Behind the GI Impact of the COVID-19 Pandemic

Dr. Buch:
At the beginning of the epidemic, clinicians believed COVID-19 was just a respiratory virus, but as cases rapidly rise, emerging evidence reveals that this infection can impact the entire body, including the GI tract. How does COVID-19 impact preexisting GI disorders and the GI system, overall? 

Welcome to GI Insights on ReachMD. I’m Dr. Peter Buch and joining me today to discuss COVID-19 pandemic and its GI impact is Dr. Myron Brand, a Clinical Professor of Medicine, Yale University School of Medicine, who practices here in Connecticut. Dr. Brand, I’m so honored to have you join us here today.

Dr. Brand:
I’m thrilled to be with you.

Dr. Buch:
So, let me ask you this, Dr. Brand: there’s a percentage of patients who just have GI symptomatology without having pulmonary symptomatology; can you tell the audience a little bit about that?

Dr. Brand:
Peter, this is a difficult question. And one that we, just don’t know the answer to right now. We do know that the virus attacks the GI tract and replicates in the liver, the pancreas, stomach, small intestine, and colon. These organs are all very rich in ACE2 receptors, which the virus needs to get into cells. We also know that 20% of patients who initially present with COVID will present initially with GI symptoms and these might include diarrhea, nausea, vomiting, and abdominal pain. In my own personal experience with COVID-19 and my IBD patients, I’ve seen patients present with diarrhea but as of yet, I haven’t really seen them flare their inflammatory bowel disease, their Crohn’s Disease or ulcerative colitis. But this is really a question that’s in evolution and is actually being looked at by a national registry called the “Secure Registry for IBD.” I can tell you that I really do worry about my liver patients who get COVID. There is data to show that cirrhotic patients, even if they’re compensated, may decompensate with this infection and they might decompensate because of a viral injury to the liver, the medications that we use, the systemic hypoxia and blood pressure changes, causing an ischemia or even hypercoagulability that’s been associated with COVID-19. So, ultimately, what I have to say, at least in the tubular GI tract, is that whether there’s going to be chronic issues, we just don’t know. I think time is going to tell us that. I will tell you this, that it is clear that other organs are affected chronically by this virus, including the lungs, the heart, and the neuromuscular system and it’s clear that these organs can sustain long-term injury and indeed, there are hospitals in the country, and I know Mount Sinai is one of them, that has set up clinics for patients who have developed long-term injury and chronic injury from acute COVID-19 infections.

Dr. Buch:
Thank you. Many of our patients are on proton pump inhibitors and wonder if there is an increased risk of contracting COVID-19. Would you kindly address this?

Dr. Brand:
Here, the data is a bit more conflicting and even controversial. Early in the pandemic, there was data from Asia, and I believe it was from Japan and Thailand, that did show that PPIs not only increased the risk of getting COVID-19, but also increased the severity of the disease. More recently, in our country, Dr. Bill Chey and Dr. Brendan Spiegel reviewed a national COVID-19 U.S. Registry of COVID patients; what they did find was that patients that were on double dose PPI were at an increased risk of contracting the disease but not of having increased severity of the disease. Interestingly, patients who are on single dose PPI, or over-the-counter PPI, or even H2 blockers did not seem to be at an increased risk of developing or contracting COVID-19. In fact, there was even a signal that patients who were on H2 blockers might actually even do a little bit better if they contracted the disease. You know, this all made sense to me in the sense that acid in our stomach is supposedly protective from bacteria, viruses, and fungi, so it would make sense that if you block the acid, you are going to expose the GI tract to a greater pathogen load, so I could really understand how a double dose PPI could potentially be a problem. My take on this is pretty simple, that is: use drugs appropriately. And that is, if a patient doesn’t need a double dose of a PPI or doesn’t need to be on a PPI, don’t be on it. On the other hand, if the patient needs it, I certainly would continue those drugs.

Dr. Buch:
Perfect. And are patients being actively treated for hepatitis B and C at increased risk?

