Table 1.
Effect of COVID-19 infection on gastrointestinal disorders and diseases
| Disease or Disorder | Clinical Characteristics | Mechanism |
|---|---|---|
| Anosmia & ageusia/dysgeusia | Very common. Often the first symptom to manifest with COVID-19 infection and the last symptom to resolve. Bothersome symptoms but not life-threatening. Proposed, unproven therapies include corticosteroids and Paxlovid. | Not associated with nasopharyngitis, nasal obstruction, glossitis, zinc deficiency, or rhinorrhea. Postulated decreased sensitivity of olfactory neurons associated with expression of ACE-2 in alveolar epithelial cells. |
| Geographic (COVID) tongue | Affects about 4% of infected patients. Associated with minor symptoms. | Loss of filiform papillae in rear of tongue from damage caused by high expression of ACE-2 in epithelial cells. |
| GERD (gastroesophageal reflux disease) | Very common with COVID-19 infection but also very common without COVID-19 infection. GERD likely does not arise from acute COVID-19 infection but likely arises from shared risk factors, such as obesity. | COVID-19 may preferentially infect Barrett’s epithelium over normal esophageal mucosa, and PPI therapy may be associated with increased COVID-19 susceptibility. |
| Esophageal candidiasis | Risk factors include acute respiratory distress syndrome, chronic corticosteroid therapy, and prolonged endotracheal intubation. Often associated with severe COVID-19 infection and has a high mortality due to this association. Typical symptoms are dysphagia and odynophagia. EGD classically demonstrates a cheesy exudate in esophagus. Endoscopic brushings are usually diagnostic. Primary therapies are echinocandins and azoles. | Associated with profound immune dysregulation with COVID-19 infection, but the specific underlying immunologic defects are unknown. |
| Pill-induced esophagitis | More prevalent in COVID-19 infected patients. | Partly related to increased use of doxycycline antibiotics to treat COVID-19 infection and increased corrosive ingestion due to COVID-19 pandemic–related stress. |
| Eosinophilic esophagitis | Apparently eosinophilic esophagitis does not increase the frequency or severity of COVID-19 infection. Acute COVID-19 infection does not apparently cause flares of eosinophilic esophagitis. | Patients with eosinophilic esophagitis typically have mild COVID-19 infection. COVID-19 esophageal infection might be related to oral corticosteroid therapy for eosinophilic esophagitis. |
| Gastric ulcers | Gastric ulcers very common in patients with COVID-19 infection who are undergoing EGD. | H pylori does not apparently affect the severity of COVID-19 infection. Several patients had esophageal or gastric ulcers from primary COVID-19 infection, as demonstrated by electron microscopy. |
| GI hemorrhage | Occurs in about 9% or less of hospitalized COVID-19–infected patients. Often the GI bleeding is mild and does not mandate endoscopy. Patients with GI bleeding often have a worse prognosis from COVID-19 infection than nonbleeding COVID-19–infected patients. GI hemorrhage in patients with COVID-19 is often from gastric ulcers. GI bleeding may sometimes arise from anticoagulation used to treat a hypercoagulopathy associated with COVID-19 infection. | GI bleeding rarely due to ulcers associated with primary COVID-19 infection. |
| Celiac disease | Celiac patients do not have increased susceptibility to COVID-19 infection and do not have a worse outcome from COVID-19 infection. The mainstay of therapy in COVID-19–infected patients is maintenance of a gluten-free diet. | The 2 different diseases do not seem to significantly interact. |
| Multisystem inflammatory syndrome | Rare syndrome that occurs in children. Clinically can resemble regional enteritis. Can cause GI obstruction, fistula, or contained GI perforation. | Syndrome associated with an abnormal immune response due to viral cytopathic effects. |
| Mesenteric ischemia | COVID-19 infection likely increases the risk of mesenteric ischemia. Mesenteric ischemia has a high mortality in COVID-19–infected patients. | Most likely increased frequency of mesenteric ischemia due to microcirculatory thrombosis, but sometimes can occur from large vessel thrombosis. COVID-19 can produce a hypercoagulopathy. High mortality from mesenteric ischemia attributed to delayed diagnosis because symptoms can be confused with acute COVID-19 infection. |
| Small bowel intussusception | Frequency may increase with COVID-19 infection. | Attributed to bowel wall or mesenteric lymph node inflammation, edema and thickening from local viral infection that forms a lead point for the intussusception. |
| GI infection with mucormycosis | Increased risk with advanced COVID-19 infection due to immunosuppression. Associated with high mortality. | Increased risk attributed to high-dose corticosteroid therapy, exposure to mechanical ventilation, and advanced COVID-19 infection. |
| Collagenous colitis | Significantly higher rate of contracting COVID-19 infection, having severe COVID-19 infection, and of being hospitalized for COVID-19 infection than patients with lymphocytic colitis or controls. | May relate to genetic factors associated with predisposition to developing collagenous colitis such as an extended HLA haplotype or the rs13071258 A variant on genetic locus 3p21.31 associated with collagenous colitis. This genetic locus harbors 6 genes potentially affecting the immune defense against viral infections. |
| Lymphocytic colitis | Has similar rate of contracting COVID-19 infection and developing severe infection as controls. Lymphocytic colitis should be considered in the differential of watery diarrhea after contracting acute COVID-19 infection. | Unlike collagenous colitis, lymphocytic colitis is not associated with genetic abnormalities affecting host defenses against viruses. |
| Tocilizumab-associated colonic perforation | Case report of developing terminal ileal and cecal ulcers that caused colonic perforation after initiating tocilizumab therapy for suspected cytokine release syndrome in a patient with COVID-19 infection. | Tocilizumab has previously been associated with lower GI perforation and colonic diverticular perforation after its use to treat rheumatoid arthritis. |
| Acute appendicitis and acute diverticulitis | COVID-19 infection does not affect the frequency of hospitalization, colonic perforation, or surgery from these 2 diseases. | COVID-19 infection does not seem to affect the natural history of these 2 diseases. |
| Irritable bowel syndrome | During pandemic patients with irritable bowel syndrome experienced more severe GI symptoms, more severe extraintestinal symptoms, and more sleep difficulties than before the COVID-19 pandemic. | Patients likely experience more severe symptoms of irritable bowel syndrome due to anxiety related to the pandemic. |
| Inflammatory bowel disease | COVID-19–infected patients have a worse outcome from inflammatory bowel disease when treated with corticosteroids but not when treated with tumor necrosis factor antagonists. | Corticosteroids may decrease immunologic defenses against COVID-19 infection. Another chapter in this monograph is devoted to COVID-19 infection in patients with inflammatory bowel disease. |