Patients with COVID-19 GI symptoms experience delayed diagnosis, viral clearance
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Patients who develop new-onset digestive symptoms, like diarrhea, after a possible exposure to COVID-19 should be suspected for the illness, according to research published in The American Journal of Gastroenterology.
In the study, Xiaohua Hou, MD, PhD, of the division of gastroenterology at Union Hospital, Tongji Medical College, Huazhong University of Science and Technology in Wuhan, China, and colleagues wrote that these patients should be suspected for COVID-19 even without common respiratory symptoms, such as cough, shortness of breath, sore throat or fever.
“This study is vital because it represents the 80% or more of patients who do not have severe or critical disease,” Brennan M.R. Spiegel, MD, MSHS, FACG, director of health research at Cedars Sinai, said in a press release issued by the American College of Gastroenterology. “This is about the more common scenario of people in the community struggling to figure out if they might have COVID-19 because of new-onset diarrhea, nausea, or vomiting.”
For the study, researchers identified patients with mild COVID-19 and one or more digestive symptoms (diarrhea, nausea or vomiting), with or without respiratory symptoms and compared them with a group of patients who presented only with respiratory symptoms. They followed the patients until they tested negative for COVID-19 on at least two sequential respiratory tract specimens collected at least 24 hours apart. Then, they compared clinical features between patients with digestive symptoms versus respiratory symptoms.
Of 206 total patients, 48 presented with only digestive symptoms, 69 presented with both digestive and respiratory symptoms and 89 presented with only respiratory symptoms. In the two groups with digestive symptoms, 67 presented with diarrhea, and of those patients, 19.4% experienced diarrhea as their first symptom. Researchers found concurrent fever in 62.4% of patients with a digestive symptom.
Patients who experienced digestive symptoms presented for care later than those with respiratory symptoms (16±7.7 days vs. 11.6±5.1 days; P < .001). They also had a longer duration between symptom onset and viral clearance (P < .001) and were more likely to test fecal virus positive compared with patients who experienced respiratory symptoms (73.3% vs. 14.3%; P = .033).
“Clinicians should recognize that new-onset, acute digestive symptoms in a patient with a possible COVID-19 contact should at least prompt consideration of the illness, particularly during times of high COVID-19 incidence and prevalence,” Hou and colleagues wrote. “Failure to recognize these patients early and often may lead to unwitting spread of the disease among outpatients with mild illness who remain undiagnosed and unaware of their potential to infect others.” – by Alex Young
Reference:
Han C, et al. “Prevalence and Clinical Characteristics of Mild Severity COVID-19 Patients with Digestive Symptoms.” Am J Gastroenterol. Pre-Print March 30, 2020.
Disclosure: The authors report no relevant financial disclosures.
Perspective
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Jean-Paul Achkar, MD
There are a growing number of studies highlighting the GI manifestations of COVID-19. Although initial studies suggested a low prevalence of GI symptoms in patients with COVID-19, more recent studies have suggested rates as high as 50% to 60%.
This study by Han and colleagues assessed 206 patients who tested positive for COVID-19 and were classified as having mild disease severity (no dyspnea or respiratory distress with the ability to maintain oxygen saturation above 93% at rest). Of note, although these patients had mild disease, they were admitted to hospital for monitoring purposes and to maintain quarantine during the peak of the Wuhan outbreak. Each patient was matched to another patient with respiratory, but not digestive symptoms. Patients with digestive symptoms were further subdivided into those with only digestive symptoms, and those with both digestive and respiratory symptoms.
These results highlight the importance of recognizing that, among the approximately 80% of patients with mild COVID-19, GI symptoms may be the only presenting manifestation with no associated fever or respiratory symptoms. Such GI symptoms included decreased appetite (60%), diarrhea (57%), and vomiting (21%) while abdominal pain was only present in 8% of patients. Further, the total time between symptom onset and viral clearance was significantly longer (by 7-8 days) in patients with GI symptoms compared with patients with respiratory symptoms only.
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