Dr. Brand:
Peter, here there is very little data. I can tell you that in the summer of 2020, there was a large survey done, which I think included about 5,700 patients, and this survey was done in New York City, and they looked at the population of people who have contracted COVID-19 to see if there was any predisposing factors, and they did not find that patients with hepatitis B or C seemed to be over-represented. In fact, they were actually even under-represented. I’m not sure that means anything, but it certainly doesn’t look like these people are at an increased risk. However, again, I do want to emphasize that it’s not so much whether somebody has hepatitis B or C, it’s really the stage of their liver disease as to whether that they’re going to get into trouble from COVID-19. So, if a patient is cirrhotic and they’ve gotten it from, you know, non-alcoholic fatty liver disease or one of the viral illnesses or sclerosing cholangitis or primary cholangitis, to me, these people will be at an increased risk of getting more severe disease if they get COVID-19.

Dr. Buch:
For those just joining us, this is GI Insights on ReachMD. I’m Dr. Peter Buch and today I’m speaking with Dr. Myron Brand about the GI impact of COVID-19. So, let’s continue. Dr. Brand, can you discuss the consequences of COVID-19 fears delaying prompt diagnosis of important GI issues. 

Dr. Brand:
Unfortunately, Peter, COVID-19 has caused delays in the diagnosis and treatment of GI issues. However, I want to make the point that this is just not isolated to the GI tract, but to all fields of medicine, including cardiology, oncology, endocrinology, and so on. This is just not an issue that affects gastroenterologists, so the question is, “Why is this happening?” and I think there are two important factors that come into play here. One factor clearly is patient fear. Patients were, and I think still are, afraid of going for testing and treatment for fear of being exposed to the COVID virus. Even now, patients at our Yale endoscopy center very commonly will cancel their upper endoscopies or colonoscopies for fear of coming into contact with staff or other patients which may have COVID-19. I think a good example of patient fear was highlighted over the summer of 2020 when many emergency rooms noted there was a decrease in visitations for patients with chest pain and abdominal pain. People just were simply afraid to go to emergency rooms for fear of being exposed to other patients with COVID-19 and that caused delays in the diagnosis and treatment of heart attacks, strokes, and abdominal emergencies. I think the other factor here that’s delaying testing and treatment was actually patient access and that clearly was an issue in the spring of 2020. An example here for us would be our Yale endoscopy center was closed from mid-March to mid-June; we simply were not doing any elective cases and cases that needed to get done were done over at the hospital. During that time, we needed to figure out how to safely reopen and protect our staff and patients that had visited us. I think at this point, of course, we have figured out the appropriate protocols for patients. I think the bottom line here is that, not just in GI, but in all fields of medicine, there has been a delay in treatments. In GI, I think there’s been a delay in some patient’s diagnosis of inflammatory bowel disease and certainly of cancers. But again, I think this really applies to all fields of medicine. I think we’re all affected and there was delays in treatment and diagnoses in all fields of medical specialties.

Dr. Buch:
Next question, is having inflammatory bowel disease a risk factor for contracting COVID-19?

