Transcription:
COVID-19: Key Considerations for Gastroenterologists

Melanie Cole (Host):  This is the Northwestern Medicine podcast on COVID-19 dated April 2,2020.

Welcome. This is Better Edge, a Northwestern Medicine Podcast for physicians. I’m Melanie Cole. Joining me in this panel today are Dr. Stephen Hanauer. He’s a Professor of Medicine in the Division of Gastroenterology and Hepatology and the Medical Director of the Digestive Health Center at Northwestern Medicine. And Dr. Scott Strong. He’s a Professor of Surgery in the Division of Gastrointestinal Surgery and Surgical Director of the Digestive Health Center at Northwestern Medicine. Gentlemen, I’m so glad to have you with us today and today, we’re discussing key considerations for gastroenterologists in the context of COVID-19 and how the Division of Gastroenterology and Hepatology and Division of GI Surgery at Northwestern Medicine are evolving care. Thank you so much for joining us. Dr. Hanauer, I’d like to start with you. Tell us about the risks for patients with inflammatory bowel disease or other conditions who may be taking immunosuppressive drugs.

Stephen Hanauer, MD (Guest):  Thank you for hosting us today Melanie. I participate in a weekly Teleconference of 70 inflammatory bowel disease experts from around the world regarding the impact of COVID on patients with inflammatory bowel disease. And these clinicians include the United Kingdom, France, Italy, China, Spain, Hong Kong, and many other countries. So, we are constantly updated on what’s going on in the world. In addition, there is an international registry called Secure IBD that is updated daily where clinicians have been entering data regarding any of their IBD patients who develop COVID and their outcomes according to their age and their medications so that we can track this.

Fortunately, to answer your question, as of today April 2^nd, patients with inflammatory bowel disease do not seem to be at any increased risk of developing the COVID infection. And parallel very much the general population. The primary risks are age, with older individuals being at greater risk, cigarette smoking and there is a slight predominance of men over women just as we see in the general population. Thus far, despite the recognized impact of immunosuppressive medications, we have not seen any particular medicine or group of medicine put patients at any specific increased risk.

Host:  Thank you for that answer. Dr. Hanauer should these patients continue taking their medications or delay treatment and should they continue their infusion protocol? Do they still come in? What would you like them to know and what would you like their primary care providers to know about advising them?

Dr. Hanauer:  The consensus among this international working group is that patients should continue taking their medications. The risk of a flare up or complications of stopping medications greatly exceeds any risk of infection or complications of infections thus far. We do not recommend delaying treatment with either their ongoing oral medications, injections or infusions. All of the infusion centers are safe for patients who are entering them, and they are using precautions regarding the COVID infection.

Host:  So, tell us a little bit Dr. Hanauer what extra precautions are you advising them to take to protect themselves if they are coming in for infusions or having to go out and get groceries? What would you like them to know?

Dr. Hanauer:  Well the first precaution is most important which is the same as the general population which is social distancing and hygiene. Of late, there has been a change in recommendations regarding masks and I would advise any patient on immunosuppressive medications to wear a mask if they are in the public or certainly in the hospital environment. Indeed, any individual entering our hospital which includes our infusion center; will be provided with a mask and they will be queried as to whether or not they have had fever, or any symptoms or exposure to anyone who has the COVID infection.

Host:  Dr. Strong, how are you determining if a patient’s surgery should continue or be postponed?

Scott Strong, MD (Guest):  Sure, that’s a great question Melanie and it’s a pleasure to be speaking with you and your audience. This COVID-19 has resulted in our hospitals and healthcare system being strained by the number of critically ill patients. And for reasons of patient and provider safety and to ensure that resources such as hospital beds, and equipment are available to those patients that are critically ill with the COVID-19; the CDC as well as the American College of Surgeons have kind of weighed in on this. And we are no longer performing nonemergency procedures. They are being delayed. All elective cases have been postponed while emergency surgeries are proceeding as usual, but we are placing an emphasis on early operations so that we are decreasing patient length of stay and we are using appropriate measures to avoid consuming some of these limited resources.

And obviously the patients’ COVID status also plays into our treatment approach. We will be rescheduling these operations but that will depend on a variety of things such as the speed in which this COVID crisis resolves, the patient’s health and need for an operation, our surgical team so schedule and availability of our facilities to schedule such procedures.

