Current understanding of the impact of COVID-19 on gastrointestinal disease: Challenges and openings

Table 3 Recommendation guidelines for the management of patients with liver disease during coronavirus disease-2019

S. No.	Clinical condition	Consulting organization	Recommendation guidelines for management during COVID-19
1	Out-patient care	AASLD, EASL-ESCMID	(1) Offering telehealth; (2) Mail order of prescriptions & medications; (3) If viral hepatitis occurs: continue medication; (4) Tracking & recording alcohol usage; (5) Limiting testing, imaging & blood withdrawal; and (6) For patients with autoimmune liver disease, immunosuppression medication is continued.
2	In-patient care	AASLD, EASL-ESCMID	(1) Clustering COVID-19 & non-COVID-19 patients separately; (2) Minimizing personnel on rounds; (3) Safe discharge planning; (4) Usage of remote care- telehealth communications & video monitoring; (5) Limiting patient visitors; (6) Minimizing testing, imaging & blood withdrawal; and (7) Avoiding inter/intra- transfer between facilities.
3	Endoscopy	AASLD, EASL, APSDE, AGA, ESGE, ASGE	(1) Limiting emergent indications such as ERCP (for cholangitis), severe GI bleeding or variceal bleeding; (2) Minimizing personnel during procedures; (3) Every clinician/personnel recommended to use N95 masks and PPE as there is high aerosol generation during clinical procedures; and (4) Postponing certain elective procedures such as esophageal variceal screening.
4	NAFLD	AASLD, EASL	(1) Notification to patients regarding adverse hepatic/metabolic implications associated with social isolation & lifestyle; (2) In line with existing directives, arterial hypertension treatment should continue; and (3) All NAFLD patients who may be infected with SARS-CoV-2 should have early admission.
5	Viral hepatitis (HBV & HCV)	AASLD, EASL	(1) If under care, continue treatment for chronic HCV and chronic HBV; (2) For follow-up patients, offer telehealth and laboratory testing; (3) Mail order of direct-acting anti-viral prescriptions & medications, if initiated; (4) Alternative therapy should be considered as associated risks of IFN-α is unknown; (5) Case-by-case basis decision in consultation with a medical specialist should be undertaken for patients with COVID-19 and high disease flare; and (6) Use of anti-viral therapy is considered in individuals with resolved or chronic HBV and COVID-19 conditions undertaking immunosuppressive therapy.
6	Liver cirrhosis	AASLD, EASL	(1) Clustering COVID-19 & non-COVID-19 patients separately; (2) Early admission and prioritized COVID-19 testing for patients with ACLF or deteriorating/chronic hepatic conditions is advised; (3) Every attempt must be made, wherever feasible, to restore highest quality treatment for patients; (4) Prophylactic course of action for GI hemorrhage, hepatic encephalopathy etc. must be trialed; (5) Use of vasoconstrictor therapy ought to be undertaken with great consideration and care; and (6) Vaccination recommended for Streptococcus pneumoniae and influenza.
7	ALD	AASLD, EASL	(1) It is recommended that there should be no reduction in immunosuppressant dosing in patients with ALD & COVID-19. Under special conditions, dosage may be decreased but, after consultation with a clinician; (2) Monitoring of corticosteroid treatment in patients with elevated doses as they have increase susceptibility to viral infection; (3) Agents such as budesonide is recommended as a primary treatment to reduce the systemic risk of glucocorticoids; and (4) Vaccination is recommended for Streptococcus pneumoniae and influenza.
8	ARLD	AASLD, EASL	(1) Reduction in consumption of alcohol; (2) Implementing strategies such as cessation and online (telephone) alcohol liaison services; (3) Monitoring of corticosteroid treatment in patients with elevated doses as they have an increase susceptibility to viral infection; (4) Awareness of online circulation of misinformation or fabrication concerning alcoholic effects.
9	Liver transplantation and surgery	AASLD, EASL, ILTS, LTSI, ATS, TTS	(1) Avoid evaluation of in-patient transplants; (2) Screening of recipients and donors for COVID-19; (3) Reduction in immunosuppression in chronic COVID patients; (4) Routine reduction in immunosuppression doses should not be encouraged; (5) Edge to urgent indications/case-by-case; (6) Minimize workforce during treatment procedures; (7) Safe anesthesia practice with appropriate PPE and N95 masks use is recommended; and (8) Deferring elective procedures such as hepatic resection.
10	Hepatocellular carcinoma	AASLD, EASL, ILCA, ASCO, ESMO	(1) Postponing HCC screening for some months; (2) Pausing enrolment in clinical trials; (3) If surgery or extirpation are delayed, then trans-arterial bridging therapies should be offered; and (4) The patient needs to continue, if already taking tyrosine kinase inhibitor medications.

NAFLD: Non-alcoholic fatty liver disease; ALD: Auto-immune liver disease; ARLD: Alcohol-related liver disease; COVID-19: Coronavirus disease-2019; ERCP: Endoscopic retrograde cholangiopancreatography; GI: Gastrointestinal; PPE: Personal protective equipment; SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2; HBV: Hepatitis B virus; HCV: Hepatitis C virus; ACLF: Acute-on-chronic liver failure; ALD: Alcoholic liver disease; HCC: Hepatocellular carcinoma; AASLD: American Association for the Study of Liver Diseases; EASL: European Association for the Study of the Liver; ESCMID: European Society of Clinical Microbiology and Infectious Diseases; APSDE: Asian Pacific Society for Digestive Endoscopy; AGA: American Gastroenterological Association; ESGE: European Society of Gastrointestinal Endoscopy; ASGE: American Society for Gastrointestinal Endoscopy; ILTS: International Liver Transplantation Society; LTSI: Liver Transplant Society of India; ATS: American Thoracic Society; TTS: Transplantation Society; ILCA: International Liver Cancer Association; ASCO: American Society of Clinical Oncology; ESMO: European Society for Medical Oncology.