The emergence of coronavirus disease 2019 (COVID-19), which caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has put unprecedented challenges on the public health [1, 2]. It is well- known that most of the infected patients presented with fever or respiratory manifestations, while a portion of patients presented with gastrointestinal (GI) symptoms [2]. In early published study from the USA, SARS-CoV-2 viral RNA has been present in the feces of the illness [3]. However, part of COVID-19 patients present GI symptoms at the onset of diseases may be overlooked by clinicians [4].
Our experience was conducted in Ningbo First Hospital, Jingzhou Central Hospital, and Hubei Provincial Hospital of Integrated Chinese & Western Medicine. One hundred fifty-seven patients we treated were diagnosed as COVID-19 according to the World Health Organization interim guidance [5]. Nasopharyngeal swabs and chest computed tomography were collected from all patients. Demographic data, symptoms, laboratory values, comorbidities, and clinical outcomes were collected from the electronic medical records.
Of 157 patients with COVID-19, 63 (40.1%) presented with 1 or more GI symptoms (anorexia, nausea, or diarrhea). The mean age of 157 patients was 49.3 years (standard deviation, SD, 14.5), and 74 (47.1%) were male.
Of the 63 patients, 21 (33.3%) had nausea, 47 (74.6%) had anorexia, and 25 (39.7%) had diarrhea. The mean age of those patients was 51.9 years (SD, 14.9). Twenty-four (38.1%) were male, and 24 (38.1%) had chronic diseases. The most common symptoms were cough, fatigue, fever, and muscle soreness. Neither the median white blood cell nor lymphocyte counts were different between patients with and without GI symptoms (Table 1).
Table 1.
Demographics and clinical features of coronavirus disease 2019
| Total (n = 157) | GI symptoms(n = 63) | Without GI symptoms (n = 94) | p value* | |
|---|---|---|---|---|
| Age, mean (SD), years | 49.3 (14.5) | 51.9 (14.9) | 47.5 (14.0) | 0.0599 |
| Gender | ||||
| Male | 74 (47.1%) | 24 (38.1%) | 50 (53.2%) | 0.0633 |
| Female | 83 (52.9%) | 39 (61.9%) | 44 (46.8%) | |
| Comorbidities | ||||
| Hypertension | 28 (17.8%) | 12 (19.1%) | 16 (17.0%) | 0.7451 |
| Diabetes | 9 (5.7%) | 5 (7.9%) | 4 (4.3%) | 0.5337 |
| Chronic kidney disease | 3 (1.9%) | 1 (1.6%) | 2 (2.1%) | 1.0000 |
| Chronic lung disease | 2 (1.3%) | 1 (1.6%) | 1 (1.1%) | 1.0000 |
| Heart disease | 2 (1.3%) | 2 (3.2%) | 0 | 0.1595 |
| Malignancy | 4 (2.6%) | 1 (1.6%) | 3 (3.2%) | 0.9135 |
| Total with ≥ 1 comorbidity | 55 (35.0%) | 24 (38.1%) | 31 (33.0%) | 0.5101 |
| Symptoms | ||||
| Fever | 65 (41.4%) | 23 (36.5%) | 42 (44.7%) | 0.3082 |
| Cough | 109 (69.4%) | 47 (74.6%) | 62 (66.0%) | 0.2491 |
| Sore throat | 12 (7.6%) | 4 (6.4%) | 8 (8.5%) | 0.8468 |
| Muscle soreness | 44 (28.0%) | 23 (36.5%) | 21 (22.3%) | 0.0527 |
| Fatigue | 73 (46.5%) | 44 (69.8%) | 29 (30.9%) | < 0.001 |
| Initial laboratory parameters, median (IQR) | ||||
| WBCs count, × 109/L | 4.9 (3.8–6.3) | 4.9 (3.4–6.0) | 5.0 (4.0–6.4) | 0.4838 |
| Lymphocyte count, × 109/L | 1.0 (0.7–1.4) | 1.0 (0.7–1.4) | 1.0 (0.7–1.5) | 0.4423 |
| C-reactive protein, mg/L | 13.2 (3.4–32.9) | 17.8 (7.2–41.1) | 9.1 (2.9–30.3) | 0.0561 |
| ALT level, IU/L | 21.7 (15.4–38.8) | 23.1 (15.0–43.0) | 21.7 (16.2–34.3) | 0.8062 |
| AST level, IU/L | 26.2 (20.7–34.7) | 26.0 (20.0–35.0) | 26.9 (20.8–34.7) | 0.7189 |
| Severe cases | 41 (26.1%) | 8 (12.7%) | 33 (35.1%) | 0.0016 |
| Corticosteroid usage | 112 (71.3%) | 40 (63.5%) | 72 (76.6%) | 0.0751 |
| Hospital course, mean (SD), days | ||||
| Duration onset to treatment | 5.3 (5.4) | 5.9 (6.0) | 4.9 (4.9) | 0.2580 |
| Clinical recovery time | 9.8 (4.9) | 10.7 (4.5) | 9.1 (5.2) | 0.0607 |
