Unique challenges of endotherapeutics in malignant lower gastrointestinal bleeding in a patient with COVID-19 pneumonia—case report and literature review

: Acute lower gastrointestinal bleeding (LGIB) attributed to malignant colorectal lesion presents an endoscopically demanding task to manage due to multiple contributing factors. This ranges from an array of compounding issues such as tumour friability, neovascularization and coagulopathy arising from either medical comorbidities or pharmacological medications. We present a challenging case of malignant rectosigmoid colonic tumour bleeding in the setting of COVID-19 infection at its highest level in our country where all resources were severely stretched and strained. A 58-year-old man admitted for stage 3 COVID-19 pneumonia had been complaining of intermittent hematochezia for 1 month. Relevant blood investigations revealed a hemoglobin count of 5.1 g/dL with normal coagulation profile. Index colonoscopy demonstrated a bulky, circumferential rectosigmoid colon tumour with significantly narrowed (3–4 mm) luminal opening. As there was no bleeding, no endoscopic intervention was forthcoming. Staging computed tomography (CT) scan done the following day, confirmed a large but localized rectosigmoid colon tumour measuring 5 cm in length with no signs of bowel obstruction. Owing to hospital restrictions in place during the pandemic, he was unable to undergo definitive surgical intervention when he rebled 10 days later. This was complicated with hemodynamic instability which warranted an urgent endoscopic treatment with argon plasma coagulation (APC). This timely intervention was successful in buying sufficient time for him to recover from COVID-19 pneumonia and subsequently undergo surgery. The final overall diagnosis was pT3N0M0 moderately differentiated colonic adenocarcinoma. Though APC has limited role in the management of bleeding colorectal cancers due to high rebleeding rates, its’ temporizing hemostatic benefits may still be of use when other modalities are unavailable. The COVID-19 pandemic has brought about various disruptions in our routine endoscopic practices. Aside from delays in timely diagnosis and definitive intervention, endoscopic practices alongside performance are equally affected by resource limitation which is highlighted in our case.