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 trained extra for one particular thing, which is to do this invasive procedure called an ERCP, which is a life saving procedure for some people, where he actually goes into this bile duct and can remove stones and things like that. While you were talking. I was thinking, wow, if it's upregulated, there were gastroenterologists we may be more exposed than we actually thought you may be more exposed than me. Now after hearing that, yeah, we're doing really...

Yeah and unfortunately there's not much PPE that we can use for things like that. We have to be extra vigilant to be sure that we're not being exposed, or at least the least amount possible. While we try to help people with emergencies.

I know as soon as you said that, I was saying thinking oh my goodness, how many people can come in with elevated liver test etiology unclear? Is it COVID and we're gonna get into the next article, which really gets you thinking about how many people may be may be missing. So just to summarize, this first article was really just showing kind of the basis that look, there is a potential way that the virus can get into the gastrointestinal tract. The next article, which in my opinion is a little goes into some really cool data about different things. And then this is where after that I want to expand on some different ideas about where we think this is heading on a gastrointestinal standpoint, what are the implications of all this? This one has been accepted, it's a preprint that's been accepted into the what we call the red journal, which is the American College of Gastroenterology. The title is clinical characteristics of COVID 19 patients with digestive symptoms in Hubei, China, a multi-center study. So long winded title, basically these guys, and I really admire them for doing this. They just keep going back looking at the data, this same group had published something earlier in the month, I mean, in one month to come out with two different articles is pretty amazing. This is what they're doing is they're looking in an aggregate of patients, and they looked at 204 patients with COVID 19. And of course, most of them presented with fever and the usual things, but then they started going, wait a minute. Now let's go back and start asking questions. Let's go back and look at their charts. So this is sort of a chart analysis. This one I think, is a little bit more interesting. Why don't you give just a quick overview of your take on this article, Dr. Akerman? 

Yeah, so I agree this, this was a little more nitty gritty and looked at actual patient data analysis and provided a lot more information. So in this study, they looked at 204 patients, the average age of the patient was 53, which I think is a really important piece of information because we keep talking about how patients over 60 over 70 are high risk patients. But you know, an infection sometimes doesn't know age. And most patients almost almost all presented initially, or at least presented for their COVID diagnosis, I would say, with respiratory symptoms, but when they looked at their overall symptoms, not just focusing on their cough and shortness of breath and things along the respiratory side, they found that 50% of the patients had digestive symptoms as well. 

Stop right there. Say that one more time.

Yeah, so in addition to the respiratory symptoms, nearly more than one in two patients had some sort of digestive issue as well that they were noticing with the onset of their symptoms,

And we won't we're going to get into those digestive symptoms, but I thought something very interesting that when they looked back 78.6, almost 80% of the people had anorexia. Meaning they were not hungry, and that there's a relevance to this. And I'm going to I'm going to piece it together later. But yeah, you're doing a great job, but it didn't mean to interrupt there.

Okay, no worries. So, yeah, like you said, you know, almost as 78% of patients had some form of a lack of appetite or anorexia, a third of patients had diarrhea. And several of them also had abdominal pain and vomiting. You know, things we don't necessarily associate with a respiratory illness like, like a pneumonia or bronchitis.

100% I do want to point out that the diarrhea, this is what's really interesting, because, I mean, this is something you and I deal with every single day people come in and they this is this is our bread and butter. What I was shocked on this article is that the diarrhea was not that severe. And it was actually three loose stools a day on but as the disease got worse, the diarrhea got worse. So I would not even think I'm not as a ER doctor ICU Doctor, I wouldn't be going, oh, do you have diarrhea? and somebody's like, listen, I'm feeling pretty bad here. Yeah, I guess I got three loose stools a day. How long has that been going on? I don't know, two weeks. Now think about that. This is what I'm implying that maybe that because the other really interesting thing about this study that I found incredible was all the people with gastrointestinal symptoms, or the majority presented after having symptoms for 8.1 days, as opposed to the people that just presented with respiratory symptoms that presented earlier, which means these people were out in the community longer before they came in. So is it plausible that the gastrointestinal symptoms were there and they were ignoring them? And then it became pulmonary, which then brought them into the hospital?

