COVID-19-associated diarrhea: Difference between revisions
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==Overview== | ==Overview== | ||
SARS-CoV-2 mainly causes severe acute respiratory syndrome but may also present with gastrointestinal symptoms like diarrhea. It invades through the Angiotensin-converting enzyme 2 (ACE2) and the serine protease TMPRSS2 receptors present abundantly not only in the lungs but also in the enterocytes of the small intestine. A greater percentage of occurrence of diarrhea was noted in patients with severe COVID-19 when compared to non-severe disease. Likewise, patients with gastrointestinal symptoms were more likely to have a severe respiratory disease with ARDS requiring ventilatory support. The presence of the virus in the stool raises suspicion for fecal-oral transmission of SARS-CoV-2. Appropriate personal protective equipment(PPE) must be used while handling sources of contamination like feces. | SARS-CoV-2 mainly causes severe acute respiratory syndrome but may also present with gastrointestinal symptoms like diarrhea. It invades through the [[Angiotensin-converting enzyme 2|Angiotensin-converting enzyme 2 (]]ACE2) and the serine protease [[TMPRSS2]] receptors present abundantly not only in the lungs but also in the [[Enterocyte|enterocytes]] of the [[small intestine]]. A greater percentage of occurrence of [[diarrhea]] was noted in patients with severe [[COVID-19]] when compared to non-severe disease. Likewise, patients with gastrointestinal symptoms were more likely to have a severe [[respiratory]] disease with [[Acute respiratory distress syndrome|ARDS]] requiring ventilatory support. The presence of the [[virus]] in the [[Human feces|stool]] raises suspicion for fecal-oral transmission of SARS-CoV-2. Appropriate personal protective equipment(PPE) must be used while handling sources of [[contamination]] like [[feces]]. | ||
==Historical Perspective== | ==Historical Perspective== | ||
* The etiological agent is SARS-CoV-2, named for the similarity of its symptoms to those induced by the [[severe acute respiratory syndrome]], causing coronavirus disease 2019 (COVID-19), is a [[virus]] identified as the cause of an outbreak of [[respiratory illness]] first detected in Wuhan, China.<ref>{{Cite web|url=https://www.cdc.gov/coronavirus/2019-ncov/about/index.html|title=|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref><ref name="LuCui2020">{{cite journal|last1=Lu|first1=Jian|last2=Cui|first2=Jie|last3=Qian|first3=Zhaohui|last4=Wang|first4=Yirong|last5=Zhang|first5=Hong|last6=Duan|first6=Yuange|last7=Wu|first7=Xinkai|last8=Yao|first8=Xinmin|last9=Song|first9=Yuhe|last10=Li|first10=Xiang|last11=Wu|first11=Changcheng|last12=Tang|first12=Xiaolu|title=On the origin and continuing evolution of SARS-CoV-2|journal=National Science Review|year=2020|issn=2095-5138|doi=10.1093/nsr/nwaa036}}</ref> | * The etiological agent is SARS-CoV-2, named for the similarity of its symptoms to those induced by the [[severe acute respiratory syndrome]], causing coronavirus disease 2019 (COVID-19), is a [[virus]] identified as the cause of an outbreak of [[respiratory illness]] first detected in Wuhan, China.<ref>{{Cite web|url=https://www.cdc.gov/coronavirus/2019-ncov/about/index.html|title=|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref><ref name="LuCui2020">{{cite journal|last1=Lu|first1=Jian|last2=Cui|first2=Jie|last3=Qian|first3=Zhaohui|last4=Wang|first4=Yirong|last5=Zhang|first5=Hong|last6=Duan|first6=Yuange|last7=Wu|first7=Xinkai|last8=Yao|first8=Xinmin|last9=Song|first9=Yuhe|last10=Li|first10=Xiang|last11=Wu|first11=Changcheng|last12=Tang|first12=Xiaolu|title=On the origin and continuing evolution of SARS-CoV-2|journal=National Science Review|year=2020|issn=2095-5138|doi=10.1093/nsr/nwaa036}}</ref> | ||
*The growing number of [[patients]] however, suggest that human-to-human transmission is actively occurring.<ref name="HuangWang2020">{{cite journal|last1=Huang|first1=Chaolin|last2=Wang|first2=Yeming|last3=Li|first3=Xingwang|last4=Ren|first4=Lili|last5=Zhao|first5=Jianping|last6=Hu|first6=Yi|last7=Zhang|first7=Li|last8=Fan|first8=Guohui|last9=Xu|first9=Jiuyang|last10=Gu|first10=Xiaoying|last11=Cheng|first11=Zhenshun|last12=Yu|first12=Ting|last13=Xia|first13=Jiaan|last14=Wei|first14=Yuan|last15=Wu|first15=Wenjuan|last16=Xie|first16=Xuelei|last17=Yin|first17=Wen|last18=Li|first18=Hui|last19=Liu|first19=Min|last20=Xiao|first20=Yan|last21=Gao|first21=Hong|last22=Guo|first22=Li|last23=Xie|first23=Jungang|last24=Wang|first24=Guangfa|last25=Jiang|first25=Rongmeng|last26=Gao|first26=Zhancheng|last27=Jin|first27=Qi|last28=Wang|first28=Jianwei|last29=Cao|first29=Bin|title=Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China|journal=The Lancet|volume=395|issue=10223|year=2020|pages=497–506|issn=01406736|doi=10.1016/S0140-6736(20)30183-5}}</ref><ref>{{Cite web|url=https://www.cdc.gov/coronavirus/2019-ncov/about/transmission.html|title=|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref> | *The growing number of [[patients]] however, suggest that human-to-human [[Transmission (medicine)|transmission]] is actively occurring.