COVID-19 and gastrointestinal endoscopy: What should be taken into account?

On March 11, 2020 the World Health Organization declared COVID-19 pandemic, leading to a subsequent impact on the entire world and health care system. Since the causing Severe Acute Respiratory Syndrome Coronavirus 2 houses in the aerodigestive tract, activities in the gastrointestinal outpatient clinic and endoscopy unit should be limited to emergencies only. Health care professionals are faced with the need to perform endoscopic or endoluminal emergency procedures in patients with a confirmed positive or unknown COVID-19 status. With this report, we aim to provide recommendations and practical relevant information for gastroenterologists based on the limited amount of available data and local experience, to guarantee a high-quality patient care and adequate infection prevention in the gastroenterology clinic.     

COVID-19 and pediatric fatty liver disease: Is there interplay?

The rapid global spread of coronavirus disease 2019 (COVID-19) infection has become a major health issue with higher morbidity and mortality rates. Besides respiratory symptoms, a growing body of evidence indicates a variety of gastrointestinal manifestations including liver involvement. In this regard, several data supported an association between COVID-19 infection and liver injury in adults, while in children there is compelling but currently limited evidence. In particular, patients with COVID-19 have shown a higher risk of liver injury (mainly expressed as increased transaminase levels or hepatic steatosis). Conversely, a greater risk of more severe forms of COVID-19 infection has been observed in subjects with pre-existing chronic liver diseases. The dramatic interplay between COVID-19 and liver damage has been related to the inflammatory pathways chronically active in patients with nonalcoholic fatty liver disease and acutely in those affected by COVID-19, but other different pathogenic mechanisms have also been supposed. Of note, patients with previous metabolic comorbidities also had a higher risk of severe COVID-19 infection. This emphasizes the pathogenic interrelation of the inflammatory pathways with a dysregulated metabolic milieu in COVID-19 patients. Taking into account the prognostic role of fatty liver in COVID-19 patients and its intrinsic relationship with metabolic abnormalities even in childhood, a strict monitoring of this condition is recommended. We aimed to summarize the most recent evidence regarding the potential interplay between pediatric fatty liver and COVID-19.     

Gastrointestinal symptoms in patients with COVID-19: Is there a relationship with mortality and new variations of SARS-CoV-2?

Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although, respiratory symptoms are typical the digestive system is also a susceptible target with gastrointestinal symptoms present even in the absence of respiratory symptoms. The gastrointestinal symptoms of COVID-19 include diarrhea, abdominal pain, anorexia, and nausea among other symptoms. Some questions that remain to be answered include: Do patients with gastrointestinal symptoms have a higher mortality? SARS-CoV-2 variants are already a global reality: Do these variants present with a greater prevalence of gastrointestinal symptoms? Do patients with these symptoms warrant more intensive care unit care?     

Tissue harmonic imaging: is it useful in hepatobiliary and pancreatic ultrasonography?

The introduction of tissue harmonic imaging (THI) could solve problems related to ultrasound in technically difficult patients by providing a marked improvement in image quality. Tissue harmonics are generated by tissue vibration while the transmitted pulse propagates through tissue and are multiples of the fundamental frequency. The harmonic image is obtained by separating the fundamental and harmonic frequencies, the second harmonic, or twice the fundamental frequency, being used for imaging. Through a better spatial resolution, less artifact and an increased visualization of the deep structures, tissue harmonic sonography improves the image quality. In hepatobiliary diseases THI improves the detection and characterisation of focal liver lesions, increases the conspicuity of gallbladder polyps and stones, choledocholithiasis and intrabiliary masses. Visualization of the pancreatic duct, pancreatic calcifications or duct stones is also more accurate with THI. The results with THI are better than those with conventional ultrasonography as the body mass index increases. The limitations of THI can be overcome by the use of the new pulse inversion harmonic imaging.     

Lung surgery in haematological patients: useful? hazardous?