Right? They make that comment to that effect, and it seems that there was a delay in diagnosis and the patients who had gastrointestinal symptoms, and you know, you can make the argument that it might be like you said, right, someone called and said hey, you know, I've got this vague abdominal discomfort, I'm not really that hungry, my bowel habits are starting to change, I'm getting a little bit of looser stool and, you know, someone might say, you know, we've got other things going on, you know, try some Imodium for a couple days, take it easy, you know, give me a call back if you're not feeling well. And then two, three days later now also you got the pulmonary symptoms, and you know, everyone that is on top of that getting tested and, you know, seeing who needs isolation who needs to be admitted and treated. But the one of the wake up calls from this article is, maybe we have to start paying attention, maybe those patients that call and they're having new onset symptoms, you know, not someone who has maybe chronic symptoms that get exacerbated, but someone who hasn't been having any kind of abdominal discomfort or has bowel regularity, and all of a sudden they're off. You know, do those people have to be in a heightened state of awareness and say to that, well, they don't necessarily have to run to a hospital. But maybe you say to them, you know what, I need to follow up with you in a day or two because I needed to know if those symptoms are evolving, and if we have to take this in a different in a different route.

So can you imagine that the first article that we discussed, we talked about companies developing a rapid acid to see if there's viral shedding in the stool? So now we're gonna I mean, mark my word once it becomes easy, this will be the norm for us. Just as like when somebody has significant diarrhea. We do our C diff testing, we do our stool culture. We do fecal leukocytes, lactoferrin, calprotectin, all these things that we do as specialists, we're going to end up looking for SARS CoV2 coming out in the stool with this if we can develop a rapid test.

Yeah, I mean, I think the possibilities are I don't want to say endless but but there's, there's many, you know, Dr. Brown and I utilize the services of a large pathology lab in the East Coast that has currently had to close down production of their stool tests until we figure out what's going on in COVID because of these two studies that are showing the potential for special In the fecal oral route, because they don't know if all the samples that they're processing might have COVID in them. But imagine if there was rapid testing. And they can add that to their one day turnaround test for acute bacterial and viral infections. It could be a game changer.

Yeah. And I actually admire them for taking the aggressive route of stopping business because there is the potential that they're exposing their employees to this. And then of course, part of me is just like, no, you're the one person needs to keep going and help us figure this out. But we're all learning as we go here. So now, this is also something in this study when they looked back. Well, first of all, let's talk about how the people that that had gastrointestinal symptoms tended to have more severe disease, those that had liver issues needed more meds, and anti microbials and things like that showing that once it somehow affects the liver now whether it's the drugs or whether it's the virus attaching. The one thing I'm a little bit disappointed in this study is that they did not list what the alkaline phosphatase was. And just explain that because in the first part of this, we talked about the cholangiocytes.

Right so, you know, this is, this is how it works in the medical field, you know, when you publish, you know, you have a lot of a lot of effort, a lot of sort of sweat and tears that go into analyzing and publishing your data. And then everyone kind of gets to sit around and then reanalyze it and ask all the questions, and it's

Gee it's almost like a lawyer looking at a medical file, isn't it?

Yeah, it's, it's kind of similar. So you know, we have the ability to look at both of these studies to get all that data together, and then look at it and analyze it. And now that we have the data from the first study, which, you know, tells us how this preferential expression of h2 in the cholangiocytes in the bile ducts, it'd be more interesting for us to know, okay, well do the signs and symptoms, meaning the laboratory values of cholangiopathy and inflammation and irritation of the bile duct, do they go up in preference? So when you look at we talk about this a lot and patients here saying, oh, I just need you to go get your liver tests done. What does that really mean? What that means is there's a panel that pretty much every lab the United States does for us, that looks at several different markers. And some of those markers reflect the liver tissue itself, the hepatocytes, some of those markers more reflect the bile ducts or the cholangiocytes. And in this study, they really focused more on the hepatocyte markers than the cholangiocytes markers, and it might be an opportunity for us going forward to look back at these patients who are COVID positive pull their liver test, and in particular, look at this alkaline phosphatase and bilirubin levels, which are more reflective of the cholangiopathy and see, does it go up? Is there a specific value does it go up two time's upper low normal four times five times is there a correlation that we can make with the severity of the disease?

