S2113 COVID-19-Associated Coagulopathy and GI Bleed in a Cirrhotic Patient

INTRODUCTION: Acute variceal bleeding is a major cause of upper gastrointestinal (GI) bleeding and is one of the most common causes of death in cirrhotic patients In patients with COVID-19, the risk of bleeding can increase from coagulopathic changes and the digestive tract can be affected after the virus binds via angiotensin converting enzyme II (ACE2) on enterocytes leading to further cellular damage, which requires further study This is a case of new onset variceal bleeding in a cirrhotic patient affected by COVID-19 infection with significant multifactorial coagulopathies during the hospitalization CASE DESCRIPTION/METHODS: A 65-year-old man presented to the hospital with fever, cough, abdominal pain, and diarrhea for one week, but denied melena and hematemesis Nasopharyngeal swab for SARS-CoV-2 RNA was positive Respiratory failure and hypotension developed requiring mechanical ventilation and vasopressors Past medical history included HTN, hypothyroidism, alcoholic liver cirrhosis which was under control He had no history of GI bleed and no prior colonoscopy or EGD The Hgb level was 11 3, platelets, LFT's, and INR/PTT were all within normal limits The first week of hospitalization was uneventful, but on day 14 of hospitalization he had coffee-ground gastric contents in his NG tube and melena Hgb level dropped to 7 1, platelets were 70,000, LFTs and total bilirubin were elevated, and fibrinogen was low with a three-fold increase in D-Dimer level He was given multiple units of PRBCs/FFP and cryoprecipitate and he was started on octreotide and pantoprazole drip with no improvement On day 24, patient found to have left lower extremity DVT EGD revealed large (>5 mm) esophageal varices, including a platelet plug and red wale sign over the esophagus Variceal banding was performed for hemostasis and he was continued on pantoprazole and octreotide On day 32, he had bleeding via IV sites, ET tube, and per rectum, but ultimately succumbed to cardiac arrest and expired with labs indicative of DIC DISCUSSION: This is a rare case of GI bleeding in a patient positive for COVID-19 infection The exact cause of bleeding in COVID-19 is unknown, requiring further study Cirrhotic patients with COVID-19 are prone to GI bleeding but can also be hypercoagulable as evidenced by this patient with a GI bleed and a DVT The initial management of GI bleed can be conservative, but lack of response in 24-48 hours may indicate a need for endoscopy (Figure Presented)