COVID-19 Files: Ep. 2.5

All right, welcome to the gut check project. We're going to call this episode COVID two and a half. It's going to be a shorter form. And in lieu of my regular host, I have asked my gastroenterology partner, Dr. Stuart Akerman to join us. Because what we wanted to do is go over two recent journal pre proofs one of them being accepted in the journal of gastroenterology and the other one with the American College of gastroenterology both actually augment each other and I think it's a great opportunity to look at something that a lot of people may not realize. Dr. Akerman, thank you so much for joining me on this lovely Sunday morning, March 29 2020.

Thank you so much for having Dr. Brown. And as you can see, we're both in our respective social isolation bunkers. While we have a conversation over the internet to talk about these two interesting articles, you know, the data coming out of China is fast and fast and loose. It just more information comes out every day and thankfully people are aggregating it and analyzing it so that we can get a better plan of attack against this viral pandemic.

Exactly. Right now, to date 683,641 people have COVID19 32,144 have died worldwide. Unfortunately, the US numbers continue to go up. We're at 123,828. 2,229 people have died from COVID 19. So I really admire the scientists around the world. It is like drinking from a fire hydrant at times when you go down these rabbit holes. But fortunately, these scientists put together data in two journals that you and I know it's very hard to get into, very highly respected the American Gastroenterology Association Journal and the American College of Gastroenterology. So I'm in...

And I just want to point out, you know, in case people are starting to feel like maybe things are turning here in the United States, you know, we're still very much in the thick of it and this is applicable every single day all over because, you know according to our current analysis, cases are getting diagnosed and doubling at a rate every two days. We're very much still in the thick of this increase in the curve

100% and one thing that we're going to be discussing today is we may be missing a lot of these people. And we may be missing a very important route of how we could be infecting each other. So let's just jump right into this because the science is well for you and it's pretty interesting because it really involves us if you're wondering why two gastroenterologist are talking about a virus. Neither one of us are virologists or infectious disease doctors, who are most of the people out there talking Well, now we got to play a big role in this. So let's talk about the first article. The title is COVID19 gastrointestinal manifestation, and potential fecal oral transmission. This article is out of Shanghai. Dr. Akerman, I will just throw it to you real quick that, can you give us an overview of this article?

Yes. So this article is, like you said, coming out of Shanghai, it talks about patients that were tested for COVID19 and found very positive and that even after discharge, so in other words, they did well, they thankfully recovered. And this is not, you know, similar to what's happening to us. This is not someone who, you know, was sick for a day or two, they may have been ill possibly ventilated in the hospital for weeks on end, discharged, and still displaying evidence of virus on stool specimens that were taken to culture.

Absolutely, because right now, the way that most people and certainly at the time when China was doing this, everybody to try and detect SARS, CoV2 the virus that causes COVID19. There, you're doing throat swabs. And what they're looking for is the viral load right there and I will say that on a prior episode, we discussed how this is 1000 times more contagious than the SARS 2003 outbreak, and they're actually showing much higher viral loads in the back of the throat. So it makes sense that that's where we're going. But now there's evidence that non respiratory routes like you're talking about include the digestive system. Now one of the theories behind that is is that the same receptor that the virus binds to called the h2 receptor, is heavily concentrated in the gastrointestinal tract, and also the lungs. And so once the virus comes in, it sees this receptor, it gets integrated into the cell. And then once it's there, it hijacks the cell, and that's how it replicates. So the implication that the gut is involved is huge. So what's really I think, fascinating is that these guys figured this out and figured out a test to actually look for in the stool.

That's right, and there are two. There are two laboratories in China that are currently successfully isolating it from the stool using PCR techniques. And hopefully we'll be able to commercialize that in the near future to have it available for water distribution. You know, it's a big deal to be able to isolate the live virus because evidence of virus is not the same as viral activity or active infection. And what they found in this study is that they have essentially proof of live virus and if live virus is shedding, that means that the patients can still be contagious can still give it to other people and act as vectors.

100%. In fact, there's we're probably missing a lot of people because this article goes on to say that this appears to show this fecal oral route the next article goes way deeper into it, and that's where we get into the nuts and bolts. They did reference in 2003, remember that this virus is very similar in structure to the SARS 2003 virus, that is the coronavirus so when they say novel, coronavirus, it's it causes a different type of infection. But a lot of the data they do look back and go, oh, SARS 2003 did this. What they did show is that some of those people had liver damage. And on liver biopsies back then they showed hepatitis. And they were questioning whether it was due to drugs or whether it was actually due to the virus. And the next article, the next article we get into really goes a little bit more into that. These guys even implied that if it binds to the h2 receptor, then there's h2 receptors in the GI tract, but also in the liver, which is something that you're very familiar with and even the bile ducts or cholangiocytes, can you explain everybody what that aspect means and that part of the gastrointestinal system?

Yeah absolutely. So the liver is an organ that we have it sits in the right side of our body and it helps kind of like a filtration system. And there are many, many different injuries that can happen to the liver. I think the most common ones, we think about our viral illnesses like Hepatitis B and Hepatitis C, we talk about fatty liver disease a lot lately, and then probably the most common is alcoholic liver injury, right? If you drink either enough or enough over time, you start damaging those cells. But the liver has different kinds of cells there or the liver, liver tissue cells themselves, which are called hepatocytes. And then there's an intricate bile system called the bile ducts, kind of like a tree where all the branches are sitting in the liver and they drain down to the trunk, and that trunk exits out of the liver goes through your pancreas, and then empties into the small intestine. So when we talk about digestion and bile flow, we're talking about bile which originates in the liver and the cells that line that are called cholangiocytes. And in reference to this article, they found that h2 expression is significant in cholangiocytes in about 60% of cells and hepatocytes, maybe a little bit less, only about 3%. So to be more specific when we're talking about the potential for liver injury, yes, liver injury in general, but in specific, a lot of bile duct injury, also called cholangiopathy, or cholangitis. 

So I want to clarify the Dr. Akerman this is actually his subspecialty. He is trai...