COVID-19-associated nausea and vomiting

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Main article: COVID-19

For COVID-19 frequently asked inpatient questions, click here

For COVID-19 frequently asked outpatient questions, click here
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. Nausea and vomiting are the less common gastrointestinal symptoms associated with COVID-19. Anorexia and diarrhea are more common.

Historical Perspective

Classification

There is no established system for the classification of nausea and vomiting in COVID-19.

Pathophysiology

Causes

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Differentiating COVID-19 associated nausea and vomiting from other Diseases

COVID-19 associated nausea and vomiting must be differentiated from other diseases that cause nausea and vomiting in a hospitalized patient inlclude:

Epidemiology and Demographics

Risk Factors

Some gastrointestinal factors may predispose patients to infection with COVID-19. Common risk factors in the development of nausea and vomiting include:[10]

Screening

  • There is insufficient evidence to recommend routine screening.

Natural History, Complications, and Prognosis

Diagnosis

Diagnostic Study of Choice

  • COVID-19 nausea and vomiting can be diagnosed based on the history of gastrointestinal symptoms like anorexia, diarrhea and a positive stool test for SARS-CoV-2
  • There are no established criteria for the diagnosis of nausea and vomiting in COVID-19.

History and Symptoms

Physical Examination

Patients with gastrointestinal symptoms of COVID-19 usually appear listless. Physical examination of patients is non-specific.

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. The fecal test remained positive until 12 days after the disease onset in patients with diarrhea.[11]
  • 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

There are no ECG findings associated with nausea and vomiting in patients with COVID-19.

X-ray

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with nausea and vomiting in COVID-19.

CT scan

There are no CT scan findings associated with nausea and vomiting in COVID-19.

MRI

There are no MRI findings associated with nausea and vomiting in COVID-19.

Other Imaging Findings

There are no other imaging findings associated with nausea and vomiting in COVID-19.

Other Diagnostic Studies

There are no other diagnostic studies associated with nausea and vomiting in COVID-19.

Treatment

Medical Therapy

Primary Prevention

  • Effective measures for the primary prevention of COVID-19 include:[13]
    • 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 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.[14]

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. [15]
  • Patients listed for fecal microbiota transplantation and donors should be screened for the SARS-CoV-2.

Secondary prevention

References

  1. https://www.cdc.gov/coronavirus/2019-ncov/about/index.html. Missing or empty |title= (help)
  2. 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.
  3. 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.
  4. https://www.cdc.gov/coronavirus/2019-ncov/about/transmission.html. Missing or empty |title= (help)
  5. 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).
  6. 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. Wahba L, Jain N, Fire AZ, Shoura MJ, Artiles KL, McCoy MJ; et al. (2020). "An Extensive Meta-Metagenomic Search Identifies SARS-CoV-2-Homologous Sequences in Pangolin Lung Viromes". mSphere. 5 (3). doi:10.1128/mSphere.00160-20. PMC 7203451 Check |pmc= value (help). PMID 32376697 Check |pmid= value (help).
  8. 8.0 8.1 Redd WD, Zhou JC, Hathorn KE, McCarty TR, Bazarbashi AN, Thompson CC; et al. (2020). "Prevalence and Characteristics of Gastrointestinal Symptoms in Patients with SARS-CoV-2 Infection in the United States: A Multicenter Cohort Study". Gastroenterology. doi:10.1053/j.gastro.2020.04.045. PMC 7195377 Check |pmc= value (help). PMID 32333911 Check |pmid= value (help).
  9. 9.0 9.1 Luo S, Zhang X, Xu H (2020). "Don't Overlook Digestive Symptoms in Patients With 2019 Novel Coronavirus Disease (COVID-19)". Clin Gastroenterol Hepatol. 18 (7): 1636–1637. doi:10.1016/j.cgh.2020.03.043. PMC 7154217 Check |pmc= value (help). PMID 32205220 Check |pmid= value (help).
  10. 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).
  11. 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).
  12. 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.
  13. "How to Protect Yourself & Others | CDC".
  14. "NIH clinical trial of investigational vaccine for COVID-19 begins | National Institutes of Health (NIH)".
  15. 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).
  16. 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).
  17. "Contact Tracing for COVID-19 | CDC".