COVID-19-associated abdominal pain

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Javaria Anwer M.D.[2]

Synonyms and Keywords: COVID-19 associated abdominal pain, COVID associated abdominal pain, COVID linked abdominal pain, COVID-19 linked abdominal pain, coronavirus associated abdominal pain, coronavirus related belly pain, abdominal pain associated with COVID-19, abdominal pain associated with SARS CoV2, SARS CoV2 related abdominal pain, SARS CoV2 linked abdomin pain, abdominal pain and COVID-19, abdominal pain and SARS CoV2 ,abdominal pain in COVID, abdomin pain in COVID, abdominal pain in nCoV, abdominal discomfort in COVID-19, abdominal discomfort in SARS CoV2.

Overview

Abdominal pain is a common symptom and may present a challenge to differentiate potential diagnoses. Although COVID-19 is mainly a respiratory disease, abdominal pain is one of the symptoms of COVID-19 infection. Abdominal pain may be due to direct injury of an involved abdominal organ or merely one of the symptoms of COVID-19. A potential explanation for abdominal pain in COVID-19 is the presence of cellular ACE 2 in esophagus, ileum, colon and cholangiocytes. Patients may present with global, epigastric, ileac fossa or epigastric pain. Cases of abdominal pain associated with COVID-19 infection may present as acute appendicitis, acute pancreatitis, upper GI bleed, or gut perforation. In an unexplained abdominal pain it is important to suspect coronavirus-19 infection and take nasopharyngeal RT-PCR or CXR or chest CT as positive COVID-19 findings of these tests have been demonstrated among patients presenting with abdominal symptoms. Abdominal scans may show signs of mucosal inflammation. Contact tracing is an important secondary prevention step.

Historical Perspective

Classification

There is no established system for the classification of abdominal pain in COVID-19. But a differentiation can be made based on the organ injury related to COVID-19 causing abdominal pain.

Pathophysiology


Causes

Differentiating COVID-19 associated abdominal pain from other Diseases

  • For further information regarding the differential diagnosis, click here.
  • To view the differential diagnosis of COVID-19, click here

Epidemiology and Demographics

  • The Weighted Pooled Prevalence (WPP) of COVID-19 associated abdominal pain is approximately 6.2% (2.6%-10.3%). The information is based upon the systematic review and meta-analysis including 78 observational studies (from Dec 2019 to May 7th, 2020).[22]
  • The pooled prevalence of COVID-19 associated abdominal pain/ abdominal discomfort in Hong Kong is approximately 9.2%. The information is presented in a meta-analysis from the cohort of COVID-19 patients from Hong Kong (N = 59, from February 2 through February 29, 2020). 25% of the patients had GI symptoms associated with COVID-19. [23]

Age

  • COVID-19 associated abdominal pain is more commonly observed among middle-aged patients according to the limited data available.
  • One retrospective observational study from Oslo, Norway (patient population= 9) demonstrating patients with COVID-19 presenting with acute abdominal pain as their main symptom, reported a mean age of 48 years.[21]
  • Another retrospective observational study from Wuhan, China (1,141 patients) demonstrated the average age of COVID-19 patients having abdominal pain as one of their symptoms to be 53 years.[24]
  • A meta-analysis from the cohort of COVID-19 patients from Hong Kong (N = 59, from February 2 through February 29, 2020) the medial age was 58.5 years.[23]

Gender

  • COVID-19 associated abdominal pain as one of the symptoms of COVID-19 was more commonly observed in males (56%) according to a retrospective observational study from Wuhan, China (1141 patients).[24]

Race

  • Non-Chinese individuals are more likely to develop COVID-19 associated abdominal pain according to a systematic review and meta-analysis of observational studies on 12,797 patients. The information is based upon the higher weighted pooled prevalence of abdominal pain associated with COVID-19 among non-Chinese subgroup and compared to Chinese subgroup.[22]

Risk Factors

Screening

There is insufficient evidence to recommend routine screening for COVID-19 associated abdominal pain.

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Criteria

History and Symptoms

Physical Examination

Physical examination may be remarkable for:

Laboratory Findings

Electrocardiogram

  • There are no ECG findings associated with COVID-19 associated abdominal pain.
  • Studies suggest that up to 50% of the hospitalized acute pancreatitis patients have non-specific ST–T segment changes on ECG. The changes that have been described include diffuse T-wave inversions (V4 - V6), ST-segment elevation of 2 mm, peaked upright T waves (V1 - V3) along with reciprocal changes in lead II and bizarre T waves in the limb leads.[41][42] COVID-19 associated acute pancreatitis has not been shown to demonstrate ECG abnormalities in the case reports.
  • The electrocardiogram findings in COVID-19 can be viewed by clicking here.

X-ray

Echocardiography or Ultrasound

CT scan

Sagital lung view on a CT scan. Pneumonia in a COVID-19 patient presenting with just fever and right iliac fossa pain. Bilateral multifocal peripheral ill-defined ground-glass opacities with basal and posterior predominance, associated with few subpleural atelectatic bands - Case courtesy of Dr Ahmed Samir, Radiopaedia.org, rID: 76604


MRI

Other Imaging Findings

In a case series, based on their experience, Poggiali et al. strongly recommend bedside lung ultrasound to detect the signs of respiratory COVID-19 infection even when there are no respiratory symptoms.[33]

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary prevention

Effective measures for the secondary prevention of COVID-19 associated abdominal pain include the following:

  • Contact tracing helps reduce the spread of the disease.[49]
  • In an unexplained abdominal pain, CXR, Chest CT scan or nasopharyngeal swab RT-PCR should be performed to diagnose the infection and treat it timely.
  • The guidelines issued by the Chinese IBD Society include postponing elective surgery and endoscopy.[27]
  • Compliance with tertiary protection regulations even for emergency surgery has been practiced and recommended. It requires all involved medical personnel to wear full PPE (that includes N95 masks, respirators, double gloves, eye protection, visors, caps, shoes, and body protection coveralls or gowns).[15]Protective eyewear (such as goggles or a face shield) used by healthcare personnel should cover the front and sides of the face with no gaps between glasses and the face.[50].
  • If a patient with IBDs takes ⩾20 mg/day of prednisone, they should reduce the dose or taper the dose to discontinue to prevent COVID-19 infection. In case of positive test for COVID-19 infection, drug should be tapered to discontinue.[25]
  • For the prevention of transmission through gastrointestinal tract (presence of viral RNA in the stool raise suspicion for fecal-oral transmission)

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