COVID-19 infection manifesting as a severe gastroparesis flare: A case report

RATIONALE

Coronavirus disease 2019 (COVID-19) is a disease caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which commonly presents with symptoms including fever, cough, and dyspnea. More recently, however, some patients have tested positive for COVID-19 after developing gastrointestinal (GI) symptoms either solely or in conjunction with respiratory symptoms. This may be due to SARS-CoV-2 infection of the GI tract. In patients with chronic GI illnesses, COVID-19 may initially present as a flare of their underlying GI conditions as viruses have historically been implicated in exacerbations of GI disorders, including gastroparesis.

PATIENT CONCERNS

We report a case of a 37-year-old female with a history of diabetic gastroparesis who presented to the Emergency Department (ED) with nausea and vomiting similar to her gastroparesis flares.

DIAGNOSES

Her symptoms in the ED failed to improve with fluids and anti-emetic medications. After developing a fever, she was tested and found to be positive for COVID-19.

INTERVENTIONS

She was started on antibiotic, steroid, and antiviral medications.

OUTCOMES

Her symptoms improved, her fever defervesced on day 4 of hospitalization, and she was discharged on day 5 of hospitalization. The patient reported symptom improvement at a follow-up outpatient gastroenterology visit 2 months after hospitalization.

LESSONS

To the best of our knowledge, at the present time, this is the first report of a patient with COVID-19 presenting with signs and symptoms of a gastroparesis flare. This case illustrates that COVID-19 may present in an exacerbation of symptoms of an underlying disorder, such as a severe gastroparesis flare, in a patient with underlying gastroparesis. Initial presentation of these patients manifesting as a flare of their chronic GI disease, more severe than usual, should prompt an index of suspicion for COVID-19.

Vascular pressure bands on high-resolution esophageal manometry with impedance studies

Horizontal pressure bands on high-resolution esophageal manometry with impedance (HREMI) tracings are often seen and thought to be due to cardiovascular structures compressing the esophagus. The aim of this study was to determine the prevalence and location of vascular pressure bands on HREMI studies and correlate these pressure bands to bolus clearance. HREMI studies in supine and upright positions from patients and normal volunteers were reviewed. Pressure bands were defined as bands of horizontal pressure greater than the 20 mmHg isobaric contour. Each swallow was reviewed with impedance to determine if bolus transit was impaired by the band. 38.6% of 251 patients and 36.4% of 11 normal controls had a pressure band present. There were a greater number of bands in supine versus upright position (patients: 130 vs. 25, P < 0.001 and controls: 6 vs. 1). Patients with pressure bands had similar demographics (age, gender, BMI) compared to those without. Average distal contractile integral of bands was greater in supine compared to upright (133 ± 201 vs. 60 ± 148 mmHg cm s, P < 0.05). Bands were commonly located clustered at 46 and 72% of esophageal length. Bolus transit was impaired by bands in 20.4% of supine and 14.0% of upright swallows. Vascular pressure bands can have a prominent appearance on HREMI studies, present in, being more prevalent and having greater pressure in the supine than the upright position. These vascular bands, when present, may impair esophageal transit.

Multiple Rapid Swallows (MRS) Complements Single-Swallow (SS) Analysis for High-Resolution Esophageal Manometry (HREM)

BACKGROUND

Multiple rapid swallows (MRS) during HREM assess post-deglutitive inhibition, LES relaxation, and subsequent esophageal contraction.

AIMS

(1) To determine the relationship between MRS and single-swallow (SS) responses and (2) to determine if MRS provides information for symptomatic patients.

METHODS

Healthy volunteers (HVs) and patients underwent HREM [30-s landmark, ten 5-mL SS, MRS (5 consecutive 2-mL swallows every 2-3 s)] and were analyzed with ManoView software version 3 with CC version 3.0.

RESULTS

In 20 HVs, MRS response consisted of: (1) reduction in GEJ pressure; (2) absence of esophageal contractile activity during MRS; and (3) post-MRS peristaltic contraction greater than SS contractions. In 20 HVs and 403 patients, MRS IRP correlated with SS IRP (r = 0.65; p < 0.0001) and post-MRS contraction DCI correlated with SS DCI (r = 0.76; p < 0.0001). Abnormally elevated MRS IRP was seen in 68% type 2 achalasia, 50% type 3 achalasia, 47% EGJOO, and 9% jackhammer. Increased MRS DCI was seen in 53% type 2 achalasia, 92% type 3 achalasia, 10% EGJOO, 22% jackhammer, and 18% DES. Increased DCI post-MRS was seen in 38% patients with jackhammer, 8% type 3 achalasia, 12% EGJOO, and 9% DES. 14 out of 143 (10%) patients with normal or indeterminate results on SS analysis had at least one abnormality on MRS.

CONCLUSIONS

MRS IRP correlated with SS IRP, and post-MRS DCI correlated with SS DCI. Patients with defined CC disorders have abnormalities on MRS. There were MRS abnormalities in some patients with normal SS studies, most notably suggesting impaired LES relaxation and/or spastic esophageal motility. MRS may complement the baseline SS study analysis.

Wide-area transepithelial sampling with computer-assisted 3-dimensional analysis (WATS) markedly improves detection of esophageal dysplasia and Barrett's esophagus: analysis from a prospective multicenter community-based study

The 4-quadrant forceps biopsy (FB) protocol for identifying Barrett's esophagus (BE) and esophageal dysplasia (ED) suffers from poor sensitivity due to significant sampling error. We investigated the benefit of wide-area transepithelial sampling with 3-dimensional computer-assisted analysis (WATS) used adjunctively to the combination of random and targeted FB in the detection of ED, and as a secondary outcome, BE. In this multicenter prospective trial, community endoscopists at 21 sites utilized WATS as an adjunct to both targeted and random FB in patients undergoing BE screening and surveillance. Investigators alternated taking FB and WATS samples first. WATS specimens were analyzed at CDx Diagnostics (Suffern, NY) while FB samples were analyzed by each site's regular pathologists. Data were de-identified and then aggregated for analysis. Of 12,899 patients enrolled, FB identified 88 cases of ED, and WATS detected an additional 213 cases missed by FB. These 213 cases represented an absolute increase of 1.65%, raising the yield from 0.68% to 2.33%. Adding WATS to FB increased the overall detection of ED by 242% (95% CI: 191%-315%). Fewer than 61 patients needed to be tested with WATS to identify an additional case of ED. The combination of random and targeted FB identified 1,684 cases of BE, and WATS detected an additional 2,570 BE cases. The absolute incremental yield of adding WATS to FB is 19.9%, increasing the rate of detection from 13.1% to 33%. Adding WATS to FB increased the overall detection of BE by 153% (95% CI: 144-162%). The number needed to test with WATS in order to detect an additional case of BE was 5. Whether FB or WATS was done first did not impact the results. In this study, comprised of the largest series of patients evaluated with WATS, adjunctive use of the technique with targeted and random FB markedly improved the detection of both ED and BE. These results underscore the shortcomings of FB in detecting BE-associated neoplasia, which can potentially impact the management and clinical outcomes of these patients.