Indian Journal of Gastroenterology

https://doi.org/10.1007/s12664-020-01077-0

EDITORIAL

Editorial commentary on the Indian Journal of Gastroenterology

May-June 2020
Jimmy K Limdi 1,2

# Indian Society of Gastroenterology 2020

“Learn from yesterday, live for today and hope for Voluntary perioperative colorectal cancer
tomorrow. And never stop questioning.” registry from Kerala – an initial overview
-Albert Einstein
Colorectal cancer (CRC) ranks among the six most common
The emergence of the Severe Acute Respiratory Syndrome malignancies in India; yet, outcomes data outside of selected
Corona Virus-2 (SARS-COV 2) from Wuhan, China in centers are lacking [5]. Krishnan and colleagues report the first
December 2019 and the resulting Corona Virus Disease outcomes data from 1018 CRC cases from 15/25 participating
(COVID-19) has gripped the world in a global pandemic from centers of the Association of Surgical Gastroenterologists of
its unprecedented spread, changing our perceptions and para- Kerala CRC registry between 2016 and 2018 [6]. The major-
digms around disease and the world, as we have known it. As ity of CRC cases were rectal (39.88%) and rectosigmoid
of 11 July 2020, there have been 12,322,395 confirmed cases (20.33%), with minimally invasive surgery (MIS) performed
of COVID-19, including 556,335 deaths, reported to WHO in 73% cases and 56.74% of colonic malignancies. MIS was
[1] with 22,123 deaths in India [2]. Even as the world remains associated with reduced length of hospital-stay compared to
under the influence of this cataclysmic crisis, the medical and the open approach (10.46 ± 5.08 vs. 12.26 ± 6.03 days;
scientific communities have continued to work tirelessly and p=0.001and 10.29 ± 4.58 vs. 12.46 ± 6.014 days;
collaboratively to find answers for this hitherto unknown dis- p=<0.001), with an overall 2.16% mortality. The data are lim-
ease. Although a predominantly respiratory disease with ited by selection bias from voluntary participation but under-
multi-systemic ramifications, gastrointestinal (GI) symptoms pin the need for wider adoption, identifying outcome modi-
such as diarrhea, vomiting, abdominal pain and hepatic abnor- fiers, and providing much-needed transparency for physi-
malities have been reported in up to 20% of patients with cians, patients, and stakeholders in driving excellence in the
COVID-19, including those with minimal symptoms [3, 4]. overall delivery of care.
The potential for SARS-COV2 to affect the GI tract and im-
plications to patients with underlying GI and liver disease are
of particular relevance to gastroenterologists. With this in Platelet to lymphocyte ratio as a predictive
mind, this issue focusses on COVID-19 with a series of re- biomarker of liver fibrosis (on elastography)
search articles and clinical reviews on COVID-19 and GI in patients with hepatitis C virus (HCV)
disease, constituting essential and timely reading for the prac- -related liver disease
tising gastroenterologist. We hope you find these useful. And
we wish you and your patients well… Chronic hepatitis C with antecedent complications from cir-
rhosis is a major source of morbidity and mortality globally.
Assessment of liver fibrosis is key to critical decisions with
anti-viral therapy [7]. Liver biopsy remains the standard
* Jimmy K Limdi
[email protected]
criterion for the histological evaluation although non-
invasive assessment (transient elastography) is preferred for
1
Inflammatory Bowel Diseases, Division of Gastroenterology, The the serial evaluation but limited by cost and availability [7].
Pennine Acute Hospitals NHS Trust, Manchester M8 5RB, UK There is a resurgent interest in platelet to lymphocyte (PLR)
2
Manchester Academic Health Sciences, University of Manchester, and neutrophil to lymphocyte ratios (NLR) in predicting liver
Manchester M8 5RB, UK fibrosis beyond an assessment of inflammatory activity.
 Indian J Gastroenterol