<ref name="HuangWang2020">{{cite journal|last1=Huang|first1=Chaolin|last2=Wang|first2=Yeming|last3=Li|first3=Xingwang|last4=Ren|first4=Lili|last5=Zhao|first5=Jianping|last6=Hu|first6=Yi|last7=Zhang|first7=Li|last8=Fan|first8=Guohui|last9=Xu|first9=Jiuyang|last10=Gu|first10=Xiaoying|last11=Cheng|first11=Zhenshun|last12=Yu|first12=Ting|last13=Xia|first13=Jiaan|last14=Wei|first14=Yuan|last15=Wu|first15=Wenjuan|last16=Xie|first16=Xuelei|last17=Yin|first17=Wen|last18=Li|first18=Hui|last19=Liu|first19=Min|last20=Xiao|first20=Yan|last21=Gao|first21=Hong|last22=Guo|first22=Li|last23=Xie|first23=Jungang|last24=Wang|first24=Guangfa|last25=Jiang|first25=Rongmeng|last26=Gao|first26=Zhancheng|last27=Jin|first27=Qi|last28=Wang|first28=Jianwei|last29=Cao|first29=Bin|title=Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China|journal=The Lancet|volume=395|issue=10223|year=2020|pages=497–506|issn=01406736|doi=10.1016/S0140-6736(20)30183-5}}</ref><ref>{{Cite web|url=https://www.cdc.gov/coronavirus/2019-ncov/about/transmission.html|title=|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref> | ||
*The outbreak was declared a Public Health Emergency of International Concern on 30 January 2020. | *The outbreak was declared a Public Health Emergency of International Concern on 30 January 2020. | ||
*On March 12, 2020, the [[World Health Organization]] declared the COVID-19 outbreak a [[pandemic]]. | *On March 12, 2020, the [[World Health Organization]] declared the COVID-19 outbreak a [[pandemic]]. | ||
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==Causes== | ==Causes== | ||
Diarrhea in a patient hospitalized due to COVID-19 may be due to- | Diarrhea in a patient hospitalized due to COVID-19 may be due to- | ||
* COVID-19 associated diarrhea | * COVID-19 associated [[diarrhea]] | ||
* Secondary [[Bacteria|bacterial]] infections | * Secondary [[Bacteria|bacterial]] infections | ||
*[[Clostridium difficile diarrhea resident survival guide|Clostridium difficile diarrhea]] and recent use of [[antibiotics]] | *[[Clostridium difficile diarrhea resident survival guide|Clostridium difficile diarrhea]] and recent use of [[antibiotics]] | ||
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==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
*Diarrhea is an uncommon gastrointestinal symptom (anorexia, nausea, and vomiting are more common) in patients with COVID-19 but may be the presenting symptom in a few patients. | *Diarrhea is an uncommon gastrointestinal symptom ([[anorexia]], [[Nausea and vomiting|nausea]], and [[Nausea and vomiting|vomiting]] are more common) in patients with [[COVID-19]] but may be the presenting symptom in a few patients. | ||
*The frequency of occurrence of diarrhea varies between 1%-35%. <ref name="pmid32253163">{{cite journal| author=Li XY, Dai WJ, Wu SN, Yang XZ, Wang HG| title=The occurrence of diarrhea in COVID-19 patients. | journal=Clin Res Hepatol Gastroenterol | year= 2020 | volume= | issue= | pages= | pmid=32253163 | doi=10.1016/j.clinre.2020.03.017 | pmc=7270575 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32253163 }} </ref>It varies widely between different studies probably due to the different criteria used to define diarrhea. | *The frequency of occurrence of diarrhea varies between 1%-35%. <ref name="pmid32253163">{{cite journal| author=Li XY, Dai WJ, Wu SN, Yang XZ, Wang HG| title=The occurrence of diarrhea in COVID-19 patients. | journal=Clin Res Hepatol Gastroenterol | year= 2020 | volume= | issue= | pages= | pmid=32253163 | doi=10.1016/j.clinre.2020.03.017 | pmc=7270575 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32253163 }} </ref>It varies widely between different studies probably due to the different [[Criterion|criteria]] used to define [[diarrhea]]. | ||
* Greater percentage of occurrence of diarrhea was noted in patients with severe COVID-19 when compared to non-severe disease. | * Greater percentage of occurrence of [[diarrhea]] was noted in patients with severe [[COVID-19]] when compared to non-severe disease. | ||
*Likewise, patients with gastrointenstinal symptoms were more likely to have severe respiratory disease with ARDS requiring ventilatory support. <ref name="pmid32213556">{{cite journal| author=Jin X, Lian JS, Hu JH, Gao J, Zheng L, Zhang YM | display-authors=etal| title=Epidemiological, clinical and virological characteristics of 74 cases of coronavirus-infected disease 2019 (COVID-19) with gastrointestinal symptoms. | journal=Gut | year= 2020 | volume= 69 | issue= 6 | pages= 1002-1009 | pmid=32213556 | doi=10.1136/gutjnl-2020-320926 | pmc=7133387 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32213556 }} </ref> <ref name="pmid32109013">{{cite journal| author=Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX | display-authors=etal| title=Clinical Characteristics of Coronavirus Disease 2019 in China. | journal=N Engl J Med | year= 2020 | volume= 382 | issue= 18 | pages= 1708-1720 | pmid=32109013 | doi=10.1056/NEJMoa2002032 | pmc=7092819 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32109013 }} </ref> | *Likewise, patients with [[Stomach|gastrointenstinal]] symptoms were more likely to have severe respiratory disease with [[Acute respiratory distress syndrome|ARDS]] requiring [[Ventilation|ventilatory]] support. <ref name="pmid32213556">{{cite journal| author=Jin X, Lian JS, Hu JH, Gao J, Zheng L, Zhang YM | display-authors=etal| title=Epidemiological, clinical and virological characteristics of 74 cases of coronavirus-infected disease 2019 (COVID-19) with gastrointestinal symptoms. | journal=Gut | year= 2020 | volume= 69 | issue= 6 | pages= 1002-1009 | pmid=32213556 | doi=10.1136/gutjnl-2020-320926 | pmc=7133387 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32213556 }} </ref> <ref name="pmid32109013">{{cite journal| author=Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX | display-authors=etal| title=Clinical Characteristics of Coronavirus Disease 2019 in China. | journal=N Engl J Med | year= 2020 | volume= 382 | issue= 18 | pages= 1708-1720 | pmid=32109013 | doi=10.1056/NEJMoa2002032 | pmc=7092819 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32109013 }} </ref> | ||
There is no data on predilection based on age, gender, geographical location, or race. | There is no data on predilection based on age, gender, geographical location, or race. | ||
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Some gastrointestinal factors may predispose patients to infection with COVID-19. | Some gastrointestinal factors may predispose patients to infection with COVID-19. | ||
*[[Inflammatory bowel disease]] patients- due to use to [[glucocorticoids]], but not [[TNF-alpha|TNF-alpha inhibitors]] <ref name="pmid32425234">{{cite journal| author=Brenner EJ, Ungaro RC, Gearry RB, Kaplan GG, Kissous-Hunt M, Lewis JD | display-authors=etal| title=Corticosteroids, but not TNF Antagonists, are Associated with Adverse COVID-19 Outcomes in Patients With Inflammatory Bowel Diseases: Results from an International Registry. | journal=Gastroenterology | year= 2020 | volume= | issue= | pages= | pmid=32425234 | doi=10.1053/j.gastro.2020.05.032 | pmc=7233252 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32425234 }} </ref> | *[[Inflammatory bowel disease]] patients- due to use to [[glucocorticoids]], but not [[TNF-alpha|TNF-alpha inhibitors]] <ref name="pmid32425234">{{cite journal| author=Brenner EJ, Ungaro RC, Gearry RB, Kaplan GG, Kissous-Hunt M, Lewis JD | display-authors=etal| title=Corticosteroids, but not TNF Antagonists, are Associated with Adverse COVID-19 Outcomes in Patients With Inflammatory Bowel Diseases: Results from an International Registry. | journal=Gastroenterology | year= 2020 | volume= | issue= | pages= | pmid=32425234 | doi=10.1053/j.gastro.2020.05.032 | pmc=7233252 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32425234 }} </ref> | ||
* Increasing age | * Increasing [[age]] | ||
* Other [[Comorbidity|comorbidities]] | * Other [[Comorbidity|comorbidities]] | ||
* Use of [[glucocorticoids]] | * Use of [[glucocorticoids]] | ||
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==Diagnosis== | ==Diagnosis== | ||
===Diagnostic Study of Choice=== | ===Diagnostic Study of Choice=== | ||
* COVID-19 diarrhea can be diagnosed based on the history of diarrhea and a positive [[Human feces|stool]] test for SARS-CoV-2 | *[[COVID-19]] [[diarrhea]] can be diagnosed based on the history of diarrhea and a positive [[Human feces|stool]] test for SARS-CoV-2 | ||
* There are no established criteria for the diagnosis of diarrhea in COVID-19. | * There are no established [[Criterion|criteria]] for the diagnosis of diarrhea in COVID-19. | ||
===History and Symptoms=== | ===History and Symptoms=== | ||
* According to Jin et al<ref name="pmid32213556">{{cite journal| author=Jin X, Lian JS, Hu JH, Gao J, Zheng L, Zhang YM | display-authors=etal| title=Epidemiological, clinical and virological characteristics of 74 cases of coronavirus-infected disease 2019 (COVID-19) with gastrointestinal symptoms. | journal=Gut | year= 2020 | volume= 69 | issue= 6 | pages= 1002-1009 | pmid=32213556 | doi=10.1136/gutjnl-2020-320926 | pmc=7133387 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32213556 }} </ref>, the definition of diarrhea was the passing of loose stools >3 times per day. | * According to Jin et al<ref name="pmid32213556">{{cite journal| author=Jin X, Lian JS, Hu JH, Gao J, Zheng L, Zhang YM | display-authors=etal| title=Epidemiological, clinical and virological characteristics of 74 cases of coronavirus-infected disease 2019 (COVID-19) with gastrointestinal symptoms. | journal=Gut | year= 2020 | volume= 69 | issue= 6 | pages= 1002-1009 | pmid=32213556 | doi=10.1136/gutjnl-2020-320926 | pmc=7133387 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32213556 }} </ref>, the definition of diarrhea was the passing of loose [[Human feces|stools]] >3 times per day. | ||
* According to this study, 8.1% had diarrhea at onset and the symptoms lasted for approximately 4 days. | * According to this study, 8.1% had diarrhea at onset and the symptoms lasted for approximately 4 days. | ||
