Spotlight on COVID-19
In the past month, several studies focused on the gastrointestinal manifestations of coronavirus disease 2019 (COVID-19), as well as the virus' possible fecal-oral route of transmission.
Clinicians should be careful not to overlook digestive symptoms in patients with coronavirus disease 2019 (COVID-19) and should be aware that SARS-CoV-2, the virus that causes the disease, sheds into the stool of infected patients, raising the possibility of fecal-oral transmission, according to recent research from China.
In the first study, of 1,141 hospitalized patients with confirmed COVID-19, 183 (16%) initially presented with gastrointestinal (GI) symptoms only. Men slightly outnumbered women, and the most common GI symptom was loss of appetite (98%), followed by nausea (73%) and vomiting (65%), according to results published online as a case series on March 20 by Clinical Gastroenterology and Hepatology. One-quarter of patients had abdominal pain, and 37% had diarrhea. Twenty percent had both nausea and vomiting, 9% had both abdominal pain and diarrhea, and 7% reported all symptoms.
The mean time elapsed for confirmation of COVID-2019 was 3.5 days from the onset of symptoms. Of the 183 patients, seven died due to progressive respiratory failure, and the remainder recovered. “It is important that clinicians are aware that COVID-19 can present with predominantly GI symptoms, and maintain appropriate vigilance and high index of suspicion,” the authors wrote.
A research letter published online on Feb. 26 by Gut pointed out that diarrhea may be underestimated in COVID-19 case reports. Researchers collected data from three studies and compared the incidence of clinical features of COVID-19 among them. They found that the incidences of leukopenia, fever, and diarrhea were significantly different, with diarrhea displaying the smallest P value (P=0.016), suggesting that the criteria for diagnosing diarrhea may differ between hospitals. “Due to the different criteria, clinicians may underestimate the value of this symptom in clinical practice, and it may affect the preliminary diagnostic accuracy,” the authors wrote.
Other research focused on GI infection with the virus. In one study, researchers assessed the biodistribution of the virus among 1,070 clinical specimens, including feces, collected from 205 patients with COVID-19 at three hospitals in the Hubei and Shandong provinces and Beijing, China, from Jan. 1 through Feb. 17, 2020. The mean age of the patients was 44 years (range, 5 to 67 years), and 68% were male. Results were published online as a research letter on March 11 by JAMA.
Lower respiratory tract samples most often tested positive for the virus. Bronchoalveolar lavage fluid specimens showed the highest positive rates (14 of 15; 93%), followed by sputum (72 of 104; 72%) and nasal swabs (5 of 8; 63%). Forty-four of 153 (29%) feces samples tested positive, but none of the 72 urine specimens tested positive. Twenty patients had two to six specimens collected simultaneously. Viral RNA was detected in single specimens from six patients (respiratory specimens, feces, or blood), while seven patients excreted virus in respiratory tract specimens and in feces (n=5) or blood (n=2). Live SARS-CoV-2 was observed in stool samples from two patients who did not have diarrhea.
“Importantly, the live virus was detected in feces, implying that SARS-CoV-2 may be transmitted by the fecal route. … Transmission of the virus by respiratory and extrarespiratory routes may help explain the rapid spread of disease,” the study authors wrote. The study was limited by a lack of detailed clinical information for some patients, they said, and further investigation of patients with detailed temporal and symptom data and consecutively collected specimens from different sites is warranted.
In another study, published online on March 3 by Gastroenterology, researchers from China used real-time reverse transcriptase polymerase chain reaction to test the viral RNA in feces from patients (age range, 10 months to 78 years) with SARS-CoV-2 infection during their hospitalizations. From Feb. 1 to 14, 2020, among 73 patients infected with the virus, 39 (53.4%) tested positive for SARS-CoV-2 RNA in stool. The duration of positive stool ranged from one to 12 days. Furthermore, 17 patients (23.3%) had positive stool after respiratory samples tested negative.
Given the evidence suggesting the potential for coronavirus transmission through droplets and perhaps fecal shedding, endoscopy and colonoscopy may pose risks to other patients, endoscopy personnel, and clinicians, according to a joint message from four GI societies. The March 15 message, authored by the presidents of the American Gastroenterological Association, the American Association for the Study of Liver Diseases, the American College of Gastroenterology, and the American Society for Gastrointestinal Endoscopy, offers 13 recommendations for GI endoscopy and clinic practices, including a request to strongly consider rescheduling elective nonurgent endoscopic procedures.
Finally, an article published online on March 11 by The Lancet Gastroenterology & Hepatology focused on the implications of COVID-19 for the management of patients with pre-existing digestive diseases, including inflammatory bowel disease (IBD). The authors, representing the Chinese Society of IBD, Chinese Elite IBD Union, and Chinese IBD Quality Care Evaluation Center Committee, offered recommendations regarding potential risk factors for infection, medication for patients with IBD, surgery and endoscopy, and patients with IBD and fever.