Gastrointestinal and hepatic diseases during the COVID-19 pandemic: Manifestations, mechanism and management

Table 5 Recommendations of the American Association for the Study of Liver Diseases, Asian Pacific Association for the Study of the Liver, and European Association for the Study of the Liver for management of liver disease during coronavirus disease 2019

	Selected recommendations
To limit nosocomial spread	(1) Decrease in-person visits via other alternatives such as virtual platforms
	(2) Symptom investigation before entering hospitals to identify COVID-19 patients
	(3) Reduce staffing to essential staff only
	(4) Reduce the frequency of screening and laboratory examinations
	(5) Adhere to recommended PPE by HCW and patients
	(6) Maintain proper social distancing in hospitals
	(7) Postpone unnecessary or elective operations
Management of CLD patients with COVID-19	(1) These patients should be admitted to hospital early
	(2) Prioritization of COVID-19 testing for patients with cirrhosis, CLD patients taking immunosuppressive agents and acute decompensated patients
	(3) Repeated LFTs are advisable
	(4) Early registration in clinical trials as much as possible
	(5) COVID-19 patients with NAFLD should be kept under supervision
	(6) Screening of hepatitis B surface antigen should be taken into consideration
	(7) Drug-induced liver injury should be monitored
	(8) These patients can receive 2-3 g/d of acetaminophen, while limiting the use of NSAIDs when possible
	(9) HBV prophylaxis should be considered before starting immunosuppressive agents
	(10) Stopping Remdesivir in decompensated liver disease patients with ALT more than 5 times the upper limit of normal
Management of chronic viral hepatitis (HCV and HBV)	(1) Despite COVID-19 status, treatment continuity of chronic HCV and HBV is recommended
	(2) In the absence of flare, HBV treatment should be stopped
	(3) For uninfected individuals, HCV and HBV treatment should be continued according to guidelines
Management of HCC	(1) HCC treatment should be continued according to guidelines; however, it can be delayed if necessary
	(2) In the case of COVID-19 patients, delaying elective transplants and resection surgery, and stopping immunotherapy are advisable
	(3) Early admission to hospital is recommended for HCC patients
Management of pre- and post-transplant recipients	(1) Screening donor and recipient for COVID-19 is suggested
	(2) For donors testing positive for COVID-19, transplantation surgery should be postponed
	(3) Prioritization of patients with short-term prognosis
	(4) For post-transplant patients, a reduction in immunosuppressive dose can be considered for moderate COVID-19 cases, while for mild COVID-19 cases, the dose should not be reduced
	(5) For post-transplant recipients, vaccination against pneumonia and influenza is advisable

PPE: Personal protective equipment; HCWs: Healthcare workers; CLD: Chronic liver disease; COVID-19: Coronavirus disease 2019; LFTs: Liver function tests; NAFLD: Nonalcoholic fatty liver disease; NSAIDs: Non-steroidal anti-inflammatory drugs; HBV: Hepatitis B virus; ALT: Alanine aminotransferase; HCV: Hepatitis C virus; HCC: Hepatocellular carcinoma.