Okay, quick side, rabbit hole here. This is what happens when you do a podcast with somebody with ADD. You just got me thinking about something. So a lot of people that are dying in the ICU, they're dying and multi organ failure and sepsis, obviously pneumonia, we've been blaming the pneumonia. What if there could be a component of some colangitis, for instance, causing this colangitis is the infection that can happen in the bile ducts where it it can't get out where the basically the bowel can't get out. Now, I just thought about something wild and this is this is your I'm challenging you to do this as...on the fly. Could you imagine? So what Dr. Akerman does is he gets into the bile duct and frequently he places plastic stents or stents to open things up. They I just got an article which showed so you know, my world is this molecule of polyphenols. That's where I do a lot of research. That's where we see, we now realize that these polyphenols have antiviral activity, they have antimicrobial activity. I just was sent a pre proof on possibly making polyphenol masks and polyphenol disinfecting cloths because it's that effective. In fact, we're talking about a rapid test on last on COVID to show there's a German company that actually is doing an asa rapid asa to do a filtration, what's called an agglutination test where they put the SARS CoV-2 virus and then they put it in with quercetin and luteolin which are polyphenols, and then they tag those and if it clumps, they know that that's doing it. That's how strongly it binds so just thinking like that coding stents with possibly hydroxychloroquine possibly polyphenols, possibly other anti things that could be really interesting, because if the concentration of virus is in the bile duct, you may end up having something to directly combat the virus,

Right, it's almost akin to placing radiation beads for local tumors where, instead of treating the entire body, you focus your efforts on the one area that's problematic and just try to focus on it instead, you know, kind of like just to localized therapy and sometimes that works better than the systemic therapy.

I, I'm really proud of you as a, as a clinician to not tell me to stop recording and get up and go, I'm gonna go work on this right now. This could be my thing.

Well, hopefully enough people see this and enough bright minds are getting tasked to it right away. I know,

That just just hit me coding a stent with an antiviral in because one thing that we're going to learn about this, these numbers are are there but until we come up with a true vaccine, which is not going to happen for quite a while, these other treatments are really good. This is not going to be a blizzard and then we're done. I feel like this is going to be seasons, it's going to come and do this. It how infective it is. So maybe starting to think about something like that is really cool. That was quick side note. So.

Yeah but you know what? It's relevant, right? Because the reality is right now, we're focusing on isolating the individuals, and then essentially treating them with supportive therapy, right? If you can't breathe, and we have to put you on a ventilator, that helps you breathe to give you time to fight the virus, right? I mean, we there's a lot of talk about, you know, plaquenil and chloramphenicol. And then these, you know, other azithromycin and all these drug combinations that may or may not have benefit. And, you know, the reason is simple. We don't have a treatment currently, which is true of many viruses, right? Many viruses. There are some that we have antivirals for and they have specific actions against that virus like HIV and hepatitis B and hepatitis C, but we don't have direct therapies right now. We're really, you know, sort of playing defense rather than on offense. And if we can figure out a way to, you know, figure out which individuals would benefit from specific therapies and then have those targeted therapies available. It could change the entire landscape of the disease. 

Oh, it could totally like if we realized that I mean, we could do this in our hospital where we're at we're kind of a funnel hospital we get a lot of the people are not a lot but if we could look at those charts, and say somebody has presented with a fever and cough they now imagine the flow of this. Okay, so somebody comes in says, I have a fever and a cough. I'm not feeling well I've got myalgia. Okay, let's do a SARS test throat swab. Next thing is, Do you recall not wanting to eat we're going to get into that in a second. Do you recall having a change in your ability to smell? Have you had any change in your bowel habits, then it becomes test the stool while they get it admitted, alkaline phosphatase is up. And then it's like Dr. Akerman, we needed to get in there we believe this person is going to have a worse outcome. Because it is now in the liver. It is in the cholangiocytes, we believe we know that they have COVID 19 your role could be a play something which is really cool.