* The duration of diarrhea ranged from 2-4 days with 3-8 bowel movements per day, according to various studies. <ref name="pmid32139552">{{cite journal| author=Song Y, Liu P, Shi XL, Chu YL, Zhang J, Xia J | display-authors=etal| title=SARS-CoV-2 induced diarrhoea as onset symptom in patient with COVID-19. | journal=Gut | year= 2020 | volume= 69 | issue= 6 | pages= 1143-1144 | pmid=32139552 | doi=10.1136/gutjnl-2020-320891 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32139552 }} </ref><ref name="pmid31986261">{{cite journal| author=Chan JF, Yuan S, Kok KH, To KK, Chu H, Yang J | display-authors=etal| title=A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. | journal=Lancet | year= 2020 | volume= 395 | issue= 10223 | pages= 514-523 | pmid=31986261 | doi=10.1016/S0140-6736(20)30154-9 | pmc=7159286 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31986261 }} </ref> | * The duration of diarrhea ranged from 2-4 days with 3-8 [[bowel]] movements per day, according to various studies. <ref name="pmid32139552">{{cite journal| author=Song Y, Liu P, Shi XL, Chu YL, Zhang J, Xia J | display-authors=etal| title=SARS-CoV-2 induced diarrhoea as onset symptom in patient with COVID-19. | journal=Gut | year= 2020 | volume= 69 | issue= 6 | pages= 1143-1144 | pmid=32139552 | doi=10.1136/gutjnl-2020-320891 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32139552 }} </ref><ref name="pmid31986261">{{cite journal| author=Chan JF, Yuan S, Kok KH, To KK, Chu H, Yang J | display-authors=etal| title=A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. | journal=Lancet | year= 2020 | volume= 395 | issue= 10223 | pages= 514-523 | pmid=31986261 | doi=10.1016/S0140-6736(20)30154-9 | pmc=7159286 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31986261 }} </ref> | ||
* There is not enough data from other studies on the number of evacuations, consistency of stool, and duration of symptoms. | * There is not enough data from other studies on the number of evacuations, consistency of stool, and duration of [[Symptom|symptoms]]. | ||
===Physical Examination=== | ===Physical Examination=== | ||
Patients with diarrhea due to COVID-19 usually appear very sick, since diarrhea is seen in a greater percentage of patients with severe [[respiratory]] disease than non-severe disease. <ref name="pmid32109013">{{cite journal| author=Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX | display-authors=etal| title=Clinical Characteristics of Coronavirus Disease 2019 in China. | journal=N Engl J Med | year= 2020 | volume= 382 | issue= 18 | pages= 1708-1720 | pmid=32109013 | doi=10.1056/NEJMoa2002032 | pmc=7092819 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32109013 }} </ref> | Patients with diarrhea due to [[COVID-19]] usually appear very sick, since diarrhea is seen in a greater percentage of patients with severe [[respiratory]] disease than non-severe disease. <ref name="pmid32109013">{{cite journal| author=Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX | display-authors=etal| title=Clinical Characteristics of Coronavirus Disease 2019 in China. | journal=N Engl J Med | year= 2020 | volume= 382 | issue= 18 | pages= 1708-1720 | pmid=32109013 | doi=10.1056/NEJMoa2002032 | pmc=7092819 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32109013 }} </ref> | ||
Physical examination due to diarrhea may be remarkable for | Physical examination due to diarrhea may be remarkable for | ||
* Weak, low volume [[pulse]] | * Weak, low [[volume]] [[pulse]] | ||
*[[Hypotension]] | *[[Hypotension]] | ||
*[[Eyes|Sunken eyes]] | *[[Eyes|Sunken eyes]] | ||
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===Laboratory Findings=== | ===Laboratory Findings=== | ||
* Infectious [[virions]] released from the GI tract can be monitored by real-time [[Reverse transcription polymerase chain reaction|reverse transcriptase polymerase chain reaction]] (rRT-PCR) | * Infectious [[virions]] released from the GI tract can be monitored by real-time [[Reverse transcription polymerase chain reaction|reverse transcriptase polymerase chain reaction]] (rRT-PCR) | ||
* A study by Xiao et al assessed the clinical significance of measuring [[SARS-CoV-2]] RNA in the feces. <ref name="pmid32142773">{{cite journal| author=Xiao F, Tang M, Zheng X, Liu Y, Li X, Shan H| title=Evidence for Gastrointestinal Infection of SARS-CoV-2. | journal=Gastroenterology | year= 2020 | volume= 158 | issue= 6 | pages= 1831-1833.e3 | pmid=32142773 | doi=10.1053/j.gastro.2020.02.055 | pmc=7130181 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32142773 }} </ref> | * A study by Xiao et al assessed the clinical significance of measuring [[SARS-CoV-2]] RNA in the [[feces]]. <ref name="pmid32142773">{{cite journal| author=Xiao F, Tang M, Zheng X, Liu Y, Li X, Shan H| title=Evidence for Gastrointestinal Infection of SARS-CoV-2. | journal=Gastroenterology | year= 2020 | volume= 158 | issue= 6 | pages= 1831-1833.e3 | pmid=32142773 | doi=10.1053/j.gastro.2020.02.055 | pmc=7130181 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32142773 }} </ref> | ||
* The fecal test remained positive until 12 days after the disease onset in patients with diarrhea. | * The fecal test remained positive until 12 days after the disease onset in patients with diarrhea. | ||
