。结论HSP患儿胃镜下消化道黏膜病变检出率较高,胃镜检查对儿童HSP,特别是以腹痛为首发症状HSP的早期诊断和鉴别诊断有重要意义。

系统性红斑狼疮消化系统受累患者实验室指标的多因素分析

目的探讨实验室指标对于预测系统性红斑狼疮消化系统受累患者的临床意义。方法回顾性分析2005年8月至2006年8月在北京协和医院诊断明确、资料完整的177例SLE住院患者,对白蛋白、C3、CH50和抗中性粒细胞胞浆抗体(antineutrophil cytoplasmic antibodies,ANCA)进行多变量分析。结果 ANCA阳性,C3和CH50降低是系统性红斑狼疮患者易于伴发消化系统受累的独立危险因素。其中ANCA阳性系统性红斑狼疮患者伴发消化系统表现风险增加8.882倍,C3和CH50降低分别增加患消化系统疾病风险为0.03和0.04倍。Bina-ry Logistic回归分析显示,系统性红斑狼疮有消化系统受累的患者病死率增加16.54倍(P=0.000)。结论 ANCA阳性、C3降低和CH50降低可以预测系统性红斑狼疮患者易于伴发消化系统疾病/症状。由于患消化系统疾病的系统性红斑狼疮患者病死率增加,因此早期诊断和早期治疗很必要。

儿童腹型过敏性紫癜

过敏性紫癜为儿童期最常见的系统性血管炎,其病因与致病机制尚不十分清楚,其诊断标准为,可触性皮疹并至少以下一项表现:腹痛,IgA沉积,关节痛或关节炎,或肾脏受累.以胃肠道表现为主的过敏性紫癜为腹型紫癜.临床表现多见皮疹,阵发性腹痛及便血.超声检查为首选检查方法,可及时发现异常肠管及并发症,而内镜检查可直接观察胃肠道黏膜病变,并取活检了解有无免疫复合物的沉积及是否存在白细胞碎裂性血管炎.腹型紫癜需要与具有相似皮疹或肠壁肿胀的两类疾病鉴别.大部分儿童存在自愈倾向,部分患儿需服用激素等内科药物治疗,多不建议外科治疗.

胃肠道症状与糖尿病关系的分析

目的:通过对因糖尿病住院患者的胃肠道症状观察,了解糖尿病胃肠道症状的特点。方法:收集1986年1月～1997年4月间于我院住院治疗的674例糖尿病患者的相关临床资料,分析糖尿病患者胃肠道症状的发生率及其临床特点。结果:224例糖尿病患者出现一项或一项以上的胃肠道症状,以腹胀、恶心、呕吐、腹泻及便秘为主。1型糖尿病患者胃肠道症状与疾病病程无关,2型糖尿病患者病程与胃肠道症状发生成正比。有胃肠道症状组空腹血糖显著高于无症状组,而糖化血红蛋白水平在两组无差异。有胃肠道症状组糖尿病患者神经病变、糖尿病肾病及视网膜病变发生率显著高于无症状组患者。结论:33.2％糖尿病患者存在胃肠道症状,以腹胀、恶心、呕吐、腹泻及便秘为主,1型糖尿病、病程长于10年、空腹血糖高及存在糖尿病慢性合并症的患者胃肠道症状发生几率大,应引起重视。

血管炎的胃肠道表现

血管炎是一组由不同病因引起的以血管壁炎症和坏死为主要病理改变的自身免疫性疾病,常累及多器官或系统,亦可累及消化系统,如胃肠道、肝胆、胰腺等,引起多种胃肠道症状。这些胃肠道症状表现多样且不具有特异性,特别是以此为首发表现者,容易造成误诊。本文通过介绍血管炎的胃肠道表现,旨在提高临床医师对这类疾病的重视。

成人过敏性紫癜性肾炎合并胃肠道表现的危险因素分析

目的研究成人过敏性紫癜性肾炎合并胃肠道表现的危险因素。方法对2004年1月至2009年5月在卫生部中日友好医院住院的118例成人过敏性紫癜性肾炎患者的人口统计学资料、临床表现、实验室检查、病理学结果及转归等指标进行回顾性分析。结果 118例患者中,52例(44.1%)有胃肠道表现,为病例组;其余66例无胃肠道表现,为对照组。病例组与对照组相比,表现出较高的关节受累(P<0.001)、较高的中性粒细胞计数(P<0.05)、较高的血小板计数(P<0.01)、较低的白蛋白水平(P<0.05)、较低的血钠(P<0.05)和较低的免疫球蛋白G水平(P<0.05)。非条件Logistic回归分析显示,关节受累、中性粒细胞计数和免疫球蛋白G水平是3个独立的危险因素,OR值分别为5.010、1.248和0.999。结论关节受累、较高的中性粒细胞计数和较低的IgG水平是成人过敏性紫癜性肾炎合并胃肠道表现的3个独立的危险因素。

婴儿牛奶蛋白过敏在胃肠道表现的临床研究

目的：探讨以胃肠道表现为首发症状的婴儿牛奶蛋白过敏的临床特点,以减少误诊。方法：选取2014年3月至2015年3月南京医科大学附属儿童医院消化门诊就诊的224例诊断为婴儿牛奶蛋白过敏的患儿,采用问卷调查法收集临床资料,应用Co Mi SS表进行症状量化评估。结果：224例患儿中,男108例,女116例,发病年龄以0~6个月为主。胃肠道首发症状就诊中腹泻50.0%,便血28.6%,反流或呕吐8.9%,阵发性哭闹7.1%,便秘5.3%。患儿治疗前Co Mi SS评分为（10.25±2.61）分,饮食回避2~4周后评分为（3.69±1.18）分,下降〉50%以上。224例患儿中误诊病例148例,不同胃肠道首发症状患儿的误诊率为腹泻54.1%,便血29.7%,阵发性哭闹5.4%,反流或呕吐5.4%,便秘5.4%。既往误诊病例中抗生素使用率达60.8%。误诊病例中发生营养不良56例,非误诊病例中发生营养不良2例,差异有统计学意义（P〈0.05）。结论：胃肠型婴儿牛奶蛋白过敏主要症状为腹泻及便血。因症状缺乏特异性,临床实践中误诊发生率较高。Co Mi SS症状评分法有助于临床医师对该病轻中度患儿的诊断和疗效观察。

原发胃肠道淋巴瘤的临床病理特点及治疗现状

原发胃肠道淋巴瘤(PGIL)是最常见的结外淋巴瘤,具有独特的临床病理特征、病理分类和分期标准。综合胃镜活组织检查、超声内镜、影像学检查、组织学和实验室检查等,有利于PGIL的诊断和评估。它的治疗和预后与胃肠道癌有很大差异,PGIL的治疗主要采取综合性治疗措施,预后与PGIL的病理类型、临床分型及对综合治疗敏感性密切相关。