S3456 COVID-19 and Upper GI Bleeding Due to Duodenal Ulcers: A Management Dilemma

Abstract

INTRODUCTION: COVID-19 has had a drastic impact on global health and the medical community Gastrointestinal manifestations have been reported in up to 20% of COVID hospitalized patients One such complication is gastrointestinal bleeding We report here three cases of patients with COVID pneumonia who developed upper GI bleeding secondary to duodenal ulcers CASE DESCRIPTION/METHODS: A 56-year-old male with COVID pneumonia needing intubation and pressors developed melena and anemia Upper endoscopy (EGD) showed one spurting cratered duodenal ulcer with a visible vessel, which was successfully treated with gold probe and one clip (Figure 1A-C) However, he continued to have melena and needed IR guided embolization of the gastroduodenal artery (GDA) A 78-year-old female with cardiac stents (on plavix) admitted for COVID pneumonia developed melena and anemia CT angiogram of the abdomen showed active bleeding in the duodenum EGD showed a bleeding duodenal ulcer with visible vessel that was treated with bipolar cautery but the bleeding persisted (Figure 2A-B) She underwent IR guided embolization of the GDA Upon discharge, she was started on xarelto for a DVT Subsequently, she was readmitted for GIB and repeat EGD showed a bleeding vessel in the duodenal bulb that was treated successfully with epinephrine and three clips (Figure 2C-D) IVC filter was then placed A 59-year-old male with history of renal transplant for chronic kidney disease was admitted for COVID pneumonia and needed ECMO and tracheostomy GI was consulted for percutaneous endoscopic jejunostomy tube placement EGD showed a large ulcer covering the bulb with an adherent clot (Figure 3A-B) Patient then developed melena and anemia Given limited endoscopic intervention, IR was recommended for embolization of the GDA DISCUSSION: Our cases demonstrate that life-threatening upper GIB due to duodenal ulcers can be a complication in COVID-19 patients Endoscopic management is challenging due to intubation, extubation, and risk of viral exposure to the staff involved in the EGD The etiology of duodenal ulcers appears to be multi-factorial: stress-induced from mechanical ventilation, steroid use, coagulopathy, and anticoagulation Once GIB is suspected, these patients should be managed aggressively with protonix drip and possible EGD One can even recommend daily prophylactic protonix in all COVID patients Further research is needed to determine if there are direct effects of the virus on the GI tract