Host:  Thank you for that answer Dr. Strong. Dr. Hanauer for just a minute, IBD patients sometimes have bowel obstructions. What do you want them to know if they start coming up with symptoms that they know could be an obstruction? What do you want them to know about calling their gastroenterologists or going into the ER, prednisone, things that are generally done when this happens sometimes?

Dr. Hanauer:  If the patient recognizes that they are developing increasing abdominal pain, nausea or vomiting; it’s strongly recommended that they contact their clinician. It’s pretty obvious that we are trying to avoid individuals walking into the emergency room as they are absolutely consumed with this virus and risk actually contacting individuals in that setting. Nevertheless, we are able to give them individual advice regarding managing their symptoms at that time. And hopefully, avoid having them present to an emergency room. That may be modifying their diet, as you mentioned. It may be giving a course or increasing a dose of medication including corticosteroids but certainly, if a patient feels that they are in a crisis and have greatly increasing abdominal pain or cannot maintain hydration; they should present to an emergency room.

Host:  Dr. Strong, we’re learning more about this virus every day. It seems that respiratory symptoms represent the most common manifestations but what can you tell us about the gastrointestinal manifestations in patients with COVID?

Dr. Strong:  Yes, we’re learning more about this as our experience with the infection evolves. And what we know from our colleagues in China is that about one half of patients that present with Covid-19 infection will actually have a digestive symptom. Most commonly it’s a lack of appetite which is kind of nonspecific but if you look at those things that are really GI specific, about a third will complain of diarrhea and that’s usually having a looser stool maybe up to three times a day. Whereas vomiting or abdominal pain are quite uncommon, only about two to four percent of people will complain of that.

And so, it’s unusual also for the digestive symptoms to occur without the presence of respiratory complaints. But the symptoms related to the GI system seem to get more pronounced as the severity of the respiratory disease increases. So, what’s happening now is that some people are actually suggesting that it’s maybe reasonable as testing becomes more available to test patients for the virus if they present with new GI symptoms and recent contact with a COVID-19 case even if they don’t have any fever or respiratory symptoms.

Dr. Hanauer:  Let me add that that’s – we’re recognizing this increasingly in particular since up to 20% of patients may have no symptoms even if they are infected. So, minor changes in the bowel frequency or mild diarrhea may actually be a symptom in someone who has asymptomatic respiratory disease. And for instance, one of the most common presentations is actually lose of taste and Dr. Strong emphasized or loss of smell and that may be the only symptom of this virus. The problem is we don’t have adequate testing for individuals to see if these minor symptoms actually reflect an underlying exposure.

Host:  That is so interesting doctors. And Dr. Hanauer are you aware if the virus can spread through fecal oral transmission and if so, what are the steps for preventing that spread?

Dr. Hanauer:  Well I would only state that it’s possible that it could be spread through fecal oral. There’s very limited information around that because patients who are sharing food for instance, are also often face to face. So separating whether there is a food-borne transmission is quite challenging at the present time. We do know as you’ve suggested, Melanie, that patients may actually continue to have virus in their stool for 20 days after their nasal swabs are clear. So, we’ve emphasized hygiene as well as social distancing and of course, the first step in hygiene is handwashing. And so, that would help to reduce any potential fecal oral transmission but as I said, thus far, we are not convinced that that is a major source of spread.

Host:  Again, that’s so interesting. Dr. Hanauer, sticking with you for a minute. How are you and your team at Northwestern evolving care for your patients during this pandemic?

Dr. Hanauer:  Well it’s quite interesting from our standpoint because we have been developing the potential for Telehealth over the past number of months, but this pandemic has thrust us into Telehealth absolutely immediately. And we’re having to try to organize around that. There are currently two mechanisms of Telehealth. One is a telephone call and the other is a video encounter. We are able to perform both; however, telephone calls are much easier and much more secure. There are a variety of different means of doing video health, but these continue to evolve. They include using sources such as Zoom, or Microsoft Teams or Skyping. Thus far, the only secure means has been through Microsoft Teams which requires a patient to download an application and make scheduling a little bit more complicated.

Nevertheless, similar to what’s going on around the country and around the world, virtually all of our visits have now been transformed to virtual or Telehealth visits. We are only seeing patients who absolutely need a physical examination in the clinic and that’s to limit both exposure of patients and clinicians as Dr. Strong emphasized. For those visits, patients will require having a mask and the practitioners will be using the personal protective equipment including mask, gown and gloves.