| Time of virus nucleic acid turn to negative | 12.4 (6.4) | 13.0 (6.1) | 12.0 (6.7) | 0.3509 |
| Hospitalization duration | 16.0 (4.9) | 16.1 (5.1) | 15.8 (4.7) | 0.7003 |
GI gastrointestinal, IQR interquartile range, SD standard deviation, WBC white blood cell, ALT alanine aminotransferase, AST aspartate aminotransferase
*P values indicate differences between patients with GI symptoms and those without. P < 0.05 was defined as statistically significant
There was no significant difference in viral shedding, the time to clinical recovery, or hospitalization duration between patients with and without GI symptoms (Table 1). Among patients with GI symptoms, 63.5% received corticosteroids treatment, which is much lower than patients without GI symptoms group (63.5% vs 76.6%; p = 0.0751). Moreover, less patients with GI symptoms developed into severe cases compared with those without GI symptoms (12.7% vs 35.1%; p = 0.0016).
In our experience, 4 out of 10 patients with COVID-19 have significant GI symptoms. There was no significant difference in gender, age, and comorbidities between patients with and without GI symptoms. Leukocyte and lymphocyte counts were similar between the two groups. Besides, there was no significant difference in viral shedding, the time to clinical recovery, or hospitalization duration between patients with and without GI symptoms. Nonetheless, less patients with GI symptoms received corticosteroids and developed into severe cases.
This study suggested that GI symptoms in COVID-19 are frequent but are not associated with the severity of diseases or worse outcomes. However, because SARS-CoV-2 can be found in patient feces and the digestive system, we should be cautious with these potential routes for transmission [2, 3]. This study is limited by the lacked of data of reverse transcriptase polymerase chain reaction on COVID-19 in GI specimens. Our observations indicate that a substantial number of patients present with predominantly GI symptoms, and caution about this atypical presentation is necessary.
Acknowledgements
Not applicable.
Abbreviations
- COVID-19
Coronavirus disease 2019
- SARS-CoV-2
Severe acute respiratory syndrome coronavirus 2
- GI
Gastrointestinal
- IQR
Interquartile range
- SD
Standard deviation
- WBC
White blood cell
- ALT
Alanine aminotransferase
- AST
Aspartate aminotransferase
Authors’ contributions
CC, LH, JX, and XC design the study; CC, MC, LH, and JX acquired and interpreted the data; CC, MC, and JX analyzed the data and wrote the paper; XC supervised the study. All authors have seen and approved the final draft.
Funding
This work was supported by the Medical and Health Program of Zhejiang (2019KY156 and 2019KY563).
Availability of data and materials
Participant data without names and identifiers will be made available after approval from the corresponding author.
Ethics approval and consent to participate
Ethical approvals for this study were obtained from the Ethics Commission of Ningbo First Hospital (2020-R017) and the Ethics Commission of Jingzhou Central Hospital (2020-2-19). Written informed consent was waived due to the rapid emergence of this disease.
Consent for publication
Not applicable.
Competing interests
Authors have disclosed no conflicts of interest.
Footnotes
Publisher’s Note
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Chao Cao, Meiping Chen and Li He contributed equally to this work.
References
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Associated Data
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Data Availability Statement
Participant data without names and identifiers will be made available after approval from the corresponding author.