The Incidence and Mortality Impact of Gastrointestinal Bleeding in Hospitalized COVID-19 Patients.

BACKGROUND: Patients requiring hospitalization to critical care units are at a higher risk for gastrointestinal (GI) bleeding. Although severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) infection is predominantly a pulmonary disease, other serious manifestations including thromboembolic phenomenon are reported. Acute respiratory distress syndrome (ARDS) requiring mechanical ventilation, use of steroids and anticoagulation are all known to increase the risk of GI bleeding significantly. AIM: To study the incidence of GI bleeding and its impact on mortality in patients admitted with SARS-CoV-2. METHODS: We retrospectively reviewed all patients admitted with SARS-CoV-2 from February 1, 2020 to April 15, 2020. We collected data including demographics, comorbid conditions, laboratory parameters, steroid and anticoagulant use. Coffee ground emesis, hematemesis, melena and hematochezia were defined as GI bleeding. All-cause mortality was reviewed for all patients included in the study. The relationship between GI bleeding and mortality was studied using logistic regression. RESULTS: We had a total of 1206 patients hospitalized with SARS-CoV-2 infection with an all-cause mortality of 34% (n = 411). The overall incidence of GI bleeding was 3.1% (n = 37) with no significant difference between the patients who survived versus died during hospitalization (1.3% vs 1.5%, p = 0.77). Logistic regression analysis did not identify GI bleeding as an independent predictor of mortality. Therapeutic doses of anticoagulation were administered in 13.3% (n = 161) of patients, of which 6.8% (n = 11) developed GI bleeding. Patients were more likely to develop GI bleeding with use of therapeutic doses of anticoagulation (29.7% vs 12.8%, p = 0.003), steroids (37.8% vs 18.5%, p = 0.003) and mechanical ventilation (48.6% vs 30.4%, p = 0.018). CONCLUSION: Patients hospitalized with SARS-CoV-2 infection are at risk of gastrointestinal bleeding. Therapeutic doses of anticoagulation, mechanical ventilation and steroid use are significant risk factors for GI bleeding. However, GI bleeding did not significantly alter the mortality rates in SARS-CoV-2-infected patients.

Diarrhea due to SARS-CoV-2-Related Exocrine Pancreatic Insufficiency.

Gastrointestinal symptoms, especially diarrhea, are common with novel coronavirus SARS-CoV-2 infection. Angiotensin-converting enzyme-2 (ACE-2) receptors are heavily expressed in enterocytes and serve as entry receptors for SARS-CoV-2. ACE-2 receptors may also be responsible for pancreatic injury in patients infected with SARS-CoV-2. Diarrhea associated with SARS-CoV-2 is usually believed to be due to viral invasion of enterocytes. However, exocrine pancreatic insufficiency resulting from SARS-CoV-2 is another plausible mechanism leading to diarrhea in such patients. We present a case series of three SARS-CoV-2-infected patients with predominant respiratory symptoms at presentation who developed diarrhea, and further fecal analysis revealed exocrine pancreatic insufficiency as the underlying mechanism.

Co-Occurrence of Rarest Type of Dysphagia Lusoria (Type N-1) and Eosinophilic Esophagitis in a Cognitively Disabled Individual.

Dysphagia is an expressive symptom, described by an individual as "difficulty in swallowing." Dysphagia due to esophageal compression from an aberrant right subclavian artery is rare, and it is termed as "dysphagia lusoria." We present a rare case of co-occurrence of dysphagia lusoria with esophageal eosinophilia in a patient with cognitive disability which portends a case with diagnostic challenge and treatment dilemma. A 31-year-old man with intellectual disability, cerebral palsy, previous history of feeding difficulty, and esophageal food impaction presented with esophageal foreign body impaction. He has no known history of atopy and food allergies. There was no laboratory evidence of peripheral eosinophilia. The IgE-mediated allergic test was unremarkable. His prior presentation revealed a diagnosis of eosinophilic esophagitis. The imaging studies showed proximal esophageal dilatation with extrinsic compression at the level of the upper esophagus. The foreign bodies were removed successfully through the help of upper endoscopy. Subsequent evaluation revealed a rare type of dysphagia lusoria (type N-1) due to an aberrant left subclavian artery arising from the right-sided aortic arch. The patient's family refused further management of artery lusoria. Prolonged stasis of secretions and food in the esophagus can also lead to increased esophageal eosinophils. In our case, it remains undetermined whether increased number of esophageal eosinophils resulted from primary eosinophilic esophagitis or due to prolonged food stasis from esophageal compression caused by an aberrant subclavian artery. However, food impaction right above the compression site makes dysphagia lusoria the likely etiology.

Tuberculosis septic shock, an elusive pathophysiology and hurdles in management: A case report and review of literature.

BACKGROUND: Tuberculosis (TB) is a rare etiology of the septic shock. Timely administration of the anti-microbial agents has shown mortality benefit. Prompt diagnosis and a high index of suspicion are crucial to the management. We present three cases of TBSS with poor outcome in the majority despite timely and susceptible antibiotic administration. CASE SUMMARY: Sixty-seven-year-old woman with latent TB presented with fever, cough, and shortness of breath. She was promptly diagnosed with active TB and started on the appropriate anti-microbial regimen; she had a worsening clinical course with septic shock and multi-organ failure after initiation of antibiotics. Thirty-three-year-old man immunocompromised with acquired immune deficiency syndrome presented with fever, anorexia and weight loss. He had no respiratory symptoms, and first chest X-ray was normal. He had enlarged liver, spleen and lymph nodes suspicious for lymphoma. Despite broad-spectrum antibiotics, he succumbed to refractory septic shock and multi-organ failure. It was shortly before his death that anti-TB antimicrobials were initiated based on pathology reports of bone marrow and lymph node biopsies. Forty-nine-year-old woman with asthma and latent TB admitted with cough and shortness of breath. Although Initial sputum analysis was negative, a subsequent broncho-alveolar lavage turned out to be positive for acid fast bacilli followed by initiation of susceptible ant-TB regimen. She had a downward spiral clinical course with shock, multi-organ failure and finally death. CONCLUSION: Worse outcome despite timely initiation of appropriate antibiotics raises suspicion of TB immune reconstitution as a possible pathogenesis for TB septic shock.

Lung cancer metastasis to the gastrointestinal system: An enigmatic occurrence.

Adenocarcinoma of the lung infrequently metastasizes to the gastrointestinal tract. We report a rare case of a 65-year-old male with no respiratory symptoms diagnosed with adenocarcinoma of the lung by histopathological examination of metastatic sites which included an ulcer in the gastric body and a mass in the rectum. Metastatic disease also involved the liver as well. Patient was treated with systemic chemotherapy but unfortunately expired five months after the diagnosis was made.