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COVID-19: The Importance of GI Symptoms and Elevated LFTs


  • Gastrointestinal symptoms have been reported by patients with COVID-19 including
    • Diarrhea | Anorexia | Vomiting
  • Pan et al. (The American Journal of Gastroenterology, 2020) assessed the prevalence of digestive symptoms and outcomes in COVID-19 patients


  • Descriptive, cross-sectional, multicenter study
  • Setting
    • 3 hospitals in Hubei province
  • Participants
    • Confirmed COVID-19 documented between January 18 to February 28, 2020
  • Study design
    • COVID-19 cases confirmed using real-time RT-PCR
    • Data included clinical characteristics, laboratory data and treatment
    • Follow-up through March 5, 2020


  • 204 patients with COVID-19 | 50.5% reported digestive symptoms
    • Mean age of COVID-19 cohort overall: 52.9 years
  • Presenting with digestive symptoms: 50.5%
  • Those with digestive symptoms had a significantly longer time from onset to admission (P=0.013)
    • With digestive symptoms: 9.0 days
    • Without digestive symptoms: 7.3 days
  • Digestive symptoms were varied
    • Anorexia: 78.6%
    • Diarrhea: 34%
    • Vomiting: 3.9%
    • Abdominal pain: 1.9%
  • Digestive symptoms but no respiratory symptoms: 6 cases
  • Association of digestive symptoms with severity and disease trajectory
    • As the severity of the disease increased, digestive symptoms became more pronounced
  • LFTs: ALT and AST were more frequently elevated (>50 U/L) in patients with digestive symptoms (P for ALT = 0.002; P for AST = 0.008)
    • With digestive symptoms: ALT: 20.4% | AST: 16.5%
    • Without digestive symptoms: ALT: 5.9% | AST: 5.0%
  • Other labs
    • In patients with digestive symptoms
      • Monocytes were more likely to be lower (0.32×109/L vs 0.45×109/L; P=0.021)
      • Prothrombin time was more prolonged (13.1s vs 12.5s; P=0.024)


  • Digestive symptoms are common in COVID-19 cases
  • Digestive symptoms appear to be a harbinger of worse COVID-19 prognosis
  • Possible explanations for GI presentation include
    • SARS-CoV-2 is similar to SARS-CoV and binds to angiotensin converting enzyme 2 (ACE-2) receptor | Upregulation of ACE-2 expression can lead to liver damage
    • Inflammatory response can damage digestive system
  • The authors suggest that

Clinicians should raise their index of suspicion when at-risk patients, such as those exposed to COVID-19, present with fever and digestive symptoms, even in the absence of respiratory symptoms

Learn More – Primary Sources:

Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional, multicenter study