Catanzaro and colleagues studied treatment-naive patients Presence of diarrhea, high aspartate aminotransferase (AST),
with chronic HCV, who underwent clinical and laboratory alanine aminotransferase (ALT), and bilirubin (odds ratio,
assessments and transient elastography and were classified [OR] 2), high prothrombin time (PT) (OR 4) and low albumin
into Metavir F0-F4 [8]. Patients with F4 fibrosis (cirrhosis) (OR 5) were associated with a severe clinical course. Patients
had a lower PLR than the non-F4 group. Patients with with underlying GI disorders may be particularly vulnerable,
PLR>89 demonstrated an increased risk of F4 fibrosis. No and these findings and rapidly evolving evidence will influ-
differences were noted in NLR values for both groups. ence our paradigms around COVID-19 and GI and liver
Further studies in well-characterized cohorts incorporating disease.
liver biopsy are now needed to validate these findings.

Poor outcomes in patients with cirrhosis

Decreasing major surgical rates for Crohn's and COVID-19
disease in an emerging economy over two
decades but is it due to biologic therapy? The association between SARS-COV 2 infection and high
mortality rates in people with cardiovascular and metabolic
Biological therapies have re-defined our perceptions around co-morbidities is well-recognized. Data on outcomes of
meaningful disease control. “Treating to target” to achieve SARS-COV 2 infection with chronic liver disease are scarce.
mucosal healing and deep remission early in the course of Shalimar and colleagues from All India Institute of Medical
the disease may limit intestinal injury and ensuing disability Sciences (AIIMS), New Delhi report outcomes data from 28
[9]. Have biological therapies influenced a reduction in surgi- patients with SARS-COV 2 infection and underlying chronic
cal resection rates? liver disease compared to age, sex, and severity-matched cir-
Chuah and colleagues conducted a retrospective study rhotic controls [13]. Twenty-six of 28 patients had cirrhosis,
across two tertiary centers in Malaysia and compared surgical and one each had non-alcoholic fatty liver disease and extra-
resection rates in Crohn's disease (CD) patients in the pre- hepatic portal venous obstruction. Mortality was numerically
biologic (cohort 1; 1991-2000) and immediate post-biologic higher in COVID-19 (42.3% vs. 23.1%, p=0.077) and 100%
era (cohort 2; 2001-2010) [10]. There was a significant reduc- among COVID-19 patients with acute-on-chronic liver fail-
tion in the 7-year cumulative intestinal surgical rates between ure, compared to 53.3% among controls (p=0.015). Over
cohorts 1 and 2, from 21.4% to 10.2% (p=0.028), but there 50% of patients had pneumonia, and on multivariate analysis,
was no statistically significant difference in biologic exposure mechanical ventilation was independently associated with
between those who underwent surgery and those who did not. mortality (hazard ratio [HR] 13.680, [p=0.025]). These out-
A small sample size, variable disease duration, and timing of comes are similar to data from larger cohorts (SECURE-
biologics may have influenced results. Long-term prospective CIRRHOSIS registry) [14], which also reported 33% mortal-
studies with early use of optimized biological treatment are ity in COVID-19 patients with cirrhosis affirming our suspi-
urgently needed [11]. cions that patients with cirrhosis contracting SARS-COV 2
have poor outcomes.

Gastrointestinal and hepatic manifestations Compliance with Ethical Standards

of COVID-19 and their relationship to severe
clinical course: A systematic review Conflict of Interest JKL declares that he has no conflict of interest.
and meta-analysis
Disclaimer The author is solely responsible for the contents of this pa-
per. In no way, the Honorary Editor-in-Chief, Editorial Board Members,
Although predominantly a respiratory disease, GI manifesta- or the printer/publishers are responsible for the results/findings and con-
tions are observed in COVID-19 [3]. Kumar and colleagues tent of this article.
performed a systematic review and meta-analysis of 62 stud-
ies, to study the frequency of GI and hepatic manifestations
and determine whether GI or hepatic manifestations are asso- References
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