key: cord-0758124-9hg5f7u2
authors: Cappell, Mitchell S.
title: Problems for Gastrointestinal Patients With Diarrheal Disorders: Limited Access to Public Bathrooms Because Previously Open Public Bathrooms Have Closed Due to COVID-19 Pandemic and Inadequate Number of Bathrooms in Some Endoscopy Suites
date: 2020-12-15
journal: Am J Gastroenterol
DOI: 10.14309/ajg.0000000000001082
sha: 8b52ab0acc24bfc7ca336541ce84dbe4bad99ef9
doc_id: 758124
cord_uid: 9hg5f7u2

nan

We read with great interest the recently published article in The American Journal of Gastroenterology about digestive tract characteristics of Coronavirus Disease 2019 (COVID-19) patients (1) . The treatment of abdominal diseases in this special period faces many risks. The gastrointestinal symptoms of COVID-19 are more challenging for clinicians than the familiar respiratory symptoms. In particular, patients with hepatitis have abdominal symptoms overlapping with novel coronavirus infection, thus bringing more difficulties and risks to the judgment of clinicians. In other words, gastroenterologists cannot make a definitive diagnosis based solely on clinical manifestations, and related examinations and may neglect the role of novel coronavirus. From this perspective, in this particular period of the pandemic, we should not focus only on the symptoms and diagnosis of hepatitis while ignoring the causes.

It should be emphasized that the gastrointestinal symptoms of COVID-19 can be confused easily with other gastrointestinal diseases, including hepatitis. This makes clinical diagnosis and treatment more difficult. To the best of our knowledge, hepatitis is a digestive tract disease mainly characterized by abdominal and constitutional symptoms, which are obviously easily confused with the abdominal symptoms of COVID-19. Given this consideration, we have come up with these new concepts-COVID-19 is mainly characterized by abdominal symptoms, hepatitis combined with COVID-19, and novel coronavirus hepatitis. It is easy to distinguish these concepts literally.

Hepatitis combined with COVID-19 means that the occurrence of the 2 diseases overlaps in time but is not cause and effect. However, novel coronavirus hepatitis indicates that hepatitis is caused by novel coronavirus infection. Novel coronavirus has been successfully isolated from liver tissue, implying a risk of novel coronavirus hepatitis (2) . This means that novel coronavirus has a potential risk of triggering hepatitis because viral infection of the liver is the main cause of hepatitis. Therefore, clinicians should always remind themselves whether the hepatitis they are dealing with is directly caused by novel coronavirus infection. However, we are not sure of the pathological and clinical characteristics of novel coronavirus hepatitis. Therefore, this concept is of great significance for subsequent research and clinical work.

Because the pandemic continues to spread and worsen, it is of great importance to accurately judge hepatitis in clinical practice. More studies are needed to confirm the pathological and clinical characteristics of novel coronavirus hepatitis, so as to better serve the clinical application. After all, we do not want to cause missed diagnosis or misdiagnosis of novel coronavirus-related diseases. Gastrointestinal (GI) patients with diarrheal diseases have complained to me, their gastroenterologist, about recently closed public bathroom facilities due to COVID-19 pandemic after they suddenly, urgently required bathroom facilities while driving due to abdominal cramps, abdominal pain, or fecal soiling from diarrhea. I recently confirmed this finding. I drove about 3 miles each way on Woodward Avenue, Royal Oak, a busy commercial strip in suburban Detroit, looking for a bathroom after experiencing sudden, crampy abdominal pain associated with diarrhea, but all 5 public commercial establishments, including banks, gas stations, and a large dental clinic, refused me bathroom access after closing their previously open bathrooms due to the pandemic. I traveled several miles further to a hospital to use a public bathroom, thereby wasting 45 minutes.

Similarly, inadequate public bathroom facilities at hospitals or freestanding ambulatory GI endoscopy suites present a problem to GI patients. I am employed as an academic clinical gastroenterologist at one of the busiest GI endoscopy units in the country performing about 25,000 GI endoscopies per annum. Yet, this endoscopy suite has only 2 bathrooms. Many patients scheduled for colonoscopy need urgent bathroom access because of diarrheal diseases, rectal bleeding, or recently taking peroral colonic lavage as a prep for colonoscopy. I surveyed the last 100 bathroom uses per bathroom in the endoscopy suite and found that the hallway bathroom is occupied and unavailable for use 29% of the time, and that the waiting room bathroom is occupied and unavailable for use 12% of the time. Recovery room bathrooms are not a problem because there are three of them and each one is rarely occupied and unavailable for use. Patients in the endoscopy suite should not be forced to go to bathrooms outside this area because walking outside this area is highly inconvenient.

The GI community, including gastroenterologists, other GI health professionals, patients suffering from diarrhea, and concerned citizens should be made aware of currently limited public bathroom access in commercial areas and in some endoscopy suites to plan trips accordingly and to consider raising public awareness about these annoying problems. A 68-year-old gentleman presented with progressively enlarging lump in the central and left upper abdomen for last 7 months. General physical examination of the patient was unremarkable. Contrast-enhanced computed tomography abdomen revealed 19 3 18-cm well-defined, round to oval, mildly enhancing solid-cystic lesion with lobulated margins involving the body and tail of the pancreas (Figure 1a) . Routine blood investigations and serum tumor marker, i.e., carbohydrate antigen 19-9 and carcinoembryonic antigen, were normal. For diagnostic as well as curative intent, we performed distal pancreatectomy with splenectomy. Spleen could not be spared because of iatrogenic injury to the splenic vein while dissection the tumor. Gross specimen consisted of a spongy soft tissue measuring 19 3 18 cm (Figure 1b) . It's cut surface was honeycomb like showing numerous thin-walled spaces filled with dark brown fluid. The pancreatic tissue was discernible only focally. Representative histopathology sections showed a vascular lesion composed of intermingled vessels of various types and caliber. There were numerous thinwalled blood vessels, lymphatics, and occasional small arteries with smooth muscle in their walls. The blood vessels were engorged with red cells; lymphatics were filled with lymph seen pale eosinophilic material. The lining endothelium was flat (Figure 2a) . There was no morphologic features suggestive of aggressive biologic behavior such as solid clusters of cells, mitoses, or necrosis. The pancreatic tissue was compressed and identified at the periphery of the lesion, and it was histologically unremarkable (Figure 2b ). In view of concomitant disorganized proliferation of blood vessels and lymphatics of the pancreas, the case was diagnosed as a vascular hamartoma of the pancreas.

Hamartomas are benign lesions, which represents conglomeration of disorganized proliferated mature tissue in a dissimilar portion. Albrecht in 1904 first coined the term hamartoma to describe tumor-like malformation occurring due to inborn errors of development of the tissues. In 1967, Willis redefined it as developmental malformation, essentially benign in nature, which contains intermixture of mature cells and tissue indigenous to anatomic area of occurrence, often with 1 element predominating (1). The relative preponderance of a certain type of native tissue within this lesion defines its subtype and clinical behavior (2) . Based on relative abundance of endogenous tissues of particular cell lineage, different subtypes of the hamartoma of tongue has been described in the literature. (3). The American Journal of GASTROENTEROLOGY VOLUME 116 | JUNE 2021 www.amjgastro.com

Clinical characteristics of COVID-19 patients with gastrointestinal symptoms in Northern Italy: A single-center cohort study

Hepatic pathology in patients dying of COVID-19: A series of 40 cases including clinical, histologic, and virologic data

Correspondence: Xianqiang Yu