Yeah. And it's interesting. You brought that up about the sense of smell or anosmia. Actually, it was my sister in law, Dr. Rachel K over and Rutgers University who started noticing that about some of the COVID patients and just relentlessly looked into this and found out that that is a significant symptom that is a common thread across all these COVID patients.

Absolutely. And so when I saw the anorexia and the first article published at the very at the end of February where they were discussing gastroenterologist perspective on COVID, I don't know if you remember that it was it was with our Neal Brannon and a few of our other of our, you know, well known academic publish...

Published in GIE. 

Yeah, yeah, they were talking well, gi issues are not a big deal. And they threw out the anorexia, which now I'm throwin' it back in because I see people with a disease called dysgeusia, which is chang in taste. And we frequently get people to come and go, you know, I'm just not smelling right. And we check their vitamin levels and all this other stuff. So I believe that that is a gastrointestinal symptom, it is an EMTs symptom as well. So I when you look at that, I think the sense of smell and that is become kind of sensationalized right now in the news, for some reason people find that fascinating to write about, but that's impressive that your sister in law was paying attention to that, which is exactly why we should be paying our fields to be paying attention to the mild diarrhea type thing, but we should be really paying attention to the anorexia, anosmia, which is what that's called, which is lack of sense of smell.

Yeah, and you know, that might be a method for us to triage patients right based on their symptoms because like you said, we see diarrhea all the time. This is this is what we do. Right? If you have diarrhea, you talk to a gastroenterologist so how do we, as sort of the gatekeepers figure out, you know who we can just say, you know what, just stay home it's totally okay. And who are the and you can see my daughter in the background here this is what happens when you do it in the in the home office rather than doing it in the studio, but this is how we have to figure out maybe...

Well, this is funny because I'm you know, we're all watching a lot of news and it's just, it's a lot of people are recording from home and stuff like that. Just out of nowhere, a cat will jump on somebody's lap and be like oh, look at that, live shot.

Just play it off. 

Yeah.

But, you know, maybe we need to have a little mental checklist right? If a patient comes to you and says, You know what? I started having some diarrhea the last few days. I'm a little worried. I've learned about some of these things. He's You know, we've been talking about it in the press, do you think that I have COVID? You could say then, well, ok, what are your other symptoms? Do you have any kind of change in your appetite? Do you have a change in your smell? Have you had any abdominal discomfort, nausea and vomiting. And if you've got kind of enough of those things stacking up, you know, we don't have enough resources right now to go tell them to go get COVID testing, right? We can't send every single patient that has the symptoms. So how are we going to figure that out? Maybe we check liver tests, right? Maybe we send that patient and go get a pretty simple, easy blood test. And if their liver tests are abnormal along with it, maybe that index of suspicion now goes higher. Maybe we say to them, you know what? Maybe we're catching this before you get your respiratory symptoms. Let's get you swabbed.

Yeah swabbed or fecal tests we can do this. I want to talk I want to finish up this article. And then I want to talk about a few other things because this is an ever expanding deal. I have actually spent all week I did three shows this past week with doctors with specialists, and I've been reading, I'm just nau...I'm not nauseous because I don't want to sit there. 

Yeah we don't have to worry about putting you through the algorithm right now.

Yeah, we don't want to do that. But alright, so I thought, well, this is very interesting. Some interesting thoughts as what I'm going to call it. Most people in this study could not recall a clear exposure. So it's not like, oh, I was in and this is a Chinese study. And so it's not like I was in Wuhan, my brother came back from Wuhan, because I got I have other things that we'll talk about that average time the hospital was 8.1 days. So it was beginning of symptoms that they could track back. So they're asking the gastrointestinal symptoms 8.1 days, imagine I'd love to sit with your sister in law and say, what if the anosmia the sense of smell starts going away before that? Different theories to that Ear, Nose and Throat doctors have been showing that that happened in SARS 2003. I just got an article here sent to me this morning that shows that it could be related to the microbiome. And we'll get into that next. But there it appears that this virus could have a partner in crime called a Prevotella bacteria, which may be causing the severe pneumonia. Separate, very detailed thing to talk about. Here's something else that I was surprised about this. Everybody's like, well, people are dying. But, you know, the...China didn't know what to do. Did you see that? 90% of these people received antiviral therapy. China was all over it, man. They were trying everything.

