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Gastrointestinal mucosal damage in patients with COVID-19 undergoing endoscopy: an international multicentre study
  1. Giuseppe Vanella1,
  2. Gabriele Capurso1,
  3. Cesare Burti2,
  4. Lorella Fanti3,
  5. Luigi Ricciardiello4,
  6. Andre Souza Lino5,
  7. Ivo Boskoski6,7,
  8. Michiel Bronswijk8,
  9. Amy Tyberg9,
  10. Govind Krishna Kumar Nair10,
  11. Stefano Angeletti11,
  12. Aurelio Mauro12,
  13. Fabiana Zingone13,
  14. Kofi W. Oppong14,
  15. Daniel de la Iglesia-Garcia15,
  16. Lieven Pouillon16,
  17. Ioannis S. Papanikolaou17,
  18. Pierluigi Fracasso18,
  19. Fabio Ciceri19,
  20. Patrizia Rovere-Querini20,
  21. Carolina Tomba2,
  22. Edi Viale3,
  23. Leonardo Henry Eusebi4,
  24. Maria Elena Riccioni6,7,
  25. Schalk van der Merwe8,21,
  26. Haroon Shahid9,
  27. Avik Sarkar9,
  28. Jin Woo (Gene) Yoo10,
  29. Emanuele Dilaghi11,
  30. R. Alexander Speight14,
  31. Francesco Azzolini3,
  32. Francesco Buttitta4,
  33. Serena Porcari6,7,
  34. Maria Chiara Petrone1,
  35. Julio Iglesias-Garcia15,
  36. Edoardo V. Savarino13,
  37. Antonio Di Sabatino12,
  38. Emilio Di Giulio11,
  39. James J. Farrell10,
  40. Michel Kahaleh9,
  41. Philip Roelandt8,21,
  42. Guido Costamagna6,7,
  43. Everson Luiz de Almeida Artifon5,
  44. Franco Bazzoli4,
  45. Per Alberto Testoni3,
  46. Salvatore Greco2,
  47. Paolo Giorgio Arcidiacono1
  1. 1Pancreatobiliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
  2. 2Digestive Endoscopy Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
  3. 3Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
  4. 4Department of Medical and Surgical Sciences, University of Bologna and Sant’Orsola Malpighi Hospital, Bologna, Italy
  5. 5GI Endoscopy Service, Hospital Casa de Saude de Santos, Santos, Brazil
  6. 6Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
  7. 7Center for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
  8. 8Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
  9. 9Robert Wood Johnson Medical School Rutgers University, New Brunswick, New Jersey, USA
  10. 10Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
  11. 11Digestive Endoscopy Unit, Sant'Andrea Hospital, Sapienza University, Rome, Italy
  12. 12Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
  13. 13Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
  14. 14Department of Gastroenterology, Newcastle upon Tyne hospitals NHS Trust, Newcastle upon Tyne, UK
  15. 15Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela. Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
  16. 16Imelda GI Clinical Research Center, Imeldaziekenhuis, Bonheiden, Belgium
  17. 17National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
  18. 18Ospedale Sandro Pertini, Rome, Italy
  19. 19Department of Hematology and Stem Cell Transplantation, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
  20. 20Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
  21. 21Department of Chronic Disease, Metabolism and Ageing (CHROMETA), KU Leuven, Leuven, Belgium
  1. Correspondence to Professor Paolo Giorgio Arcidiacono; arcidiacono.paologiorgio{at}


Background Although evidence suggests frequent gastrointestinal (GI) involvement during coronavirus disease 2019 (COVID-19), endoscopic findings are scarcely reported.

Aims We aimed at registering endoscopic abnormalities and potentially associated risk factors among patients with COVID-19.

Methods All consecutive patients with COVID-19 undergoing endoscopy in 16 institutions from high-prevalence regions were enrolled. Mann-Whitney U, χ2 or Fisher’s exact test were used to compare patients with major abnormalities to those with negative procedures, and multivariate logistic regression to identify independent predictors.

