健康知识库

--聂三

新的SARS-CoV-2病毒导致的COVID-19疾病已经吞噬了地球上成千上万的生命。截至目前，共有30万余名COVID-19患者遭受病痛折磨，1万余名患者在这场公共卫生灾难中牺牲。虽然呼吸道症状是COVID-19患者的突出特征，但这并不意味着胃肠道问题可以被忽视。腹泻、恶心、呕吐是19例患者的主要症状。易感性、癌症和炎症性肠病的管理、病毒的暴露是主要的关注点。我们仔细讨论了COVID-19相关的胃肠道问题

正如世卫组织(世卫组织)总干事Tedros于2020年3月11日宣布的，covid19全球大流行。新的SARS-CoV-2病毒导致的COVID-19疾病已经吞噬了地球上成千上万的生命。2019年12月8日。第一例COVID-19病例发生在中国武汉市。新型冠状病毒肺炎在中国和全球的暴发1。COVID-19是以SARS-CoV-2病毒引起的肺炎和相关症状命名的。截至目前，共有25万余名COVID-19患者遭受病痛折磨，1万余名患者在这场公共卫生灾难中牺牲。由于SARS- cov -2的结构分析，它与导致2002年SARS流行的SARS病毒具有高度同源性。中国研究人员发现了这种新型冠状病毒，并与全球科学家分享了它的RNA序列。与SARS感染机制相似，SARS- cov -2通过穗糖蛋白进入宿主细胞。其S糖蛋白在S1/S2亚基之间有一个裂解位点，S1亚基与宿主受体血管紧张素转换酶2 (ACE2)3-5有亲和力。ACE2在人体组织中广泛表达。一项研究显示，ACE2在小肠和肺的上皮细胞中含量丰富，而在血管内皮细胞中也有同样丰富的ACE2，这是人类内部环境中广泛感染途径的基础。ACE2通常位于上皮细胞的管腔侧，可以通过从细胞膜中分离来进行酶活性。ACE2的位置为新型冠状病毒在气道和胃肠道的感染途径提供了必要的信息。单细胞测序分析显示小鼠小肠肠上皮细胞中含有大量的SARS-CoV-2病毒受体ACE2，特别是在近端和远端肠上皮细胞中均有高表达。不仅如此，covid19患者的粘膜活检显示，病毒核衣壳蛋白(NP)存在于胃、十二指肠和直肠的腺上皮细胞中，而不存在于食管中。ACE2和SARS-CoV-2的共存证明了胃肠道上皮可能成为冠状病毒感染的靶标10。

Holshue报道了最早在一名COVID-19患者中检测到病毒核酸的情况。新型冠状病毒引起胃肠道感染的风险已经引起了胃肠病学家的关注。我们进行了一个完整的COVID-19病例收集，以区分这些患者的消化系统。共39项研究，包括详细症状描述见表110-48;尽管有病例报告和小群体。腹泻是最常见的消化系统症状，发病率从1.2%到35%不等。我们收集的总体腹泻率为6.34%，而最大的队列腹泻发生率(3.8%)。>80组患者的发生率约为5%(图1)。第二大胃肠道症状为恶心或呕吐，占收集的COVID-19患者的5.17%。其他胃肠道症状如厌食、打嗝、腹痛、消化道出血等仅占不到1%的患者。特别是，大多数危重症患者的COVID-19通常伴有凝血功能障碍，这是这些患者消化道出血的高危因素。不同中心诊断腹泻的标准可能不同。由于胃肠道症状的无意识，临床医生在临床实践中可能低估了胃肠道症状的诊断价值。Zhang和Mo44、46对胃肠道症状的详尽描述仅存在于两个队列中，这可能为COVID-19相关的胃肠道症状提供了全面的见解。虽然COVID-19患者以呼吸道症状为显著特征，但这并不意味着消化内科的作用是无效的。最重要的是，胃肠道症状如腹泻和呕吐可能是某些胃肠道病人的首发症状和唯一症状。在高危疫区住院的部分消化系统患者，应考虑COVID-19诊断。

人们可能对胃肠道肿瘤患者的COVID-19感染风险和预后感兴趣。一项研究收集了来自575家中国医院的18例covid19例癌症病史，其中3例有结直肠癌病史(1例结肠管状腺癌，1例直肠癌，1例结直肠癌)。癌症患者的COVID-19风险比非癌症患者更高，而且恶化得更快。但是一些因素，比如年龄可能会影响癌症COVID-19风险的结论比如老年人有更高的癌症风险和COVID-1950, 51。然而，中国的研究人员在两个独立的队列中调查了强壮的成年人和胃肠道癌症患者之间的RNA表达谱，ACE2的表达从健康对照组、腺瘤患者增加到结肠直肠癌患者。作为SARS-CoV-2的致病靶点，这一发现支持了胃肠道癌症患者可能对新型冠状病毒更敏感52。同时，我们也真诚关注处于晚期或正在接受PD-1抑制剂等免疫抑制治疗的癌症患者的COVID-19风险。他们可能更容易感染新型冠状病毒。在得出明确的结论之前，应该积累更严谨的数据。胃肠道肿瘤患者在治疗时必须慎重考虑。一些进展已被推荐，包括多学科治疗(MDT)，包括呼吸内科医生;新辅助治疗延迟选择性手术;尽量减少内镜的介入。

炎症性肠病主要表现为粘膜通透性平衡受损和持续的免疫紊乱。到目前为止，还没有IBD新冠状病毒感染病例的报道。然而，IBD患者在使用免疫抑制剂时应注意COVID-19的预防。在实验性结肠炎模型中，结肠炎诱导后结肠ACE2的表达增强。与健康对照组相比，IBD血浆中ACE2浓度升高。此外，蛋白质组学显示结肠节段缩氨酸在克罗恩病中的增加比溃疡性结肠炎更明显。在IBD中，特别是Crohn患者中，ACE2的增加可能与SARS-CoV-2受体有关。结肠纤维化与粘膜ACE2呈负相关，有RAS抑制剂的IBD患者不太可能进行手术和住院。鉴于此，ACE抑制剂可用于降低ACE2水平和改善结肠纤维化。在COVID-19流行期，伴有高血压、糖尿病或慢性肾脏疾病的IBD患者可能受益于ACE抑制剂。不仅如此，IBD患者的管理还应遵循一些临床指南，包括不增加不必要的免疫抑制剂量和优化生物制剂治疗。

虽然目前对COVID-19胃肠道粘膜损伤的研究较少。covid19患者内镜检查食管、胃、十二指肠和直肠未见明显损伤。危重症患者COVID-19消化道出血常存在凝血功能障碍，应引起重视。预防质子泵抑制剂将是必要的具体条件。长期以来，胃肠病学家和内窥镜医师忽视了一个问题，那就是在内窥镜检查中细菌的广泛接触。任何常规内窥镜检查通常不建议在流行，但紧急出血干预应执行充分的预防措施。

综上所述，COVID-19是一场全球性的灾难性的公共危机，每个国家都经历了重大的威胁和医疗紧缩。在这场危机中，胃肠病学家无法置身事外。所有的病人都能得到妥善的照顾。胃肠科医生应防止自己的COVID-19在关键措施和帮助病人尽可能多。

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