* Notably, stool test for [[RNA|viral RNA]] remained positive despite negative respiratory tests. This suggests the possibility of gastrointestinal transmission via the fecal-oral route despite clearance from the respiratory tract. | * Notably, stool test for [[RNA|viral RNA]] remained positive despite negative respiratory tests. This suggests the possibility of gastrointestinal transmission via the [[fecal-oral route]] despite clearance from the [[Respiratory system|respiratory]] tract. | ||
* It was recommended [[Transmission (medicine)|transmission]]-based precautions for hospitalized COVID-19 patients should be continued till the rRT-PCR for SARS-CoV-2 turns negative. | * It was recommended [[Transmission (medicine)|transmission]]-based precautions for hospitalized [[COVID-19]] patients should be continued till the rRT-[[Polymerase chain reaction|PCR]] for [[SARS-CoV-2]] turns negative. | ||
===Electrocardiogram=== | ===Electrocardiogram=== | ||
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===Echocardiography or Ultrasound=== | ===Echocardiography or Ultrasound=== | ||
There are no echocardiography/ultrasound findings associated with diarrhea in COVID-19. | There are no [[echocardiography]]/[[ultrasound]] findings associated with diarrhea in COVID-19. | ||
===CT scan=== | ===CT scan=== | ||
There are no CT scan findings associated with diarrhea in COVID-19 | There are no [[Computed tomography|CT scan]] findings associated with diarrhea in COVID-19 | ||
===MRI=== | ===MRI=== | ||
There are no MRI findings associated with diarrhea in COVID-19 | There are no [[Magnetic resonance imaging|MRI]] findings associated with diarrhea in COVID-19 | ||
===Other Imaging Findings=== | ===Other Imaging Findings=== | ||
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* Supportive management is the mainstay of treatment. | * Supportive management is the mainstay of treatment. | ||
*[[Rehydration]], fluid repletion, and [[potassium]] monitoring are essential. | *[[Rehydration]], fluid repletion, and [[potassium]] monitoring are essential. | ||
* Use of [[Probiotic|probiotics]] may have a role if the diarrhea is being caused by alteration of the [[Microbiome|gut microbiome]]. This could also be potentially useful in preventing secondary bacterial infections by restoring the gut [[Microbiome|microbiota]]. <ref name="pmid32096611">{{cite journal| author=Gao QY, Chen YX, Fang JY| title=2019 Novel coronavirus infection and gastrointestinal tract. | journal=J Dig Dis | year= 2020 | volume= 21 | issue= 3 | pages= 125-126 | pmid=32096611 | doi=10.1111/1751-2980.12851 | pmc=7162053 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32096611 }} </ref> | * Use of [[Probiotic|probiotics]] may have a role if the [[diarrhea]] is being caused by alteration of the [[Microbiome|gut microbiome]]. This could also be potentially useful in preventing [[secondary]] [[Bacteria|bacterial]] [[Infection|infections]] by restoring the gut [[Microbiome|microbiota]]. <ref name="pmid32096611">{{cite journal| author=Gao QY, Chen YX, Fang JY| title=2019 Novel coronavirus infection and gastrointestinal tract. | journal=J Dig Dis | year= 2020 | volume= 21 | issue= 3 | pages= 125-126 | pmid=32096611 | doi=10.1111/1751-2980.12851 | pmc=7162053 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32096611 }} </ref> | ||
===Primary Prevention=== | ===Primary Prevention=== | ||
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There are no available [[Vaccine|vaccines]] against COVID-19 as of now, but several vaccines are under development and in trials. Standard measures for respiratory viruses are recommended- | There are no available [[Vaccine|vaccines]] against COVID-19 as of now, but several vaccines are under development and in trials. Standard measures for respiratory viruses are recommended- | ||
* Use of face masks | * Use of face masks | ||
* Frequent hand hygiene (alcohol-based [[Disinfectant|disinfectants]] or soap and water), | * Frequent hand [[hygiene]] (alcohol-based [[Disinfectant|disinfectants]] or soap and water), | ||
* Travel restrictions | * Travel restrictions | ||
* Social distancing measures | * Social distancing measures | ||
| Line 140: | Line 140: | ||
* Presence of the virus in the stool raises suspicion for [[fecal-oral route|fecal-oral transmission]] of SARS-CoV-2 | * Presence of the virus in the stool raises suspicion for [[fecal-oral route|fecal-oral transmission]] of SARS-CoV-2 | ||
* Appropriate personal protective equipment(PPE) must be used while handling sources of contamination like feces. | * Appropriate personal protective equipment(PPE) must be used while handling sources of contamination like feces. | ||
*[[Elective]] appointments and [[Endoscopy|endoscopies]] should be rescheduled and extreme care must be taken by health care professionals of the endoscopy units to avoid spreading the virus from one patient to another. <ref name="pmid32197957">{{cite journal| author=Ungaro RC, Sullivan T, Colombel JF, Patel G| title=What Should Gastroenterologists and Patients Know About COVID-19? | journal=Clin Gastroenterol Hepatol | year= 2020 | volume= 18 | issue= 7 | pages= 1409-1411 | pmid=32197957 | doi=10.1016/j.cgh.2020.03.020 | pmc=7156804 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32197957 }} </ref> | *[[Elective]] appointments and [[Endoscopy|endoscopies]] should be rescheduled and extreme care must be taken by health care professionals of the [[endoscopy]] units to avoid spreading the virus from one patient to another. <ref name="pmid32197957">{{cite journal| author=Ungaro RC, Sullivan T, Colombel JF, Patel G| title=What Should Gastroenterologists and Patients Know About COVID-19? | journal=Clin Gastroenterol Hepatol | year= 2020 | volume= 18 | issue= 7 | pages= 1409-1411 | pmid=32197957 | doi=10.1016/j.cgh.2020.03.020 | pmc=7156804 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32197957 }} </ref> | ||