Results Between February and May 2020, during the first pandemic outbreak with severely restricted endoscopy activity, 114 endoscopies on 106 patients with COVID-19 were performed in 16 institutions (men=70.8%, median age=68 (58–74); 33% admitted in intensive care unit; 44.4% reporting GI symptoms). 66.7% endoscopies were urgent, mainly for overt GI bleeding. 52 (45.6%) patients had major abnormalities, whereas 13 bled from previous conditions. The most prevalent upper GI abnormalities were ulcers (25.3%), erosive/ulcerative gastro-duodenopathy (16.1%) and petechial/haemorrhagic gastropathy (9.2%). Among lower GI endoscopies, 33.3% showed an ischaemic-like colitis.

Receiver operating curve analysis identified D-dimers >1850 ng/mL as predicting major abnormalities. Only D-dimers >1850 ng/mL (OR=12.12 (1.69–86.87)) and presence of GI symptoms (OR=6.17 (1.13–33.67)) were independently associated with major abnormalities at multivariate analysis.

Conclusion In this highly selected cohort of hospitalised patients with COVID-19 requiring endoscopy, almost half showed acute mucosal injuries and more than one-third of lower GI endoscopies had features of ischaemic colitis. Among the hospitalisation-related and patient-related variables evaluated in this study, D-dimers above 1850 ng/mL was the most useful at predicting major mucosal abnormalities at endoscopy.

Trial registration number (ID: NCT04318366).

  • endoscopy
  • mucosal infection
  • gastrointestinal tract
  • covid-19

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • Contributors PGA and GC were involved in study concept and design. SG, JF, ELDAA, ADS, MK, PR, CB, LF, LR, ASL, IB, MB, AT, GKKN, SA, AM, FZ, KWO, DdllG, LP, ISP, PF, CT, EV, LHE, MER, SWVdM, HS, AS, JWY, ED, RAS, FA, FB, SP, MCP and PRQ were involved in acquisition of data. GV and GC were involved in statistical analysis. GV, GC and PGA were involved in analysis and interpretation of data and in drafting of the manuscript. MB, SWvdM, KWO, ES, ADS, JF, MK, GC, JIG, EDG, ELDAA, FB, PAT, SG, FC and PGA were involved in critical revision of the manuscript for important intellectual content. All authors revised the manuscript, approved the final version to be published and agree to be accountable for accuracy and integrity of any part of the work. Guarantor of the article: PGA.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests GV received travel grants from Mylan and Alfasigma. GC is a consultant for Mylan. IB is consultant for Apollo Endosurgery, Cook Medical and Boston Scientific; board member for Endo Tools; research grant recipient from Apollo Endosurgery; had food and beverage compensation from Apollo Endosurgery, Cook Medical, Boston Scientific and Endo Tools. LR is a consultant for Cancer Prevention Pharmaceuticals; has received research grants from SLA Pharma AG and Takeda and receives funds from the Italian Association for Cancer Research (IG21723). MB received travel grants from Takeda, Taewoong Medical and Prion Medical. KWO has received lecture fees from Olympus, Medtronic and Mylan. He has received a research grant from Medtronic. LP received advisory board fees from Janssen and Takeda; presentation fees from AbbVie and Ferring; and personal fees from AbbVie, Ferring, Norgine and Takeda. SWVdM holds the Cook chair in interventional endoscopy and holds consultancy agreements with Boston Scientific, Cook, Pentax and Olympus. ES has received lecture or consultancy fees from Medtronic, Reckitt Benckiser, Takeda, Merck & Co, Bristol Myers Squibb, AbbVie, Amgen, Novartis, Fresenius Kabi, Sandoz, Sofar, Malesci, Janssen, Grifols, Aurora Pharma, Innovamedica, Johnson & Johnson, SILA, Unifarco, Alfasigma, Shire, EG Stada Group. MK has done consulting work for Boston Scientific, Interscope Med and AbbVie. He has received research grants from Boston Scientific, Emcision, Conmed, Pinnacle, Cook, Gore, Merit and Olympus. PR is supported by Clinical Mandate from Belgian Foundation against Cancer (Stichting tegen Kanker) and receives speaking and consultancy fees from MSD Belgium. GC is consultant for and had food and beverage compensation from Cook Medical, Boston Scientific and Olympus.

  • Patient consent for publication Not required.

  • Ethics approval IRCCS San Raffaele Institute promoted the study and obtained local Institutional Review Board (IRB) approval under the code COVID-BioB (n.34/int/2020) as part of a general protocol registered in Each participating centre obtained approval in keeping with local IRB policy.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.