GASTROINTESTINAL SYSTEM AND COVID-19

Nearly two-thirds of U.S. patients with COVID-19 report gastrointestinal symptoms, according to a multicenter study.

"In the very early stages of the pandemic here in Boston, my co-residents and I were very impressed by how the disease was so much more than just a respiratory illness - in particular, we saw many patients struggle with those GI manifestations like anorexia and diarrhea," Dr. Walker D. Redd, internal medicine resident at Brigham and Women's Hospital, told Reuters Health by email. "Interestingly, that was even before anosmia and ageusia were being recognized as much."

This experience prompted him, along with Dr. Walter W. Chan and colleagues from Harvard Medical School, to characterize gastrointestinal manifestations associated with SARS-CoV-2 infection and to evaluate their outcomes. The study included 318 patients with confirmed COVID-19 at two tertiary care hospitals and seven community hospitals in Massachusetts.

Overall, 61.3% of patients presented with at least one gastrointestinal symptom, including most commonly anorexia (34.8%), diarrhea (33.7%), and nausea (26.4%).

Gastrointestinal symptoms were the initial symptoms in 14.2% of patients and were the predominant presenting complaint in 20.3% of patients, according to the online report in Gastroenterology.

More patients with than without gastrointestinal symptoms also reported fatigue (65.1% versus 45.5%, respectively), myalgia (49.2% versus 22%), sore throat (21.5% versus 9.8%), and loss of smell or taste (16.9% versus 6.5%).

Nausea and anorexia were significantly associated with anosmia and ageusia after controlling for other factors, whereas other gastrointestinal symptoms were not.

Laboratory findings did not differ significantly between patients with and without gastrointestinal symptoms.

Among 202 patients who had completed their hospitalizations at the time of data analysis, 17.5% required a stay in the ICU, 13% required mechanical ventilation, and 15.8% died. These rates did not differ significantly between patients with and without gastrointestinal symptoms.

"COVID-19 should be considered in patients presenting with new or acute-onset digestive symptoms, even in the absence of respiratory complaints, fevers, or other typical COVID-19 symptoms," Dr. Chan told Reuters Health by email. "Failure to identify COVID-19 patients with primarily digestive symptoms may lead to delayed care, inadequate isolation, and further transmission."

"Patients presenting with new or acute-onset digestive symptoms should be triaged and treated in the same way as patients presenting with respiratory COVID-19 symptoms," he said. "Digestive symptoms should also be included in local protocol and management guidelines to help clinicians and patients promptly recognize signs of infection."

"COVID-19 is not just cough and fever," Dr. Chan concluded.

Dr. Yael R. Nobel from Columbia University Irving Medical Center-New York Presbyterian Hospital, New York City, who also recently described gastrointestinal symptoms in patients with COVID-19, told Reuters Health by email, "This article provides further evidence that gastrointestinal symptoms are an important piece of the clinical syndrome of COVID-19. It is important for physicians and other healthcare providers to ask about gastrointestinal symptoms when evaluating patients, as these may be a sign of infection - whether in combination with respiratory symptoms, or in the absence of respiratory symptoms."

"Interestingly, while the authors found no statistical differences in clinical outcomes between patients with and without gastrointestinal symptoms, there were trends toward lower rates of ICU stay and death in the group with gastrointestinal symptoms, which is similar to early trends we have seen in New York City," she said.

SOURCE: https://bit.ly/2zHsDh3 Gastroenterology, online April 22, 2020.

The novel coronavirus (SARS-CoV-2) stays significantly longer in stool than in the lungs and serum, suggesting that the management of stool samples is important for controlling the virus, clinicians in China report.

Dr. Tingbo Liang and colleagues of First Affiliated Hospital in Hangzhou estimated the viral load from 3497 respiratory, stool, serum and urine samples from 96 patients with SARS-CoV-2 infection.

Infection was confirmed in all patients via sputum and saliva samples, they report in a fast-track report in The BMJ. In addition, viral RNA was detected in the stool of 55 (59%) patients, in the serum of 39 (41%) patients, and the urine of only one patient.

The average lifespan of the virus was 22 days (range 17-31 days) in stool compared to 18 days (range 13-29 days) in respiratory tissue and 16 days (range 11-21 days) in serum, the researchers report.

Based on this finding, they say the role of fecal excretion in the spread of SARS-CoV-2 "cannot be ignored; however, the importance of high detection in stool samples in the prevention and control of the SARS-CoV-2 epidemic requires comprehensive and careful evaluation."

They also found that the virus persists for a longer period and peaks later in respiratory tissue in people with severe disease. The average duration of virus in respiratory samples of patients with severe disease was 21 days (range 14-30 days) compared with 14 days (range 10-21 days) in those with mild disease.

In those with mild disease, the viral loads peaked in respiratory samples in the second week after disease onset, whereas viral load continued to be high during the third week in those with severe disease.

"These findings suggest that reducing viral loads through clinical means and strengthening management during each stage of severe disease should help to prevent the spread of the virus," the authors write.

They also observed that the virus lasts longer in men than women and in patients over age 60 years, which may partly explain the high rate of severe illness in older patients.

By way of limitations, they note that this was a single center cohort study, and the sample size was inadequate to compare the effects of antiviral therapy in different subgroups, "which could lead to an unbalanced distribution of confounders when evaluating viral shedding and viral load. Secondly, viral load is influenced by many factors. The quality of collected samples directly affects the viral load, so the study of viral load only partly reflects the amount of virus in the body."

Dr. Liang did not respond to a request for comment by press time.

SOURCE: https://bit.ly/2KI5OvI The BMJ, online April 23, 2020.