* Patients listed for fecal [[Microbiome|microbiota]] transplantation and donors should be screened for the SARS-CoV-2. | * Patients listed for fecal [[Microbiome|microbiota]] transplantation and donors should be screened for the SARS-CoV-2. | ||
Revision as of 17:08, 8 July 2020
For COVID-19 frequently asked inpatient questions, click here
For COVID-19 frequently asked outpatient questions, click here
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COVID-19 Microchapters |
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Diagnosis |
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Treatment |
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Case Studies |
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COVID-19-associated diarrhea On the Web |
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American Roentgen Ray Society Images of COVID-19-associated diarrhea |
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Risk calculators and risk factors for COVID-19-associated diarrhea |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ifrah Fatima, M.B.B.S[2]
Synonyms and keywords:
Overview
SARS-CoV-2 mainly causes severe acute respiratory syndrome but may also present with gastrointestinal symptoms like diarrhea. It invades through the Angiotensin-converting enzyme 2 (ACE2) and the serine protease TMPRSS2 receptors present abundantly not only in the lungs but also in the enterocytes of the small intestine. A greater percentage of occurrence of diarrhea was noted in patients with severe COVID-19 when compared to non-severe disease. Likewise, patients with gastrointestinal symptoms were more likely to have a severe respiratory disease with ARDS requiring ventilatory support. The presence of the virus in the stool raises suspicion for fecal-oral transmission of SARS-CoV-2. Appropriate personal protective equipment(PPE) must be used while handling sources of contamination like feces.
Historical Perspective
- The etiological agent is SARS-CoV-2, named for the similarity of its symptoms to those induced by the severe acute respiratory syndrome, causing coronavirus disease 2019 (COVID-19), is a virus identified as the cause of an outbreak of respiratory illness first detected in Wuhan, China.[1][2]
- The growing number of patients however, suggest that human-to-human transmission is actively occurring.[3][4]
- The outbreak was declared a Public Health Emergency of International Concern on 30 January 2020.
- On March 12, 2020, the World Health Organization declared the COVID-19 outbreak a pandemic.
Classification
There is no established system for the classification of diarrhea in COVID-19
Pathophysiology
- SARS-CoV-2 uses the Angiotensin-converting enzyme 2 (ACE2) and the serine protease TMPRSS2 receptors for cell entry. These receptors are presently abundantly not only in the lungs but also in the enterocytes of the small intestine.[5][6] Other sites of expression of the receptors in the gastrointestinal tract are-the upper esophagus, liver, and colon. [5]
- Entry of the virus causes disruption of the enterocytes and may lead to inflammation and alteration of intestinal permeability.
- COVID- 19 is being treated by a trial of many different antivirals and antibiotics. Diarrhea could also be a result of an alteration of the gut microbiota due to any of these. [7]
Causes
Diarrhea in a patient hospitalized due to COVID-19 may be due to-
- COVID-19 associated diarrhea
- Secondary bacterial infections
- Clostridium difficile diarrhea and recent use of antibiotics
- Other infectious causes
Differentiating COVID-19 associated diarrhea from other Diseases
COVID-19 diarrhea must be differentiated from other diseases that cause diarrhea, such as-
- Secondary bacterial infections
- Clostridium difficile associated diarrhea
- Other causes of diarrhea
Patients with pre-existing chronic GI conditions may also present with flares which need to be differentiated from COVID-19- [8]
Epidemiology and Demographics
- Diarrhea is an uncommon gastrointestinal symptom (anorexia, nausea, and vomiting are more common) in patients with COVID-19 but may be the presenting symptom in a few patients.
- The frequency of occurrence of diarrhea varies between 1%-35%. [9]It varies widely between different studies probably due to the different criteria used to define diarrhea.
- Greater percentage of occurrence of diarrhea was noted in patients with severe COVID-19 when compared to non-severe disease.
- Likewise, patients with gastrointenstinal symptoms were more likely to have severe respiratory disease with ARDS requiring ventilatory support. [10] [11]
There is no data on predilection based on age, gender, geographical location, or race.