Yeah, I mean, look, I mean, their pandemic response, you know, after getting caught a little bit flat footed in 2003. It was nothing short of amazing. Right. I mean, they shut borders. They shut down cities as quickly as they could, and you know what I mean? That's why that they're finally falling on the other side of the curve.

Yeah. And they had, you know, 7.8% of these people went to the ICU with a death rate of 17%, which is much better than what we initially saw where it was, like 87% of people that went on a vent died. But I don't know if if we're as aggressive to throw drugs at people as possibly they were, I don't know if we have our hands tied here by the FDA. I don't know if our physicians are just trained in a different way where it's like, that's not standard of care.

Right. Some might just be culture, right? We're more focused on diagnostics to sort of say, rather than throw everything in the kitchen sink, let's figure out what makes sense, right. I mean, especially as we get into this era of antibiotic stewardship, where we're worried that a lot of our, you know, older generation drugs are losing their efficacy because we've used them too frequently, and there's resistance that's built up. I think we've all sort of gotten on that train, where we want to make sure that we're not just using it to use it right. You get this a lot when you see the primary care doctor and you've got a cough, and you say to them oh I just need an antibiotic. And they say, Well, you know, 90% of these are viral and antibiotics not going to do anything. So, you know, let's wait and see how it goes. And sometimes that's frustrating as a patient. But, you know, by not taking that antibiotic, you're kind of doing your your public health initiative on your own, that you haven't created more resistance.

Even if it's not a resistance thing. Every time you take an antibiotic, you're just disrupting your own microbiome, and you need that microbiome to keep you healthy. It keeps your immune system healthy. Yeah. You did mention flattening the curve, the average hospital stay was 17 days. So we frequently talk about this everybody's like flattening the curve flattening the curve. What that means is that's an epidemiologic term called R0 R, little zero. And that means that at least I have not looked at it in the last week but at least a week ago the R0 in the United States was one person gets infected can infect three others that's what the R0 means and the reason

Yeah 2.5 to 3 i think is the current numbers.

And then with a hospital stay of 17 days, when I listened to Peter Addy as podcasts where he had an infectious disease doctor from New York on there, they did the math on when we will run out of beds. And that's the scary thing. Because if you need some sort of respiratory support, if you need some sort of IV treatment, there will be no beds to do that. That's why we all have to do our part and have remote podcasts here where we have special guests in the background. So

Yeah, and I think anyone who's been paying attention to the news is not immune to what's going on around the country. I mean, you might not live in New York, but you're gonna be well aware of what's happening. I mean, there are hospitals that have run out of space in the morgue, and they have to set up external refrigeration sites in their parking lots. I mean, it's, this is this is real, right? And we have to do what we can to try to flatten that curve, right. Both On the healthcare provider sides figure out, you know, who needs help quickly? How do we isolate them? How do we prevent the spread? And from from everyone else, too, right? I mean, we talked about staying at home and avoiding spread. And it goes to exactly what you just said, if you have the virus, and you might have it for 2, 3, 4 weeks, there's some data to say that there could be an incubation period, longer than we thought, right? We keep talking about two weeks and self quarantine for two weeks. But there's some data that's come out that shows that it might be as long as 28 days. So you might be completely fine, feel great. But you're shedding that virus and you walk around and you go to the grocery store, and you come in contact with 15 people, right? Doing the math, those 15 people now can infect another for another 45 and those 45 and so on and so forth. And, you know, sometimes people it's hard to see if someone's not ill, right, it's hard to internalize that that can be happening.