Dr. Brand:
This is a question that has really concerned all IBD specialists, particularly in the early spring of March and April of 2020. We were obviously very concerned that the medications that we were using to treat our patients with IBD might be putting them at an undue risk. Fortunately, both European gastroenterologists and American gastroenterologists did not find that our patients, were at an increased risk of contracting COVID-19, and I think this is a very, very important point. It’s important for our patients to know, who are stable on their IBD medications, not to be stopping their medications during this pandemic. I can tell you that there are many questions about COVID-19 and inflammatory bowel disease at this point, and there are physicians who have actually set up a registry called the SECURE-IBD Registry, which is an international registry with many thousands of patients in it, looking at the association of COVID-19 and IBD. I believe they have generated important information that have helped us taking care of our IBD population. Some of the data has shown us that 24% of patients who have IBD have actually been hospitalized with it; 4% of those patients were on ventilators and about 3% of those patients actually died. And these numbers are a little bit higher than the general population. However, the risk factor seems not to be the IBD, but the comorbidities that may be associated with our IBD patients, including an increased age, obesity, and diabetes. These seem to be the issues that are driving more serious COVID infection in our IBD population. Most importantly, they did not find, and I want to emphasize this, they did not find that our biologic drugs, such as TNF inhibitors, Ustekinumab, Vedolizumab, were putting our patients at an increased risk. Certainly when a patient has acute COVID-19, we’re going to hold these medications, but if a patient’s been on these medications, they seem to do just fine. The one medication that they did point out which was problematic was the use of steroids in treating our IBD patients. Here, high-dose steroids have been associated with a more severe COVID infection. And so, what we’ve learned here is that in our IBD patient who were on steroids, we want to get them on the lowest effective dose we can and try to get them off as quickly as possible. Another observation that was found by the secure registry was that our IBD patients seem to more likely get symptomatic; as I mentioned to you before, about 20% of patients who get COVID-19 have GI symptoms, such as diarrhea; well on our IBD patients, it’s not uncommon for these patients to get diarrhea, so there’s clearly an increased symptomatology. Again, we just don’t know whether or not the COVID-19 is going to lead to more lasting and more severe chronic issues of our IBD patients. For the moment, it doesn’t appear to be so. I can tell you this: it has become a little bit more confusing in terms of treating our IBD patients who get diarrhea because now, knowing that our IBD patients are exhibiting diarrhea who get COVID, it makes us wonder whether or not “is somebody flaring their IBD or are they losing control of their IBD from the medicines, or they’re actually having and acute flare of COVID-19?” So, it becomes a little bit more confusing to us when we see a patient with our IBD patients when they’re ill. Finally, I do want to say this, is that, obviously, COVID-19 can cause severe pulmonary issues and respiratory distress syndrome and interestingly, some of the medicines that we’re actually using to treat IBD, such as TNF inhibitors or Tofacitinib, are actually being looked at, at this point, to try to treat people with severe COVID-19, and I think that’s kind of interesting. The whole idea here, is that these medicines might actually diminish the cytokine surges that we’re seeing with people with severe COVID-19.

Dr. Buch:
Finally, is there any additional insight that you would like to share with our audience today regarding COVID-19 and the GI tract?

Dr. Brand:
I think I’ve actually covered the GI tract, Peter, pretty well in our discussions, but I do want to make some observations that clearly have affected I think all Americans. There’s no doubt that I never would’ve expected that in my lifetime that I would have seen over 350,000 Americans die within one year from an infection, and I certainly never would’ve imaged that 20 million Americans would get infected with this virus, including myself, so I think this virus is going to have some long-term effects on our medical system and let me just share with you some of the observations that I’ve made. Clearly, it’s going to change, I think, the delivery of healthcare. I never would’ve imaged a year ago that most of the people that I’m seeing in my clinic would be by telehealth. Certainly, we’ve talked about telehealth for years, but I thought it was gonna take years to implement telehealth, and here we are one year later, with, maybe 90 or 95% of the patients that I’m seeing are all telehealth or telemedicine visits. Clearly, this has changed the delivery of healthcare, and has sped up the implementation of telemedicine by years. Finally, and maybe I’m being a little bit philosophical here, is that I think the pandemic clearly has shown many of the flaws of our healthcare system. It certainly has shown that there’s differences in access and it certainly has shown us some of the flaws in the way we are going to deliver vaccines. I believe finally, when we actually do a post-mortem of this pandemic, and I believe this pandemic is going to be coming to the end with the introduction of vaccines, we are going to have learned many lessons. My great hope is that seeing the inequities of access to care will speed us to perhaps a more just and equitable access to care for all Americans.

Dr. Buch:
I want to thank Dr. Myron Brand for joining me today to discuss the impact of the COVID-19 pandemic on patients with GI disorders. Dr. Brand, it was absolutely great having you speak with us today.

Dr. Brand:
Thank you very much. It’s been my pleasure to chat with you.

Dr. Buch:
For ReachMD, I’m Dr. Peter Buch. To access this episode and others from GI Insights, visit ReachMD.com/GIInsights, where you can Be Part of the Knowledge. Thanks for listening.