Host:  Dr. Strong how is your department deploying Telehealth? What recommendations as you are telling us this, do you have for other providers who would like to implement Telemedicine for their practices?

Dr. Strong:  Well one of the benefits of the management of digestive diseases at Northwestern Medicine is that Dr. Hanauer and I work in the same environment. And so, whatever Dr. Hanauer and his colleagues are doing, we’re doing the same. And so, as he said, the future is now thrust upon us and it’s here now and so, we have kind of embraced this approach and found out that it’s working very well and some of the lessons that we learned are we maintain a schedule such that the patients know what time we’re going to call and that limits the number of missed calls and repeat calls. And we also have been working with our reimbursement folks to make sure that we know how to appropriately – the terminology that we need to use to appropriately document these encounters with our patients and the patients seem to rather enjoy it.

I think they find that it’s obviously safer for them but also more convenient and we’re able to kind of think outside the box a little bit and we have them sending in a lot of our appointments are for postoperative visits and so we’re having patients just taking a photograph of any wounds or any areas of concern and sending those to us to that we have them available before the visit. And as Dr. Hanauer mentioned, the telephone encounters are much easier to do than the video encounters. And that’s because of protection of personal health information but I think that as all of this evolves, and will evolve rather rapidly over the ensuing months, and even weeks, that that will become a resource that’s much more readily available to all of us.

So, the future is now, and I would encourage people to really embrace this technology because if there are any benefits of this pandemic this is one of them in that it’s really helped to force the issue and I think that both patients and providers are really benefiting from that.

Dr. Hanauer:  Well Dr. Strong, before we wrap up, give us your final thoughts as a surgeon. What would you like other providers, other gastroenterologists to know about COVID and IBD, GI issues and take this forward to their patients?

Dr. Strong:  Yeah, so I’ll mention about the surgical aspects and then leave the medical approach to Dr. Hanauer. But it’s really, it’s a time of change and we’re trying to be as reactive as possible and I think a lot of our national organizations such as the American College of Surgeons and our individual societies have really stepped up to help create guidelines and to really rethink how we are approaching this. No one knows when it will end. And the curve coming down will probably be less steep and more prolonged than the curve going up. But I think that we just all need to be responsible in how we manage this and understand that it’s a very stressful time for everyone, our coworkers as well as our patients. And to be understanding in that and to really reach out to individuals and communicate more. But we’ll get all – through all of this and it’s just going to be a matter of time, but people need to be understanding and accepting of it and I think that we may have some new tools coming out of it that we didn’t have going in.

Host:  Dr. Hanauer, last word to you. What would you like other providers, gastroenterologists and primary care providers to know about treating their patients during COVID-19 and what you’re doing there at Northwestern Medicine to help patients and healthcare providers?

Dr. Hanauer:  Thank you. Well as Dr. Strong emphasized, the future is now. Telemedicine is in place; it’s evolving but it will be the future. From a practitioner’s standpoint, we need to continue to understand how this is going to impact the finances of medicine and reimbursement for subsequent Telehealth as we move forward. As far as our current treatment is concerned; we are treating inflammatory bowel disease the same way. We are not stopping medications, however, as we would for general infections, if patients do develop a viral infection or a serious infection, their immunosuppressive medicines will be temporarily on hold and we will not initiate therapy with immunosuppressive medicines if patients have evidence of an active infection.

But there are several other areas where this is going to be transformative. One of the problems at the present time is that this pandemic has virtually put clinical trials for new medications on hold. I do anticipate in the future, artificial intelligence, patient home monitoring is going to be increasingly utilized within the Telehealth mechanisms and I would also emphasize that this international and national pandemic is going to change the way our systems interact. Right now we’ve heard the governors complain that they are competing with other states for resources, all of the systems are competing with other systems for resources and a greater integration at the local, state and national levels for healthcare is inevitable.

Despite these changes in healthcare, we need you to know that Northwestern Medicine is up, is running, is available to our colleagues and our patients for ongoing chronic and acute care.

Host:  That is great information. Thank you so much Doctors for joining us today and sharing your incredible expertise today in these unprecedented times. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. To refer your patient or for more information on COVID-19 please visit our website at www.nm.org to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I’m Melanie Cole.