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

BACKGROUND AND PURPOSE:

• 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

METHODS:

• 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

RESULTS:

• 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)

CONCLUSION:

• 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