Respiratory complications are frequent in haematological patients. Lung surgery, either for diagnosis or treatment, is considered useful but hazardous in these patients. We performed a reappraisal study of this purpose; retrospective study in a university centre, located in the Paris area, France. We analysed the entire records of all the haematological patients admitted in the Thoracic Surgery department from October 2001 to January 2009, among 400 haematological patients with pulmonary complications admitted to the Respiratory Diseases department. Seventeen patients (male: n = 13, mean age 47 ± 15 years) underwent lung surgery. Underlying haematological disease was acute (n = 7) or chronic (n = 5) leukaemia, lymphoma (n = 4), and eight have had stem cell transplantation. Thirteen patients had been exposed to a cytotoxic chemotherapy with known pulmonary toxicity. Respiratory diseases have been evolving for 112 days (10–663 days), and 14 patients received previously antibiotic and/or antifungal therapy. One patient was neutropenic and three had thrombopenia. Five patients underwent curative surgery for a residual pulmonary nodule after medical treatment of invasive aspergillosis, and 12 had a diagnostic procedure (open lung biopsy by video-assisted thoracoscopy [n = 2]; thoracotomy [n = 8]). Surgery permitted a final diagnosis in all 12 cases: non-specific infiltrative pneumonia (n = 4), pulmonary graft versus host disease (n = 3), granulomatous pneumocystosis (n = 1), invasive aspergillosis (n = 1), bronchial carcinoma (n = 1), EBV-related lymphoproliferation (n = 1), and tuberculosis (n = 1). Therapeutic regimens were modified according to the surgical results in ten cases (84%). All patients were extubated at the end of surgery. Post-operative complications were: prolonged air leaks (n = 3), pneumonia (n = 1), parenchymal hematoma (n = 1), acute coronary syndrome (n = 1). Seven patients were admitted in the Intensive Care Unit, and five had non-invasive ventilation. Three patients died from respiratory failure: NSIP (n = 2), pneumocystosis (n = 1). Lung surgery for selected haematological patients has two indications: (1) curative surgery, for a residual pulmonary nodule after medical treatment of invasive aspergillosis; (2) diagnostic procedure, leading frequently to modifications of therapeutic regimens, with low rate of complications, in highly selected patients.     

Is MRI useful in osteoarthritis?

Magnetic resonance imaging (MRI) can image all the tissues involved in the osteoarthritic joint-not just the cartilage but also the ligaments, synovium, menisci and subchondral bone. Despite these abilities, MRI does not have an established place in the investigation or management of osteoarthritis (OA). This chapter will overview the literature concerning MRI abnormalities in OA, and their relationship to structural progression and symptoms, in order to let the reader decide on the benefits of MRI in their particular practice. The evidence reviewed here will relate to knee OA, reflecting the vast preponderance of MRI studies in the knee.     

Is telemetry useful in evaluating chest pain patients in an observation unit?

Since the development of coronary care units (CCUs), telemetry has rapidly become the standard of care in evaluating patients with suspected acute coronary syndromes, regardless of the probability for ischemia. However, there is no data to support this practice. Our objective was to evaluate the utility of routine cardiac monitoring in a chest pain observation unit. We prospectively studied the utility of routine cardiac monitoring in 249 consecutive patients admitted to an observation unit in an academic Emergency Department over a 6-month period. All the patients presented with chest pain thought to be cardiac ischemia. Observation included serial cardiac enzymes, ECG cardiac monitoring, and exercise testing in a designated chest pain observation unit. These patients were determined to be at low risk for an acute coronary event by two criteria: first, the symptoms had resolved by the time of observation unit admission, and second, the initial ECG was normal, unchanged or non-diagnostic for acute ischemia. Adverse outcomes included cardiac arrest, hospital admission secondary to cardiac dysrhythmia, or alteration in the patient’s medical therapy upon discharge from the observation unit, secondary to cardiac dysrhythmia. There were 249 patients included with a median age of 52 with 60% women. Fifteen percent of the patients were, subsequently, admitted to the hospital for further evaluation of ischemia based on enzyme, ECG, and exercise testing results. One patient with known Tachy-Brady syndrome was noted to have 1.5–2 s pauses while sleeping, and discharged with instructions to hold beta blocker therapy pending results of a continuous loop recorder. Of the remaining 248 patients, no patient suffered a cardiac arrest, no patient was admitted to the hospital secondary to cardiac dysrhythmia, and no alteration in a patient’s medical therapy was made secondary to cardiac dysrhythmia. No patient returned to the Emergency Department within 72 h with cardiac arrest, acute dysrhythmia or acute myocardial infarction. Although telemetry may be the standard of care in evaluating the patients with suspected acute coronary syndromes, regardless of the probability of an acute ischemic syndrome, in those patients with a normal or non diagnostic ECG and resolved symptoms, routine cardiac monitoring is unnecessary.