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Given that COVID-19 may include stomach and bowel symptoms, gastroenterologists may consider the coronavirus illness when evaluating patients with GI complaints along with upper respiratory symptoms, researchers said.

Moreover, patients with inflammatory bowel disease (IBD) could be considered at high risk for COVID-19 if they are being treated with immunosuppressive agents, according to Ryan Ungaro, MD, of Icahn School of Medicine at Mount Sinai in New York City, and colleagues writing in .

Recently, several GI societies, led by the American Gastroenterological Association, released , noting "recent evidence suggesting the potential for coronavirus transmission through droplets and perhaps fecal shedding," posing a risk during endoscopy and colonoscopy procedures.

Ungaro and colleagues noted patients with COVID-19 infection may complain of gastrointestinal symptoms, such as nausea or diarrhea, similar to the SARS outbreak. Diarrhea was one of the most prominent symptoms in the first U.S. case of COVID-19, and the novel SARS-CoV-2 coronavirus has been detected in patient stool.

"Interestingly, the cell entry receptor ACE2 appears to mediate entry of SARS-CoV-2 (similar to SARS) and has been demonstrated to be highly expressed in small intestinal enterocytes," the authors wrote. "ACE2 is important in controlling intestinal inflammation and its disruption may lead to diarrhea."

Ungaro told 番茄社区app that gastroenterologists should be aware they may be encountering cases with predominantly GI symptoms.

"If you're seeing a patient with GI symptoms and some degree of upper respiratory symptoms," COVID-19 should be part of a differential diagnosis, he said.

He also emphasized that medical personnel should protect themselves against infection during endoscopy procedures.

"Gastroenterologists and staff should be donning personal protective equipment [PPE] as recommended by their institution" such as surgical masks, face shields, and eye shields, he said.

Joint GI society guidelines include strongly considering rescheduling elective or non-urgent endoscopic procedures, pre-screening all patients for high risk exposure or symptoms, and making sure appropriate PPE is available and worn by all members of the endoscopy team, and more importantly, that .

Beyond the procedures they perform, gastroenterologists need to be aware of their IBD patients on immunomodulators or biologics, as well as other GI patients on immunosuppressive therapies, Ungaro noted. Increased susceptibility to viral infection and reactivation is a hallmark of many agents used to treat autoimmune diseases.

"Until we know more about how this affects patients with IBD," Ungaro said, he recommends that patients be "aggressive about social distancing" and "particularly mindful about hand hygiene."

His group's paper cited research where viral infections were more likely among IBD patients on small-molecule immunomodulators than biologics, "but it is unclear if this can be extended to COVID-19." They emphasized that at this time they are not advising patients with IBD or other conditions such as autoimmune hepatitis to stop immunomodulator therapy, noting, "The risk of disease flare far outweighs the chance of contracting [COVID-19]."

Ungaro also highlighted research from China finding hepatic abnormalities in patients with COVID-19 infection including elevated liver enzymes and bilirubin.

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