Brennan Spiegel, MD, on GI Complications Among Patients With SARS-CoV-2 Infection

Dr Spiegel discusses the persistent gastrointestinal symptoms seen in some patients after they recover from COVID-19.

Brennan Spiegel, MD, is director of health services research at Cedars-Sinai Medical Center in Los Angeles, California.

TRANSCRIPT

Hi, I'm Brennan Spiegel. I'm the director of health services research at Cedars-Sinai here in Los Angeles. I'm also professor of medicine and public health and editor-in-chief of the American Journal of Gastroenterology.

In the next few minutes, I just want to talk about some of our most recent clinical experiences, taking care of people with COVID regarding their GI issues. What we're starting to see is that even after patients recover from COVID. I put that a little bit loosely in quotes, "recover." They continue, in many cases, to have GI complications.

For example, even in the hospital, after a patient has cleared their nasopharynx of COVID-19 and are considered to be COVID-recovered, we're starting to see in many cases still persistent serious conditions. For example, people are in some cases having gastrointestinal bleeding or having ischemic colitis in their colon, which can be very severe, possibly because of mesenteric thrombosis.

These are in some cases people who are COVID-recovered. This brings up the issue of, do we know for sure that they're recovered, or is it possible that COVID is still causing thrombosis or affecting the gut? One way to check is to look at the stool itself and see with RT-PCR if there's SARS-CoV-2 in the stool, but that's not something that in the United States we've been doing.

In China, stool testing is becoming routine and in some cases is required in order to discharge somebody from the hospital that they clear not only their nose and throat, but they also clear their stool.

There's still an open question as to whether patients who we're seeing with this ischemic colitis and GI bleeding may have persistent GI COVID or whether this is just a result of critical illness more generally, and it's not related to the COVID specifically. That's one issue.

Now, the other thing we've been seeing in the hospital is even after people have recovered, in many cases, they're still very ill and frail and require nutritional supplementation and feeding tubes. I've talked to colleagues all around the country. We're all putting in a lot more feeding tubes than we've ever been accustomed to before. This is on the backend now of the pandemic. We're seeing more and more people requiring feeding tubes. I know there's been in fact a national shortage of feeding tubes. In many major hospitals, there are fewer or even no PEG kits left. The interventional radiologists in some cases are having to do the gastrostomy placements because there are no more PEG kits until the manufacturer can ramp up development or ramp up production. These are more examples of just the high demand from a GI standpoint that our patients are seeing even after they've recovered at least from a pulmonary standpoint.

Now, once people are discharged from the hospital or even if they never were admitted to the hospital, we're certainly starting to see evidence of long-haul COVID, as it's called, affects the gut. The question that's arising is, are we going to see a surge in irritable bowel syndrome or IBS, a post-COVID IBS?

We know of course that irritable bowel syndrome occurs after certain bacterial infections, Campylobacter, for example, less so after viral infections. We think that if the microbiome is disrupted by an enteropathic bacterium or virus, that might be a trigger to promote long-term IBS symptoms.

SARS-CoV-2 is undoubtedly an enteropathic virus. It absolutely can take over the largest immune organ in the body which is the gut because the gut is packed full of ACE2 receptors. It has the highest expression of ACE2 receptors of any organ in the body. As a result, of all these ACE2 receptors, it's almost like velcro for SARS-CoV-2.

Once it gets swallowed and if it makes it through the acid layer in the stomach and into the intestines, it can invade the epithelial layer and spread. It might also affect the microbiome in the process. This might be a trigger for seeing longer-term IBS-like symptoms even after the virus has eventually cleared out of the system.

It takes on average about 11 to 12 days before the stool clears after the nasopharynx clears. That gets back to the earlier point about the potential importance of monitoring stool. Even after it clears out of the body, people may have these long-haul symptoms and GI symptoms in particular.

Many of my colleagues are starting to report to me and others that they're seeing people who have persistent diarrhea, persistent abdominal pain, again, well after the immediate illness has passed. In some cases, weeks or months after they have recovered, they have persistent IBS-like symptoms.

Our group is conducting epidemiologic studies right now to understand whether this is becoming a national issue. Just by chance, we conducted—before the pandemic—a nationwide survey of IBS. We then conducted a second survey in the middle of the first surge last year, around the March through July period. We're now about to conduct our third sampling of the general US population.

Our goal is to look and see, are there trends in the prevalence in these cross-sectional samples of IBS over the course of time before, during, and after the pandemic? If so, to see if there are predictors or associations with COVID-19 diagnoses. We're doing that. Hopefully, we'll have more results in the next several months that we can report out.

Others are examining this question too. I think more and more GI doctors are going to want answers because they're starting to see patients in their clinic who have many questions. That's where we are from my point of view right now both in the hospital and outside of the hospital with the potential long-term impact of COVID on the gut.

We'll continue to see this story unfold over the next several months, if not years, as we collect more data and monitor these patients for longer term to see how their GI symptoms evolve and hopefully, eventually regress, and what treatments may or may not be effective. For example, antibiotics, is there a role for them in post-COVID IBS? Is there even such a thing as post-COVID IBS? These are all questions that we're going to be looking into as a research community in the months and years ahead.

I hope that was a helpful quick overview, and I thank you very much for your time and be well.