So let's let's talk about that analogy that you just said about going to the super market now in the first article, we discussed a fecal oral route and everybody's like, I'm not exactly at risk. Well, here's, here's how you're at risk the viruses. If you're shedding shedding it in your stool and you use the restroom, and you don't effectively clean your hands, then anything you touch may pass it. And I just thought about going to the supermarket and picking up the pi...the grapefruit or whatever, looking at it, holding it, putting it back, getting a different one. That could be a transmissible thing,

Right? That's exactly it. Right? Most people and I don't know the numbers on this, but let me just look around what happens what what you yourself do, right? You might look at a box and try to read the ingredients and you're like, you know, maybe this isn't what I want right now. You put it back on the shelf. And you know, I think a lot of times when you say fecal oral people think I don't have stool in my hands. It's not an issue. That's not what we're saying right? Effective hand washing, which is 20 seconds. Getting between the fingers getting under the fingernails using hot water. You might be in a rush, you might not do it, maybe you don't know that you need 20 seconds. So you've got these little microscopic particles on your hands that are now touching the doorknob touching the handles touching the inside of your car when you go and you know, you could just who knows where it's going.

Speaking of who knows why in the world, did everybody went out and get all the toilet paper? I'm still confused by that. As a gastroenterologist I did not understand that.

Yeah, I mean, I'm not sure but I would definitely recommend that if someone needs that much toilet paper, they should get evaluated by one of us.

if you were hoarding and you're going through that, please, it's time to get checked. Something else fascinating in this that they speculated something really tied to our field, which now may change our interactions with our critical care Doc's and our pulmonologist. Did you see that this these infections may affect the microbiome and I say the Prevotella bacteria may be contributing to this, and they refer to this as how does this affect the gut lung access? I was talking about the gut brain access. Now these guys were referring to gut lung. Is it possible that by not having a healthy gastrointestinal system, you're then predisposing yourself to possible lung injury? Fascinating thing that they brought up.

Yeah, it's it's a very interesting point, right? Because you sort of think of immunosuppression as a global or systemic issue. Right? You're either immunosuppressed or you aren't. But does maybe poor gi microbe or gut microbiome health lead to sort of a cascade of events that ends with, you know, susceptibility to lung injury and infection as well.

I mean, I have talked when I did Dr. Chang Raun's summit with a bunch of other doctors like Dr. Mark Hyman. We talked about the possibility that having a gastrointestinal tract which could be more permeable could allow infections to take place and allow it to get into your into your bloodstream and get into and turn on your immune system, since the get people with gastrointestinal symptoms tended to have a worse outcome, or at least they were sicker. Is that possible that the cytokine storm that we talked about starts in the gastrointestinal tract sets off the inflammatory cascade? So that's the little things that we that we're thinking about. I have...do you have anything else to add on this particular article?

No, I mean, I think we talked about a lot and excuse me, I do think, you know, again, the take home points are that, not that we want to, you know, raise any alarms, we don't want everyone to worry that if they've got a loose stool that all of a sudden that means that they've got COVID, it's more that we want to raise awareness, you know, both on the side of continuing to stay at home, to encourage good hand hygiene, social distancing, because that's another way for the virus to spread and you know, take it seriously right? Wipe down all the surfaces, make sure you're washing your hands. And if you do end up having some symptoms, touch base, right virtual medicine is completely changing the way that you can see your doctors, you don't have to...

I was just going to say that the both you and I are really doing a lot of telemedicine. And I love your idea that if I get somebody and I'm going to ask those questions, how's your smell? How's this? Then the next thing I'm going to do? I'm going to check some liver tests. To make sure and we can start gathering some of this data to you know, ourselves. So if you're, I think right now initial visit has to be in state. So if you live in the state of Texas, both Dr. Akerman and I can see you virtually and talk about these different things. I don't know if that's going to change anytime soon or there can be interstate. Am I wrong on that? Is that correct?

