Guidance issued for comanagement of COVID-19 GI, liver manifestations

Two meta-analyses, one of them from the American Gastroenterological Association (AGA), found that GI symptoms and liver abnormalities are not uncommon in patients with COVID-19. The AGA issued a series of best practice statements based on its findings.


GI symptoms and liver abnormalities should not be overlooked at presentation among patients with suspected COVID-19, according to two recent meta-analyses.

The first, performed by the American Gastroenterological Association (AGA), included 47 studies that were published through April 19 and involved 10,890 unique patients with COVID-19. Most of the patients were hospitalized and in China. The researchers found pooled prevalence estimates of 7.7% (95% CI, 7.2% to 8.2%) for diarrhea, 7.8% (95% CI, 7.1% to 8.5%) for nausea and vomiting, and 2.7% (95% CI, 2.0% to 3.4%) for abdominal pain. The pooled prevalence estimates for abnormal alanine aminotransferase and aspartate aminotransferase levels, respectively, were 15.0% (95% CI, 13.6% to 16.5%) and 15.0% (95% CI, 13.6% to 16.4%). Diarrhea, nausea and vomiting, and liver abnormalities were more common in studies outside of China, and GI symptoms were rarely reported in isolation.

Based on the results of this review and meta-analysis, the AGA issued a group of best practice statements for consultative management of COVID-19. The statements are valid for three months and were published on May 11 by Gastroenterology.

In outpatients presenting with new-onset diarrhea, the AGA recommended that clinicians gather information about high-risk contact exposure, a detailed history of COVID-19-associated symptoms, and a thorough history of other GI symptoms. Such patients should be monitored for symptoms associated with COVID-19, since GI symptoms may develop before others. If the patient is presenting in an area with a high prevalence of COVID-19, COVID-19 testing should be considered, the AGA said.

For hospitalized patients with known or suspected COVID-19, a thorough history of GI symptoms should be obtained, the AGA said. Baseline liver function tests should be done at the time of admission, and monitoring of liver function throughout hospitalization should be considered, especially if patients are receiving pharmacological treatment for COVID-19. Such patients should also be evaluated for GI and hepatic adverse events related to COVID-19 treatment, the AGA said.

In all cases of elevated liver function tests and suspected or known COVID-19, both inpatient and outpatient, alternative causes should be considered, the AGA noted. In addition, it said, evidence does not currently support stool testing in routine clinical practice for COVID-19 diagnosis or monitoring.

The second systematic review and meta-analysis involved studies published between Jan. 1 and April 4 that examined epidemiologic and clinical features of COVID-19, as well as the prevalence of GI findings. Overall, 35 studies of 6,686 patients with COVID-19 were included in the study. Of these, 29 studies involving 6,064 patients reported prevalence of GI symptoms at diagnosis. The pooled prevalence of digestive symptoms was 15% (95% CI, 10% to 21%); nausea and vomiting, diarrhea, and loss of appetite were the most common. Approximately 10% of patients presented with GI symptoms but no respiratory symptoms.

Twelve studies involving 1,267 patients assessed liver function, with a pooled prevalence of 19% (95% CI, 9% to 32%) for abnormal function. In subgroup analyses, patients with severe COVID-19 had higher rates of GI symptoms (odds ratio [OR], 1.60; 95% CI, 1.09 to 2.36; P=0.020) and liver injury (OR, 2.20; 95% CI, 1.60 to 3.02; P<0.00001) than those with nonsevere disease. Risk for complications was higher in COVID-19 patients with GI involvement than in those without (OR, 2.51; 95% CI, 1.62 to 3.89; P<0.0001).

The researchers noted that all of the included studies were of low quality and that criteria used to define severe COVID-19 varied, among other limitations. They concluded that digestive symptoms and liver injury are “not uncommon” in patients with COVID-19 and are more frequently seen in those with severe disease. “Increased attention should be paid to the care of this unique group of patients,” the researchers wrote. The study was published May 12 by The Lancet Gastroenterology & Hepatology.

The authors of an accompanying editorial agreed that GI symptoms of COVID-19 could be overlooked and noted that some patients continue to shed the virus in feces although respiratory samples test negative. They recommended additional studies to determine whether such patients could represent an overlooked source of SARS-CoV-2 transmission.