University of Massachusetts Medical School eScholarship@UMMS COVID-19 Publications by UMMS Authors 2021-07-09 Insights into the management of anorectal disease in the coronavirus 2019 disease era Waseem Amjad Albany Medical Center Et al. Let us know how access to this document benefits ou.y Follow this and additional works at: https://escholarship.umassmed.edu/covid19 Part of the Digestive System Diseases Commons, Gastroenterology Commons, Infectious Disease Commons, Telemedicine Commons, and the Virus Diseases Commons Repository Citation Amjad W, Haider R, Malik A, Qureshi W. (2021). Insights into the management of anorectal disease in the coronavirus 2019 disease era. COVID-19 Publications by UMMS Authors. https://doi.org/10.1177/ 17562848211028117. Retrieved from https://escholarship.umassmed.edu/covid19/285 Creative Commons License This work is licensed under a Creative Commons Attribution-Noncommercial 4.0 License This material is brought to you by eScholarship@UMMS. It has been accepted for inclusion in COVID-19 Publications by UMMS Authors by an authorized administrator of eScholarship@UMMS. For more information, please contact [email protected]. TAG0010.1177/17562848211028117Therapeutic Advances in GastroenterologyW Amjad, R Haider 1028117research-article20212021 Advances and Future Perspectives in Colorectal Cancer Special Collection Therapeutic Advances in Gastroenterology Review Ther Adv Gastroenterol Insights into the management of anorectal 2021, Vol. 14: 1–13 https://doi.org/10.1177/17562848211028117DOI: 10.1177/ disease in the coronavirus 2019 disease era https://doi.org/10.1177/1756284821102811717562848211028117 © The Author(s), 2021. Article reuse guidelines: Waseem Amjad, Rabbia Haider, Adnan Malik and Waqas T. Qureshi sagepub.com/journals- permissions Abstract: Coronavirus 2019 disease (COVID-19) has created major impacts on public health. The virus has plagued a large population requiring hospitalization and resource utilization. Knowledge about the COVID-19 virus continues to grow. It can commonly present with gastrointestinal symptoms; initially, this was considered an atypical presentation, which led to delays in care. The pandemic has posed serious threats to the care of anorectal diseases. Urgent surgeries have been delayed, and the care of cancer patients and cancer screenings disrupted. This had added to patient discomfort and the adverse outcomes on healthcare will continue into the future. The better availability of personal protective equipment to providers and standard checklist protocols in operating rooms can help minimize healthcare-related spread of the virus. Telehealth, outpatient procedures, and biochemical tumor marker tests can help with mitigation of anorectal-disease-related problems. There is limited literature about the clinical management of anorectal diseases during the pandemic. We performed a detailed literature review to guide clinicians around management options for anorectal disease patients. We also highlighted the health challenges seen during the pandemic. Keywords: anorectal disease, Coronavirus disease 2019, telehealth Received: 1 April 2021; revised manuscript accepted: 8 June 2021. Introduction infection affects primarily respiratory systems, Coronavirus disease 2019 (COVID-19), caused cardiovascular and gastrointestinal (GI) system by a single-stranded enveloped RNA virus called involvement has been reported in the recent lit- SARS-CoV-2 (Severe Acute Respiratory erature.4–6 COVID-19 infection has not only Syndrome Coronavirus 2), originated in Wuhan impacted public health and economics but also Correspondence to: province in China in December 2019. COVID- the management of acute and chronic medical Waqas Qureshi Section of Cardiology 19 later progressed to a global pandemic that conditions. Elective ambulatory visits and surger- in Division of Internal until now has claimed more than 3.0 million ies have been cancelled to mitigate the risk of Medicine, University of 1 Massachusetts School of deaths and cases continue to grow. High infec- infection transmission and to enable healthcare Medicine, Worcester, MA tivity and transmission through asymptomatic systems to facilitate large volumes of COVID-19 01655, USA Waqas.Qureshi@ patients have led to rapid transmission across infected patients. Telehealth has played impor- umassmed.edu 2 7 geographical borders. COVID-19 has impacted tant role in this situation, providing convenience, Waseem Amjad healthcare and socioeconomics worldwide. patient and provider satisfaction, and decreased Internal Medicine, Albany