INTRODUCTION

The severe acute respiratory syndrome SARS-CoV-2 establishes the disease through COVID-19, air-transmitted viral disease which rapidly became a pandemic in the year 20201. SARS- CoV-2 mainly presents respiratory affiictions, nowadays gas- trointestinal, cardiac, and renal manifestations are also known. Gastrointestinal symptoms are present on up to 35% of patients with these being vomiting and diarrhea1-2. It is exceptional that a patient infected with coronavirus reports upper gastrointesti- nal bleeding.

CLINICAL CASE

A 43-year-old male patient, arterial hypertension currently in treatment with losartan 50mg/day, left hemiplegia due to a stroke. No history of anti-inflammatory, analgesic, antiaggregant nor anticoagulant intake.

Reported nausea and vomiting of gastric content. Stable he- modynamics, clinical anemia. Rectal examination yielded normotonic sphincter, and melena on glove.

Hemoglobin 7.5 g/dl was recorded, and the patient was transfused two volumes of red blood cells. A nasopharyngeal swab was performed due to pandemic state, positive PCR test for COVID-19, currently on the 4th day of the disease.

An emergency fibrogastroscopy was performed which yield- ed an extensive injury on the infrapyloric region extending to the second portion of the duodenum, with an isolated hem- orrhaging blood vessel (Forrest 1A), without ulcerated injury. Hemostasis through endoscopic sclerosis with adrenaline was performed (Figure 1, panel A and B).

Admitted to intensive care unit, proton-pump inhibitors were intitiaded. He showed hemodynamic inestability 24-hours afterwards, another fibrogastroscopy was performed which yielded a jet bleeding subsequent to the adrenaline injection, resolved by hemostatic clip placement.

Proper development after the last performed procedure. Third fibrogastroscopy before discharge yielded no evidence of active bleeding (Figure 1, panels C and D), negative Helicobacter pylori through biopsy.

The patient developed properly, being discharged after 15 days and continuing outpatient check-ups through a polyclinic.

Figure 1.  Emergency fibrogastroscopy. Panel A: arterial jet bleeding in the infrapyloric region. Panel B: isolated blood vessel without ulcerated injury after hemostasis with adrenaline. Check-up fibrogastroscopy. Panel C: injury on the infrapyloric region, no bleeding. Panel D: endoscopic check-up of the clipped injury. 

DISCUSSION

The most common symptoms of the COVID-19 disease are respiratory, gastrointestinal disorders are key extrapulmonary affiictions, and gastrointestinal hemorrhage is reported on 2 to 13% of admitted coronavirus patients³.

The intestinal epithelium secretes the angiostensin-converting enzyme, viral entry receptor, which is present on the esophagus, ileum, and colon^1-3. It is not yet clear if SARS-CoV-2 damages the epithelium and causes the bleeding or if it appertains to multiple factors, including stress caused by the disease, epithelium damage and active inflammation of the mucous membrane through cytokine storm⁴.

Several authors have proven that the bleeding is most frequent during hospitalization which suggests its related to the treatment or its secondary to viral factor related to the critical disease, instead of a virus-induced mucous membrane injury3. A multicenter study has proven that 80% of gastrointestinal bleeding were caused by duodenal or gastric ulcers3. In our clinical case an extensive injury of atypical topography (infrapyloric up to duodenum II) was observed, non-ulcerated where an isolated blood vessel protruded from.

The treatment of these patients must be performed by a multidisciplinary team. Firstly, perform an initial fibrogastroscopy on hemodynamically unstable patients and/or under clinical suspicion of rebleeding, due to the risk of respiratory failure for the patient and increase of infection rate for the health personnel.

Secondly, evaluate risk-benefit of anticoagulation, although the COVID-19-induced coagulopathy is recognized, which is the reason why anticoagulation is one of the treatment’s pillars, caution and extreme vigilance must be implemented in comor- bidity patients^5,6.