Not Just a Cough. Digestive Problems May Also Be Symptoms of COVID-19

March 18, 2020

Study finds respiratory, digestive symptoms overlap in COVID-19 patients

Just under half (48.5%) of the 204 COVID-19 patients seen at three hospitals in the Chinese province where the pandemic is believed to have originated came to the hospital digestive symptoms as their chief complaint, according to a study published today by the American Journal of Gastroenterology. The digestive symptoms included anorexia (loss of appetite), diarrhea, vomiting, and abdominal pain.

The CDC website lists fever, cough, and shortness breath as appearing 2-14 days after exposure to the viral infection. Digestive and gastrointestinal symptoms are not currently mentioned.

The results reported by the research team led by Lei Pan of Binzhou Medical University Hospital show overlap of digestive and respiratory symptoms. Pan and his colleagues reported that 92 of the 99 patients who presented with digestive symptoms  developed respiratory symptoms. Just 7 of the 99 presented only with digestive systems.

The researchers called for more research but said that in the meantime their findings mean that clinicians should keep in mind that digestive symptoms, such as diarrhea, may occur before respiratory symptoms and “on rare occasions are the only presenting symptom of COVID-19.”

Pan and his colleagues report that of the remaining 105 patients in their study  who presented without digestive symptoms, 85 presented only with respiratory symptoms and 20 had neither respiratory nor digestive symptoms.

This means that the patients who presented only with respiratory symptoms far outnumbered those who presented only with digestive symptoms (85 vs. 7).

If anorexia (loss of appetite) is set aside as a symptom because it is less specific to the gastrointestinal tract, then 41 (20%) of the patients in the study had gastrointestinal symptoms: 29 with diarrhea, 8 with vomiting, and 4 with abdominal pain .The researchers said the diarrhea was usually not high volume or clinically severe and was experienced as non-dehydrating loose stools three times a day.

Pan et al report that the patients with digestive symptoms had longer time between onset to hospital admission than patients without them (9 days vs. 7.3), and those with digestive symptoms were less likely to be treated successfully and discharged from the hospital.

In the discussion section of the paper, they argue that if clinicians solely [emphasis added] monitor for respiratory symptoms to establish case definitions of COVID-19, they may miss patients with extra-pulmonary symptoms or diagnose them later when respiratory symptoms emerge.

“This theory is supported by our findings that patients with digestive symptoms had a significantly longer time from onset to admission than those without digestive symptoms, possibly because they did not initially exhibit typical respiratory symptoms and thus did not receive timely diagnoses and treatment for COVID-19,” wrote Pan and his colleagues.

They offered several possible explanations for why infection with the SARS-CoV-2 virus that causes COVID-19 might affect the gastrointestinal tract: the virus may bind to an enzyme that results in liver injury, the infection may produce an overall inflammation response that that affects the GI tract, or it may disrupt of intestinal flora.

The people in this study were patients  at Wuhan Hanan Hospital, Wuhan Union Hospital, or Huanggang Central Hospital between January 18 and February 28. The researchers said they randomly selected 310 patients with pneumonia of unknown cause and then excluded 96 of the patients from their analysis because of a negative test for SARS-CoV-2, no chest CT, or incomplete medical records.

The study was funded by the Beijing Municipal Natural Science Foundation and five additional Chinese organizations and government entities.