Risk Factors
Some gastrointestinal factors may predispose patients to infection with COVID-19.
- Inflammatory bowel disease patients- due to use to glucocorticoids, but not TNF-alpha inhibitors [12]
- Increasing age
- Other comorbidities
- Use of glucocorticoids
Screening
There is insufficient evidence to recommend routine screening.
Natural History, Complications, and Prognosis
- Greater percentage of occurrence of diarrhea was noted in patients with severe COVID-19 when compared to non-severe disease.
- Likewise, patients with gastrointenstinal symptoms were more likely to have severe respiratory disease with ARDS requiring ventilatory support. [10] [11]
Diagnosis
Diagnostic Study of Choice
- COVID-19 diarrhea can be diagnosed based on the history of diarrhea and a positive stool test for SARS-CoV-2
- There are no established criteria for the diagnosis of diarrhea in COVID-19.
History and Symptoms
- According to Jin et al[10], the definition of diarrhea was the passing of loose stools >3 times per day.
- According to this study, 8.1% had diarrhea at onset and the symptoms lasted for approximately 4 days.
- The duration of diarrhea ranged from 2-4 days with 3-8 bowel movements per day, according to various studies. [13][14]
- There is not enough data from other studies on the number of evacuations, consistency of stool, and duration of symptoms.
Physical Examination
Patients with diarrhea due to COVID-19 usually appear very sick, since diarrhea is seen in a greater percentage of patients with severe respiratory disease than non-severe disease. [11]
Physical examination due to diarrhea may be remarkable for
- Weak, low volume pulse
- Hypotension
- Sunken eyes
- Decreased skin turgor
Laboratory Findings
- Infectious virions released from the GI tract can be monitored by real-time reverse transcriptase polymerase chain reaction (rRT-PCR)
- A study by Xiao et al assessed the clinical significance of measuring SARS-CoV-2 RNA in the feces. [15]
- The fecal test remained positive until 12 days after the disease onset in patients with diarrhea.
- Notably, stool test for viral RNA remained positive despite negative respiratory tests. This suggests the possibility of gastrointestinal transmission via the fecal-oral route despite clearance from the respiratory tract.
- It was recommended transmission-based precautions for hospitalized COVID-19 patients should be continued till the rRT-PCR for SARS-CoV-2 turns negative.
Electrocardiogram
- Tachycardia may be seen in a patient who is volume depleted due to diarrhea.
X-ray
- The chest x ray findings in a suspected case of coronavirus infection can mimic the findings in pneumonia, which can include:
Echocardiography or Ultrasound
There are no echocardiography/ultrasound findings associated with diarrhea in COVID-19.
CT scan
There are no CT scan findings associated with diarrhea in COVID-19
MRI
There are no MRI findings associated with diarrhea in COVID-19
Other Imaging Findings
There are no other imaging findings associated with diarrhea in COVID-19.
Other Diagnostic Studies
There are no other diagnostic studies associated with diarrhea in COVID-19.
Treatment
Medical Therapy
- Supportive management is the mainstay of treatment.
- Rehydration, fluid repletion, and potassium monitoring are essential.
- Use of probiotics may have a role if the diarrhea is being caused by alteration of the gut microbiome. This could also be potentially useful in preventing secondary bacterial infections by restoring the gut microbiota. [7]
Primary Prevention
There are no available vaccines against COVID-19 as of now, but several vaccines are under development and in trials. Standard measures for respiratory viruses are recommended-
- Use of face masks
- Frequent hand hygiene (alcohol-based disinfectants or soap and water),
- Travel restrictions
- Social distancing measures
- Avoiding contact with infected patients
Prevention of transmission through gastrointenstinal tract
- Presence of the virus in the stool raises suspicion for fecal-oral transmission of SARS-CoV-2
- Appropriate personal protective equipment(PPE) must be used while handling sources of contamination like feces.
- Elective appointments and endoscopies should be rescheduled and extreme care must be taken by health care professionals of the endoscopy units to avoid spreading the virus from one patient to another. [17]
- Patients listed for fecal microbiota transplantation and donors should be screened for the SARS-CoV-2.
References
- ↑ https://www.cdc.gov/coronavirus/2019-ncov/about/index.html. Missing or empty
|title=(help) - ↑ Lu, Jian; Cui, Jie; Qian, Zhaohui; Wang, Yirong; Zhang, Hong; Duan, Yuange; Wu, Xinkai; Yao, Xinmin; Song, Yuhe; Li, Xiang; Wu, Changcheng; Tang, Xiaolu (2020). "On the origin and continuing evolution of SARS-CoV-2". National Science Review. doi:10.1093/nsr/nwaa036. ISSN 2095-5138.
- ↑ Huang, Chaolin; Wang, Yeming; Li, Xingwang; Ren, Lili; Zhao, Jianping; Hu, Yi; Zhang, Li; Fan, Guohui; Xu, Jiuyang; Gu, Xiaoying; Cheng, Zhenshun; Yu, Ting; Xia, Jiaan; Wei, Yuan; Wu, Wenjuan; Xie, Xuelei; Yin, Wen; Li, Hui; Liu, Min; Xiao, Yan; Gao, Hong; Guo, Li; Xie, Jungang; Wang, Guangfa; Jiang, Rongmeng; Gao, Zhancheng; Jin, Qi; Wang, Jianwei; Cao, Bin (2020). "Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China". The Lancet. 395 (10223): 497–506. doi:10.1016/S0140-6736(20)30183-5. ISSN 0140-6736.
