Gastrointestinal and hepatic manifestations of COVID-19 infection: Lessons for practitioners

Table 7 Selected American Association for the Study of Liver Diseases, Asian Pacific Association for the Study of the Liver, and European Association for the Study of the Liver recommendations for liver disease management during the coronavirus disease 2019 pandemic[164]

	Selected recommendations
To limit nosocomial spread	(1) Limit in-person visits by effective triaging; (2) Use of virtual platforms such as telehealth to provide alternatives for in-person visits; (3) Symptom and exposure screening prior to entering the healthcare facility to identify at-risk individuals; (4) Minimize staffing to essential staff only; (5) Decrease frequency of laboratory and imaging monitoring; (6) Ensure adherence to recommended PPE by HCW and patients; (7) Ensure adequate social distancing at the healthcare facility (Remodel if necessary); (8) Postpone and delay nonurgent or elective procedures (refer to Table 12); and (9) Minimize research activities including clinical trials wherever possible.
Management of CLD patients with COVID-19	(1) Early hospital admission is recommended for these patients; (2) Prioritization of COVID-19 testing for cirrhotics, CLD patients on immunosuppressive therapy and those with acute decompensation; (3) Frequent LFT monitoring is recommended; (4) Consider early enrollment in clinical trial when possible; (5) Include non-COVID-19 etiologies in differentials for liver dysfunction; (6) Pay special attention to COVID-19 patients with NAFLD, which is often associated with severe COVID-19; (7) Consider hepatitis B surface antigen screening; (8) Monitor for drug induced liver injury; (9) 2-3 g/d of acetaminophen is generally safe and can be used in these patients. NSAIDs can also be used as needed but limit their use whenever possible; (10) Consider HBV prophylaxis prior to initiating immunosuppressive medications, especially IL-6; and (11) Hold Remdesivir in patients with decompensated liver disease and ALT > 5 × ULN.
Management of chronic viral hepatitis (HCV and HBV)	(1) Continuing treatment for chronic HCV and HBV despite COVID-19 status is recommended; (2) Can hold initiating treatment for HBV in the absence of flare; and (3) Treatment for HCV and HBV in the uninfected should continue according to established guidelines.
Management of HCC	(1) Based on the risk and benefit, a delay in surveillance of up to 2 mo is acceptable for high risk individuals; (2) Continuation of HCC treatment per guidelines is recommended, however can be postponed if necessary; (3) For COVID-19 patients, can consider postponing elective transplant and resection surgery and withholding immunotherapy; and (4) Early inpatient admission is advised for HCC patients.
Management of pre- and post- transplant recipients	(1) Screening of both, the donor and recipient for COVID-19 is recommended; (2) Donors testing positive for COVID-19 should be deferred; (3) CMS has classified transplant surgeries as Tier 3b. As such, these procedures should not be postponed or delayed; (4) Patients with poor short-term prognosis should be prioritized; (5) Low threshold for admitting transplant listed COVID-19 patients to the hospital is recommended; (6) For post-transplant patients, immunosuppressive dose reductions can be considered in moderate COVID-19 cases. For mild COVID-19 cases no immunosuppressive dose reduction is advised; and (7) Vaccination against pneumonia and influenza is recommended in post-transplant recipients.

AASLD: American Association for the Study of Liver Diseases; APASL: Asian Pacific Association for the Study of the Liver; EASL: European Association for the Study of the Liver; PPE: Personal protective equipment; HCWs: Healthcare workers; CLD: Chronic liver disease; COVID-19: Coronavirus disease 2019; LFT: Liver function test; NAFLD: Nonalcoholic fatty liver disease; NSAIDs: Non-steroidal anti-inflammatory drugs; HBV: Hepatitis B virus; ALT: Alanine aminotransferase; HCV: Hepatitis C virus; HCC: Hepatocellular carcinoma; CMS: Centers for Medicare & Medicaid Services.