Yeah, I know. CMS is discussing it in regard specifically to Medicare coverage, to try to get more physicians available for their Medicare patients, but I don't, I don't believe it's been passed yet but currently you have to be an in state resident they have lifted the restrictions about establishing the doctor patient relationship so it can be done via telemedicine. And you know, the nice thing about it is because it adds so much flexibility, there really is a lot more room for us to enact some of these protocols, right to say, okay, well I saw a patient on Monday, and they've had these symptoms and I don't want to raise alarms, I want to see how you're doing. Let's have you go to the lab, which is considered an essential business and it's still staying open. You go in, you get your blood drawn, you know, we get it back in a day or two, have the patient follow up again for another 15 minute visit. A quick visit on Wednesday is just check in and say okay, let's review your lab test. How are you feeling? Have you developed any new symptoms and then kind of go from there.

Alright, let's do it. I do the same protocol for the anosmia as we see our patients. So if somebody says, you know, I've kind of had some loose stools and stuff like that, let's have the same protocol where we say I would like...do you have any oranges in your house? This is my theory, cut it right now in front of me smell it, does it smell exactly like an orange should smell? Or I was just saying orange, it could be anything that has a distinct odor.

Right. That that that is universal. So everyone knows what it should smell like,

Yeah, just think about that. Maybe you and I can come up with a little protocol where that'll be part of the physical exam or part of the history.

Yeah, that was a great idea. Just another way to, you know, triage the patients and get everyone the excellent care that they need.

Yeah, absolutely. So we're done with that study. Since I've been reading so much. I just want to bring up a few other different studies that kind of tie into this. There was a study out of China that showed a case report of a 25 year old woman, and this is early on, that her brother was in Wuhan came back. She that was her contact. She was hyper aware of everything, and then ended up developing fever myalgias everything went into the hospital had a very severe case. With a CT showing the bilateral infiltrates doing all of that, and so she had a pretty rough, absolutely classic COVID 19 with the CT exposure and her her progression,

And am I remembering correctly that she had more mild imaging on presentation, but it's sort of blossomed very quickly into significant Pulmonary Disease?

It did. And what's fascinating is over when they swab or it was a negative, and then somebody was smart enough to do an immediate PCR in her stool it was positive, and then they swabbed her three more times over a seven day period. All her throat swabs remained negative. The stool was how they were able to confirm the COVID 19 even though her presentation was classic for it. So that's something that's fascinating to me. It is one case it's a case report. 

Right and you know, you have to take it I don't say with skepticism because it's you know, it's real information, but you sort of have to take it for what it's worth, right? I mean, the value of data is typically an aggregate and it is a case study. But it proves our point from what we were discussing with these two articles that, you know, fecal oral is another route that we have to really be considering. And, you know, we do this for other things too. In our daily practices, we talk about h pylori treatments and evaluation. And there are multiple methods for how you can diagnose and find it. And sometimes it makes sense to do it with a breath test, sometimes with a biopsy, sometimes with a stool specimen. And you know, each test has their limitations, one might not one might come back negative where the patient actually has the disease. And if you have a high index of suspicion, you repeat it with a different asa, and you find this positive you can isolate it and treat it.

Yeah. 100%. And then another one, which is probably going to be beneficial, but also scary. And I don't remember this I don't remember the number of people but somebody was looking at once they decided start looking at story. Somebody published a fecal viral shedding five weeks continued after pulmonary viral shedding stopped. So they got better. They didn't have any other viruses in their lungs, and they continue to shed the virus for five weeks. fecal now, just like you said, take that with a grain of salt. Very small number one person's take on it. But something to keep in mind also.

Yeah, definitely. And I think the biggest thing to take away from that is that when someone hopefully, you know, successfully overcomes the illness, they're not totally out of the woods, right? They still have to make sure that they're practicing social distancing, that they're still adhering to all these recommendations that we discussed earlier, because they might still be a vector for spread to other people.

