COVID-19-associated diarrhea: Difference between revisions
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*[[Autoimmune hepatitis]] | *[[Autoimmune hepatitis]] | ||
To review the differential diagnosis of diarrhea due to various organisms, click here. | |||
To review the differential diagnosis of diarrhea, click [[Diarrhea#Differential Diagnosis of Diarrhea of other diseases|here]]. | |||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
*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. | *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. | ||
Revision as of 21:52, 20 July 2020
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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:[8]
- Secondary bacterial infections
- Clostridium difficile associated diarrhea
- Viral causes
- Parasitic causes
To review the differential diagnosis of diarrhea due to various organisms, click here. To review the differential diagnosis of diarrhea, click here.
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
Common risk factors in the development of gastrointestinal symptoms in patients with COVID-19 infection include:
- Inflammatory bowel disease patients- due to use to glucocorticoids, but not TNF-alpha inhibitors [12]
- Increasing age
- Other comorbidities such as HTN, DM
- Use of glucocorticoids
Screening
- There is insufficient evidence to recommend routine screening in detecting covid associated diarrhea.
Natural History, Complications, and Prognosis
- Presence of diarrheal symptoms in covid-19 infection is associated with severe form of disease.
- Severe or poor prognostic form of disease can be described as 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
- Diarrhea can be defined as passing of >3 loose stools per day.[10]
- Diarrhea was the primary symptom at the onset of covid-19 infection 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
Laboratory findings consistent with the diagnosis of covid-19 associated diarrhea include complete blood count, glucose levels, white blood cells (WBC) detection, urine analysis, calcium levels, Thyroid stimulating hormone (TSH) levels, complete metabolic panel and stool examination.
- Stool examination includes the following:
- Stool culture
- Stool electrolytes
- Stool osmolality
- Ova and parasites
- Fecal lactoferrin
- Fecal leukocytes
Electrocardiogram
- An ECG may be helpful in the diagnosis of covd-19 associated diarrhea. Findings on an ECG suggestive of diarrhea include sinus tachycardia.
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
- Abdominal CT scan may be helpful in the diagnosis of covid-19 associated diarrhea.
- Findings on CT scan suggestive of diarrhea associated with covid-19 infection include peri-intestinal inflammatory reaction.[16]
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
Other diagnostic studies for covid-19 associated diarrhea include:
- 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. [17]
- 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.
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
- Effective measures for the primary prevention of COVID-19 include::[18]
- Frequent handwashing with soap and water for at least 20 seconds or using a alcohol based hand sanitizer with at least 60% alcohol
- Staying at least 6 feet (about 2 arms’ length) from other people who do not live with you
- Covering your mouth and nose with a cloth face cover when around others and covering sneezes and coughs
- Cleaning and disinfecting
- There have been rigorous efforts in order to develop a vaccine for novel coronavirus and several vaccines are in the later phases of trials.[19]
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. [20]
- Patients listed for fecal microbiota transplantation and donors should be screened for the SARS-CoV-2.
Secondary prevention
- Effective measures for the secondary prevention of COVID-19 include:
- Use of personal protective equipment (PPE) by the personnel handling the fecal matter.
- Screening of fecal microbiota transplant donors for COVID-19 is also recommended.[21]
- Contact tracing helps reduce the spread of the disease.[22]
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. - ↑ 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.
- ↑ Poggiali E, Ramos PM, Bastoni D, Vercelli A, Magnacavallo A (2020). "Abdominal Pain: A Real Challenge in Novel COVID-19 Infection". Eur J Case Rep Intern Med. 7 (4): 001632. doi:10.12890/2020_001632. PMC 7162568 Check
|pmc=value (help). PMID 32309266 Check|pmid=value (help). - ↑ 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). - ↑ "How to Protect Yourself & Others | CDC".
- ↑ "NIH clinical trial of investigational vaccine for COVID-19 begins | National Institutes of Health (NIH)".
- ↑ 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). - ↑ Green CA, Quraishi MN, Shabir S, Sharma N, Hansen R, Gaya DR, Hart AL, Loman NJ, Iqbal TH (June 2020). "Screening faecal microbiota transplant donors for SARS-CoV-2 by molecular testing of stool is the safest way forward". Lancet Gastroenterol Hepatol. 5 (6): 531. doi:10.1016/S2468-1253(20)30089-3. PMC 7225406 Check
|pmc=value (help). PMID 32240618 Check|pmid=value (help). - ↑ "Contact Tracing for COVID-19 | CDC".