- ↑ https://www.cdc.gov/coronavirus/2019-ncov/about/transmission.html. Missing or empty
|title=(help) - ↑ 5.0 5.1 D'Amico F, Baumgart DC, Danese S, Peyrin-Biroulet L (2020). "Diarrhea During COVID-19 Infection: Pathogenesis, Epidemiology, Prevention, and Management". Clin Gastroenterol Hepatol. doi:10.1016/j.cgh.2020.04.001. PMC 7141637 Check
|pmc=value (help). PMID 32278065 Check|pmid=value (help). - ↑ Liang W, Feng Z, Rao S, Xiao C, Xue X, Lin Z; et al. (2020). "Diarrhoea may be underestimated: a missing link in 2019 novel coronavirus". Gut. 69 (6): 1141–1143. doi:10.1136/gutjnl-2020-320832. PMID 32102928 Check
|pmid=value (help). - ↑ 7.0 7.1 Gao QY, Chen YX, Fang JY (2020). "2019 Novel coronavirus infection and gastrointestinal tract". J Dig Dis. 21 (3): 125–126. doi:10.1111/1751-2980.12851. PMC 7162053 Check
|pmc=value (help). PMID 32096611 Check|pmid=value (help). - ↑ Occhipinti V, Pastorelli L (2020). "Challenges in the Care of IBD Patients During the CoViD-19 Pandemic: Report From a "Red Zone" Area in Northern Italy". Inflamm Bowel Dis. 26 (6): 793–796. doi:10.1093/ibd/izaa084. PMC 7188155 Check
|pmc=value (help). PMID 32314792 Check|pmid=value (help). - ↑ Li XY, Dai WJ, Wu SN, Yang XZ, Wang HG (2020). "The occurrence of diarrhea in COVID-19 patients". Clin Res Hepatol Gastroenterol. doi:10.1016/j.clinre.2020.03.017. PMC 7270575 Check
|pmc=value (help). PMID 32253163 Check|pmid=value (help). - ↑ 10.0 10.1 10.2 Jin X, Lian JS, Hu JH, Gao J, Zheng L, Zhang YM; et al. (2020). "Epidemiological, clinical and virological characteristics of 74 cases of coronavirus-infected disease 2019 (COVID-19) with gastrointestinal symptoms". Gut. 69 (6): 1002–1009. doi:10.1136/gutjnl-2020-320926. PMC 7133387 Check
|pmc=value (help). PMID 32213556 Check|pmid=value (help). - ↑ 11.0 11.1 11.2 Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX; et al. (2020). "Clinical Characteristics of Coronavirus Disease 2019 in China". N Engl J Med. 382 (18): 1708–1720. doi:10.1056/NEJMoa2002032. PMC 7092819 Check
|pmc=value (help). PMID 32109013 Check|pmid=value (help). - ↑ Brenner EJ, Ungaro RC, Gearry RB, Kaplan GG, Kissous-Hunt M, Lewis JD; et al. (2020). "Corticosteroids, but not TNF Antagonists, are Associated with Adverse COVID-19 Outcomes in Patients With Inflammatory Bowel Diseases: Results from an International Registry". Gastroenterology. doi:10.1053/j.gastro.2020.05.032. PMC 7233252 Check
|pmc=value (help). PMID 32425234 Check|pmid=value (help). - ↑ Song Y, Liu P, Shi XL, Chu YL, Zhang J, Xia J; et al. (2020). "SARS-CoV-2 induced diarrhoea as onset symptom in patient with COVID-19". Gut. 69 (6): 1143–1144. doi:10.1136/gutjnl-2020-320891. PMID 32139552 Check
|pmid=value (help). - ↑ Chan JF, Yuan S, Kok KH, To KK, Chu H, Yang J; et al. (2020). "A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster". Lancet. 395 (10223): 514–523. doi:10.1016/S0140-6736(20)30154-9. PMC 7159286 Check
|pmc=value (help). PMID 31986261. - ↑ Xiao F, Tang M, Zheng X, Liu Y, Li X, Shan H (2020). "Evidence for Gastrointestinal Infection of SARS-CoV-2". Gastroenterology. 158 (6): 1831–1833.e3. doi:10.1053/j.gastro.2020.02.055. PMC 7130181 Check
|pmc=value (help). PMID 32142773 Check|pmid=value (help). - ↑ Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, Cheng Z, Yu T, Xia J, Wei Y, Wu W, Xie X, Yin W, Li H, Liu M, Xiao Y, Gao H, Guo L, Xie J, Wang G, Jiang R, Gao Z, Jin Q, Wang J, Cao B (January 2020). "Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China". Lancet. doi:10.1016/S0140-6736(20)30183-5. PMID 31986264.
- ↑ Ungaro RC, Sullivan T, Colombel JF, Patel G (2020). "What Should Gastroenterologists and Patients Know About COVID-19?". Clin Gastroenterol Hepatol. 18 (7): 1409–1411. doi:10.1016/j.cgh.2020.03.020. PMC 7156804 Check
|pmc=value (help). PMID 32197957 Check|pmid=value (help).