The New Gastroenterologist

COVID-19: Implications in gastroenterology


What is coronavirus disease 2019 (COVID-19)?

COVID-19 is a viral respiratory illness that can be potentially life-threatening and is caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-COV-2). The constellation of symptoms varies in severity but most often includes fever, fatigue, myalgias, cough, and dyspnea. Digestive symptoms such as anorexia, nausea, and diarrhea have also been reported.1 The incubation period of the virus appears to range from 1 to 14 days, most commonly between 3 and 7 days.2 The virus is characterized by its efficient person-to-person transmission, with each case leading to 1.4-3.9 additional infected individuals on average, which has led to a global pandemic and one of the most significant public health crises in modern history.

Dr. Vijaya Rao

What are the most vulnerable patient populations within a typical gastroenterology practice?

While the virus can affect anyone, and there are increasing reports of young individuals requiring intensive care, older patients are thought to be at the highest risk for severe disease – particularly those older than age 60 years. Those who developed disease requiring admission to an ICU in Wuhan, China, had a median age of 66 years with comorbid conditions including hypertension, diabetes, and cardiovascular and cerebrovascular disease.3 In addition to these, the Centers for Disease Control and Prevention identifies those who live in a nursing home or long-term care facility to be at high risk, and patients with chronic lung disease, severe obesity, renal failure, or liver disease also may be at increased risk.4 There is often a question if patients on immunosuppression, such as those with inflammatory bowel disease, are at increased risk for the development of infection. At the time of writing, there are not available data that demonstrate this association. Regarding pregnant and lactating women, limited studies done on pregnant patients with COVID-19 revealed that the virus was not transmitted to the fetus in later stages of pregnancy or into breast milk.5 As there is much that has yet to be clearly elucidated, it is prudent to recommend that all patients adhere to social distancing guidelines (including working from home when possible) as well as frequent and thorough hand washing, avoidance of touching one’s face, and avoidance of sick contacts.

Can COVID-19 present with gastrointestinal symptoms?

While initial reports did not describe this as a common presentation, a subsequent multicenter study out of the Hubei province in China reported that nearly half of all patients in the study with COVID-19 had one or more digestive symptoms as their chief complaint. Of note, the study cited the most common digestive complaint as anorexia, which is not necessarily specific to the gastrointestinal tract. Twenty percent of the patients in their cohort did report either abdominal pain, vomiting, or diarrhea.1,6 The majority had concomitant respiratory symptoms, though a small minority (7%) had digestive symptoms only. In patients reporting diarrhea, it was not described as high volume or clinically severe, but the digestive symptoms worsened with severity of the overall disease. Interestingly, the first patient with COVID-19 in the United States presented with nausea, vomiting, and diarrhea; ultimately, stool and respiratory specimens tested positive for the virus. This has led to the question of fecal-oral transmission in addition to, or in lieu of, aerosolization, which has been thought to be the primary mode of transmission.7 There have also been increasing reports of ageusia and anosmia, sometimes as the presenting complaint.8 More data are certainly needed; however, the possibility of gastrointestinal symptoms as a manifestation of COVID-19 and of fecal-oral transmission should be kept in mind when evaluating patients and performing procedures.

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