Medical Center, Albany, 8 Investigations on transmission, clinical presenta- healthcare costs. There are lack of standardized NY, USA tion, treatment, and vaccination have revealed guidelines to manage acute and chronic medical Rabbia Haider new aspects of this viral syndrome. COVID-19 is conditions and confusion exists in the medical Internal Medicine, Nishter Medical University, Multan, commonly transmitted as droplet infection and community. Punjab, Pakistan sometimes as airborne. There are sporadic cases Adnan Malik Internal Medicine, Loyola where fecal–oral transmission was considered as Anorectal diseases are common and can impact University School of the mode of transmission.3 Although COVID-19 the quality of life. The disease spectrum ranges Medicine, Chicago, IL, USA journals.sagepub.com/home/tag 1 Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). Therapeutic Advances in Gastroenterology 14 Figure 1. Lower GI presentation with possible mechanism. Created by biorender.com ACE2, angiotensin converting enzyme receptor 2; GI, gastrointestinal; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; TMPRS2, transmembrane serine protease 2. from benign conditions such as hemorrhoids to COVID-19’. All types of articles including malignant conditions such as cancers.9 A National reviews, case studies, observational studies and Health Service study has predicted poor out- correspondences were considered. In addition, comes of colorectal cancer in future because of we searched the references of the selected articles delays in detection and treatment of these cancers to find related articles that were not identified by during the pandemic.10 Information on manage- the electronic searches. Pertinent studies were ment of anorectal disease during this pandemic is initially searched based on the title and the scarce. In this review article, we explore the abstract, then full text was read to verify the impact of the COVID-19 pandemic on the man- relevance. agement of anorectal disease. Lower GI manifestations of COVID-19 Literature search COVID-19 commonly presents with GI symp- We searched PubMed, Medline, and Google toms. The SARS-CoV-2 virus binds to angioten- scholar from 1 December 2019 to 31 March 2021 sin converting enzyme receptor 2 (ACE-2) to with following search terms ‘COVID-19 infec- enter host cells. The ACE-2 receptor is widely tions and lower gastrointestinal tract manifesta- expressed in the human body including in alveo- tions’, ‘mechanism of gastrointestinal presentation lar type 2 cells, kidneys, adipose tissue, colon, and in COVID-19’, ‘fecal excretion of COVID-19’, the central nervous system. In fact, the ACE-2 ‘fecal transmission of COVID-19’, ‘anorectal receptor is highly prevalent in the colon. Another emergencies, rectal varices, perianal abscess, host cell protein transmembrane serine protease 2 obstructive anorectal cancer, acute hemorrhoid (TMPRSS2) assists in trafficking of the SARS- thrombosis or strangulation and COVID-19’, CoV2 virus to host cells. This protein is found in ‘benign anorectal disease, hemorrhoids, anal fis- the ileum and colon (Figure 1).11,12 In an in vitro sure, anal fistula, anal warts and COVID-19’, study of human gut enterocytes, there was evi- ‘anorectal cancers management, anorectal cancer dence of invasion and proliferation in the entero- screening and COVID-19’, ‘telehealth during cytes.13 Fortunately, the virus is deactivated at coronavirus pandemic and anorectal diseases’, gastric pH; however, patients on proton pump ‘COVID-19 vaccination and management of inhibitors have been found to be at increased risk anorectal diseases’ and ‘surgical practice during of SARS-CoV2 infection.14 This relationship was 2 journals.sagepub.com/home/tag W Amjad, R Haider et al. not seen with H2-blockers. Rather, famotidine additionally with RT-PCR in order to prevent was shown to improve the clinical outcomes in transmission with feces.33 one study.15 The common lower GI symptoms observed in observational studies included abdominal pain and diarrhea.16 Diarrhea as a pre- Inflammatory bowel disease senting symptom for COVID-19 infection is Patients with inflammatory bowel disease (IBD) observed in 2–50% patients whereas abdominal who are taking treatment are considered immu- pain is observed in 4–26%.4,17–21 These symptoms nocompromised patients. This could be a con- are non-specific and could be side effects of the cern for developing severe COVID-19 infection empirical treatments used for COVID-19 in these patients. Active IBD, advanced age, and infection.22 comorbidities are