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Journal Watch - April 2020

Gastrointestinal Manifestations of SARS-CoV-2 Infection and Virus Load in Fecal Samples from the Hong Kong Cohort and Systematic Review and Meta-analysis.

Authors: Cheung KS, Hung IF, Chan PP, Lung KC, Tso E, Liu R, Ng YY, Chu MY, Chung TW, Tam AR, Yip CC, Leung KH, Yim-Fong Fung A, Zhang RR, Lin Y, Cheng HM, Zhang AJ, To KK, Chan KH, Yuen KY, Leung WK.

Journal: Gastroenterology. 2020 Apr 3. doi: 10.1053/j.gastro.2020.03.065.

Roberto Cannella (radiologist and PhD student, University of Palermo, Palermo/IT) and Federica Vernuccio (radiologist and PhD student, University of Palermo, Palermo/IT)

The current pandemic of SARS-CoV-2 (also known as COVID-19) is having a tremendous impact on global human health. The high viral infectivity and the lack of prior immunization results in more than 1770000 confirmed cases and 110000 deaths reported by the World Health Organization up to April 13th 2020 [1]. The most common presentation of COVID-19 includes fever and respiratory symptoms (i.e. cough, shortness of breath and dyspnea), but it may also cause a life-threatening acute respiratory syndrome in most severe cases. Extra-pulmonary symptoms may also be present during the infection. Particularly, gastrointestinal symptoms have been commonly described in COVID-19 patients. Gastrointestinal manifestations have been reported with different frequencies and may include diarrhea, nausea and vomiting, elevated liver function tests, abdominal pain and discomfort [2].

A recent systematic review and meta-analysis on the gastrointestinal manifestations of COVID-19 has been published by Cheung et al. [3]. The Authors have analyzed the prevalence of gastrointestinal symptoms and detection of virus in stool in a local cohort of 59 confirmed COVID-19 patients in Hong Kong and reviewed the data from 60 published studies including 4243 patients.

In their local COVID-19 cohort gastrointestinal symptoms have been recorded in 25% of patients, most commonly including diarrhea (22.0%), abdominal pain/discomfort (11.9%), and vomiting (1.7%). Interestingly, 53% of COVID-19 patients with gastrointestinal manifestation did not have cough or dyspnea, while fever was constantly present. Presence of virus RNA in stool was reported in 15% of patients on the day of hospitalization with a significantly higher frequency in patient with diarrhea. However, 9.1% of patients had positive stool RNA even without gastrointestinal symptoms. 

Their meta-analysis of 4243 COVID-19 patients revealed a pooled prevalence of gastrointestinal symptoms of 17.6%, with a significant heterogeneity among the included studies. Most common manifestations included anorexia (26.8%), diarrhea (12.5%), nausea and vomiting (10.2%), and abdominal pain or discomfort (9.2%). Heterogeneity of the reported symptoms was more prominent in studies originating from China than other countries. The Authors detailed that 11 studies compared the prevalence of gastrointestinal symptoms with the severity of COVID-19, with a resulted pooled prevalence of 17.1% and 11.1% in patients with severe and mild COVID-19 disease, respectively. Furthermore, the pooled prevalence of gastrointestinal symptoms was evaluated in adults, pediatrics and pregnant women and was reported to be 16.7%, 24.8%, and 20.0%, respectively. Detection of viral RNA in stool was reported in 12 studies, with a pooled prevalence of stool positive samples of 48.1%. Interestingly, the Authors also describes that in 9 studies with serial RNA tests, 70.3% patients had had persistent positive stool viral RNA despite negative respiratory samples. Therefore, persistence viral RNA in stool was longer than respiratory specimens.

This meta-analysis provides important information regarding the prevalence of gastrointestinal manifestations in COVID-19 patients. Even if gastrointestinal symptoms are not the major cause of morbidity and mortality during COVID-19 infection, they should be promptly recognized also by abdominal radiologists as patients may be referred to imaging evaluation for abdominal symptoms. Importantly, gastrointestinal manifestations may be the only initial symptoms in some COVID-19 patients, presenting even without respiratory symptoms or fever in a minority of patients. Moreover, gastrointestinal symptoms are associated with more severe COVID-19 disease.

Regarding other possible abdominal manifestations of COVID-19, some studies have also reported that COVID-19 may be associated with elevated liver enzymes [4]. Particularly, patients with more severe COVID-19 disease seem to have higher frequency of liver injury [5]. This may manifest with abnormal ALT/AST levels accompanied by slightly elevated bilirubin levels [6].

Notably, despite evidences are accumulating on the gastrointestinal and liver clinical manifestations of COVID-19, there is still a lack in knowledge regarding the possible abdominal imaging findings in COVID-19 patients. Further studies are needed to evaluate the possible presence of radiological abdominal manifestations of COIVD-19 infection.

In conclusion, this meta-analysis [3] reports that gastrointestinal symptoms were present in 17.6% of patients diagnosed with COVID-19, and may be the only initial manifestations of the infection in some cases. Their knowledge may be helpful in radiologists clinical practice to suggest the correct diagnosis.

 

REFERENCES

  1. World Health Organization. Coronavirus disease (COVID-2019) situation reports. Available at www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/.
  2. Li LY, Wu W, Chen S, Gu JW, Li XL, Song HJ, Du F, Wang G, Zhong CQ, Wang XY, Chen Y, Shah R, Yang HM, Cai Q. Digestive system involvement of novel coronavirus infection: prevention and control infection from a gastroenterology perspective. J Dig Dis. 2020 Apr 8. doi: 10.1111/1751-2980.12862.
  3. Cheung KS, Hung IF, Chan PP, Lung KC, Tso E, Liu R, Ng YY, Chu MY, Chung TW, Tam AR, Yip CC, Leung KH, Yim-Fong Fung A, Zhang RR, Lin Y, Cheng HM, Zhang AJ, To KK, Chan KH, Yuen KY, Leung WK. Gastrointestinal Manifestations of SARS-CoV-2 Infection and Virus Load in Fecal Samples from the Hong Kong Cohort and Systematic Review and Meta-analysis. Gastroenterology. 2020 Apr 3. pii: S0016-5085(20)30448-0. doi: 10.1053/j.gastro.2020.03.065.
  4. Zhang Y, Zheng L, Liu L, Zhao M, Xiao J, Zhao Q. Liver impairment in COVID-19 patients: a retrospective analysis of 115 cases from a single center in Wuhan city, China. Liver Int. 2020 Apr 2. doi: 10.1111/liv.14455.
  5. Zhang C, Shi L, Wang FS. Liver injury in COVID-19: management and challenges. Lancet Gastroenterol Hepatol. 2020 Mar 4. pii: S2468-1253(20)30057-1. doi: 10.1016/S2468-1253(20)30057-1.
  6. Xu L, Liu J, Lu M, Yang D, Zheng X. Liver injury during highly pathogenic human coronavirus infections. Liver Int. 2020 Mar 14. doi: 10.1111/liv.14435.

 

Dr. Roberto Cannella is a young radiologist, a PhD student in Molecular and Clinical Medicine at the University of Palermo (Italy) and an active ESGAR member regularly attending the annual meetings. During his radiology residency, Dr. Cannella spent 17 months as research scholar at the Abdominal Imaging Division of the University of Pittsburgh Medical Center (UPMC) in Pittsburgh (Pennsylvania, USA). He has been involved in several research studies centered on hepatobiliary topics, and specifically on CT and MR imaging of focal liver lesions.

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