S2229 Gastrointestinal Bleeding Following Routine Endoscopy: An Unusual Presentation of COVID-19 Infection

Abstract

INTRODUCTION: Presenting symptoms of COVID-19 include fever, cough, dyspnea, nausea, and diarrhea. COVID-19 has been associated with coagulopathy; however, there have been little to no reports of bleeding as the presenting symptom. We present a case of immediate and delayed bleeding after routine gastric biopsy, a normally rare occurrence, as the initial presentation of COVID-19. CASE DESCRIPTION/METHODS: A 53 year-old male with history of hypertension, diabetes, and severe psoriasis presented for an outpatient esophagogastroduodenoscopy (EGD) with gastric mapping. He denied NSAID, aspirin, or SSRI use and had no history of cirrhosis. The gastric mucosa was noted to have erythematous changes suggestive of inflammation. After the initial biopsies were completed, bleeding was noted in the lesser curvature of the stomach from three biopsy sites requiring intervention. Hemostasis was achieved with epinephrine and hemostatic clipping. He had an episode of desaturation during procedure, but did not require supplemental oxygen after recovery from sedation. He was started on a pantoprazole drip and transferred to the emergency department. On admission, his review of systems were negative. Physical exam was unremarkable; vitals were within normal limits including a 97% oxygen saturation on room air. Labs included: hemoglobin 8.9, WBC 3.9, platelet 160K, lymphocyte count of 0.87, PT 10.9, and INR 0.92. His course was notable for new and persistent fevers, patchy opacities on chest X-ray, increasing oxygen requirements despite broad spectrum antibiotics, and melena with worsening anemia requiring two blood transfusions. EGD on hospital day (HD) 3 was notable for a large amount of clotted red blood with food in the gastric fundus and body and a small ulceration. On HD 4, he became hemodynamically unstable with oxygen desaturations to 70% and bilateral consolidations on chest X-ray. COVID-19 testing was positive. He was transferred to the medical ICU and intubated. His ICU course was notable for continued melena requiring two blood transfusions. Repeat EGD on HD 5 noted no bleeding or stigmata of bleeding. He had no further episodes of melena but eventually expired due to complications of COVID-19 infection. DISCUSSION: Clinically significant bleeding after EGD with biopsy requiring transfusion and hospitalization is rare. The patient described above has few risk factors associated with bleeding. His significant gastrointestinal bleeding was likely a result of a dysregulated coagulation associated with COVID-19 infection.