Summary: In an early Stanford Medicine review of U.S. COVID-19 patients, 31.9% reported gastrointestinal symptoms associated with SARS-CoV-2 infection. Loss of appetite and nausea or vomiting were each reported by about 22% of patients, while 12% experienced diarrhea. Abnormal liver tests were common: roughly 40% had elevated liver enzymes, which correlated with higher rates of hospitalization.
Source: Stanford
Fever, cough and shortness of breath are the hallmark signs of COVID-19, but a Stanford Medicine analysis suggests gastrointestinal complaints such as nausea, vomiting, loss of appetite and diarrhea are also common and may be overlooked.
Researchers at Stanford examined the earliest cohort of patients treated for COVID-19 at Stanford Health Care to evaluate the frequency and character of gastrointestinal (GI) symptoms in people infected with SARS-CoV-2. Their findings, published online April 10 in Gastroenterology, indicate that nearly one-third of patients experienced GI manifestations during their illness.
The study’s lead authors were gastroenterology fellows George Cholankeril, MD, and Alexander Podboy, MD, with Aijaz Ahmed, MD, professor of gastroenterology and hepatology, serving as senior author. The team analyzed medical records from confirmed cases to better understand how often GI complaints occurred alongside the more widely recognized respiratory symptoms.
“COVID-19 is probably not just respiratory symptoms like a cough,” said Dr. Podboy. “A third of the patients we studied had gastrointestinal symptoms. It’s possible we may be missing a significant portion of patients sick with the coronavirus due to our current testing strategies focusing on respiratory symptoms alone.”
Study setting and rationale
When the pandemic reached the San Francisco Bay Area in early March, many routine clinical activities were postponed to prepare for a potential surge of COVID-19 patients. With elective procedures and nonemergency visits reduced, several gastroenterology fellows at Stanford had the opportunity to study clinical data from the hospital’s initial COVID-19 cases. The authors noted that prior reports from China and Singapore had described GI symptoms, but data from U.S. patients were limited. The team therefore reviewed charts for the first group of Stanford patients diagnosed with COVID-19 to fill that gap.
Results
The analysis included 116 patients who tested positive for SARS-CoV-2 at Stanford Health Care between March 4 and March 24. Most of these individuals were evaluated and discharged from an emergency department or clinic setting. Thirty-three patients were admitted to the hospital; eight of those required intensive care. Median age in the sample was 50 years and 53% were male. The group recorded one death.
Overall, 31.9% of patients reported at least one gastrointestinal symptom, and most of these GI symptoms were described as mild. Specifically, 22% of patients experienced a loss of appetite, 22% reported nausea and vomiting, and 12% had diarrhea. In laboratory testing, approximately 40% of patients showed elevation of an abnormal liver enzyme. The authors observed that those with elevated liver enzymes were more likely to require hospitalization.
“We also noticed that 40% of patients had elevated levels of an abnormal liver enzyme, and that those with high levels required more hospitalization,” said Dr. Cholankeril.
Implications and testing considerations
The authors emphasize that these findings come from a single institution and represent early data, but they raise important questions about current testing strategies. Since testing criteria at the time often required respiratory symptoms, cases presenting predominantly with gastrointestinal complaints could be missed. In this cohort, the researchers note that respiratory symptoms generally preceded GI symptoms; none of the patients had isolated gastrointestinal symptoms before respiratory signs. However, they caution that this pattern may reflect testing practices rather than the full spectrum of how the virus can present.
Given their findings, the team suggests considering SARS-CoV-2 testing in people who have been exposed to the virus and who present with new gastrointestinal symptoms, particularly when respiratory symptoms are absent or minimal, while acknowledging the need for larger studies to confirm the prevalence and clinical significance of GI manifestations.
The investigators plan to continue evaluating how gastrointestinal symptoms influence disease severity, clinical course and hospitalization outcomes, and they intend to follow this patient cohort further as part of ongoing research.
Study team and support
Co-authors from Stanford include gastroenterology fellows Vasiliki Aivaliotis, MD; Branden Tarlow, MD, PhD; Edward Pham, MD, PhD; and Sean Spencer, MD, PhD; research scholar Donghee Kim, MD, PhD; and Ann Hsing, PhD, professor of medicine at the Stanford Prevention and Research Center. Funding for the study was provided in part by the National Institutes of Health (grant T32DK007056).
Publication details
Original research: “High Prevalence of Concurrent Gastrointestinal Manifestations in Patients with SARS-CoV-2: Early Experience from California.” Gastroenterology. DOI: 10.1053/j.gastro.2020.04.008.
About this COVID-19 research article
Source: Stanford
Media Contacts: Tracie White – Stanford
Image Source: The image is in the public domain.