Yeah. And that's, that's why I feel like we need to continue to try and educate as much as possible. This is not going to just go away. It's not like you know, it's that one thing like when do we lift these social restrictions? When do we allow these businesses to open up? And are we going to see a resurgence selling when that happens? Because all these people that said, Well, I socially isolated I had a mild cold. I don't know if it was that or not, but I'm sure I'm fine. And then ultimately, we need to continue with exactly what you're talking about. I mean, look, everybody should be washing their hands after they go to the restroom. And this is one of the reasons is that you don't need to see stool on anywhere on you to have the pathogen on you meaning the virus could be on you, which is you don't see the droplets coming at you. But yet there's virus coming at you. So

I would even go one step further with recommendations, you know, sort of borrowing from what we suggest to patients who develop a stool infection that we deal with a lot of pretty significant one in the United States called Clostridium difficile or C. diff. If you have a patient who tests positive or even suspect that they test positive, you tell them to go into contact Isolation in their own home, you know, what does that mean? It means that they have to use their own bathroom if possible. So if there are multiple bathrooms in the house, they should really be just using one everyone else in the family should be using a separate bathroom and just be super vigilant with wiping things down even if possible. And now it's a little bit difficult with a lack of resources but using Lysol wipes bleach wipes. In those situations, hand sanitizer doesn't help. Thankfully here it seems that COVID is responsive to hand sanitizer, so there is that sort of feather in the cap that we can use that also to mitigate spread. But it might be a good idea, you know, patients who have some of these gi symptoms and aren't necessarily displaying the typical or classic COVID symptoms, maybe need to isolate even a little bit further than just their normal social isolation in order to try to prevent spread.

That's true. And one I'm just gonna, this is just planting the seed because I need to read more about this. I've got a bunch of articles I need to get through, but there's new evidence coming out that this Prevotella bacteria may be associated with SARS, CoV2 infection, and Prevotella can cause both severe pneumonia and GI tract issues. Which is fascinating to me because one virologist published this really cool article that I, I wouldn't even do it justice trying to explain it, but basically that the virus can infect the Prevotella. And then it can use the Prevotella to replicate the virus and the Prevotella converts it to DNA and blah, blah, blah, maybe one of the reasons why we're getting negative tests. It was that was his theory. So it's a totally moving target.

Right. Yeah, I mean, more data gets published every day just enhances our ability to fight us.

So I hope everyone enjoyed this. I hope that wasn't too nerdy. But this is a slightly different gut check project where it's just Dr. Akerman and I talking about his particular specialty and my specialty. I think that as we go forward if there are other journal articles like this being published, or actually we both have access to pre publication. I think that we should do this on a semi regular basis where we can get in front of this, interpret the data, and then hopefully do some things like we thought about on the fly. We were thinking about how we're going to get over these telemedicine visits, that we can maybe have a, a smell congregate of data where people where I can ask them that maybe we this is the beginning of setting up a possible stent with some sort of anti viral thing. So it's it's discussions like this that sort of peak, the peak the boundaries of out of necessity breeds invention.

Yeah, I think the more the more of the discussions happen. The more the gastroenterologist, the pulmonologist, the ear, nose and throat doctors, the primary care doctors, the emergency physicians, you know, the allied health professionals, you know, everyone has this continued discussion. It breeds more ideas and more ways that we can be looking at the problem to try to problem solve.

Yeah. So I think that what this particular episode should be called is, you know, COVID 2.5, or COVID 3, share with your doctor. So if you look at this, I think this is very relevant for healthcare professionals to hear and a lot of us are just in over our heads right now with trying to keep up with the expenses of a practice because you can't do your procedures. But if you're doing this, what you can do as a service is like and share this with anybody you would like to but it'd be really interesting if you started sharing these with your doctors now that you're doing telemed and things like that. This way we can get some of this out there and get I'll get the healthcare community out in front of it as well.

Yeah I agree and you know, I appreciate you having me on the podcast and and you know, hopefully as more information comes out, we'll be able to discuss it further and disseminate that information to the masses.

Absolutely. All right, everybody stay safe. We're going to try and give any information we can practice all the things that Dr. Akerman just said. And if you'd like we both accept telemedicine appointments. More importantly, let's all just get through this together as a country as a world as a world.

As a world. Stay safe.

Take care everybody.