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Latest revision as of 15:55, 11 September 2020

For COVID-19 frequently asked outpatient questions, click here
For COVID-19 frequently asked inpatient questions, click here

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 loss of appetite, COVID-19 and hunger, appetite and COVID-19, loss of appetite in COVID, COVID and hunger, SARS-Cov-2 associated anorexia, SARS-Cov-2 associated loss of appetite, SARS CoV2 and hunger, Coronavirus and hunger, appetite and COVID-19, covid19 associated anorexia.

Overview

COVID-19 is primarily known to be a respiratory disease. Anorexia associated with COVID-19 is the most common digestive symptom among patients with COVID-19. The exact mechanism of loss of appetite associated with the infection is unknown, but the symptom may be due to various causes. Several diseases share loss of appetite symptom, so it is important to suspect COVID-19 and perform RT-PCR to detect the infection or CXR to detect possible lung manifestations. Patients with loss of appetite may present with associated symptoms such as nausea or vomiting and diarrhea. The mainstay of treatment in COVID-19 infection is supportive therapy and antiviral therapy. Hand hygiene and social distancing are important primary prevention tools. Contact tracing is an important tool of secondary prevention.

Historical Perspective

COVID-19 was first discovered in Wuhan, China. On 30th December 2019, three bronchoalveolar lavage samples were collected from a patient with pneumonia of unknown etiology – a surveillance definition established following the SARS outbreak of 2002-2003 – in Wuhan Jinyintan Hospital. Real-time PCR (RT-PCR) assays on these samples were positive for pan-Betacoronavirus.^[1]
Nanopore sequencing and bioinformatic analyses indicated that the virus had features typical of the coronavirus family and belonged to the Betacoronavirus 2B lineage.^[1]
COVID-19 was primarily known as a respiratory disease. In the initial reports from the World Health Organization (WHO), the mode of transmission of COVID-19 was reported to spread through droplets and fomites during close unprotected contact between an infector and an infectee. Airborne transmission was not reported initially.
Fecal shedding was demonstrated from patients, with viable virus identified in a limited number of case reports. However, fecal-oral route did not appear to drive COVID-19 transmission.^[1]^[2]
COVID-19 associated anorexia was first described as one of the less common symptoms of COVID-19 in a retrospective, single-center case series by Wang D et al. published on Feb 7th, 2020. The patient data was derived from January 1st-Jan 28th,2020 at Zhongnan Hospital in Wuhan, China.^[3]
COVID-19 associated anorexia was not only described as one of the common symptoms at the illness onset, it was reported to be more common among ICU patients.^[3]
On March 11th, 2020, WHO declared the COVID-19 outbreak a pandemic.^[4]
With the increasing evidence and ongoing research, anorexia associated with COVID-19 is now reported to be a common symptom among patients with COVID-19, and the viral infection is suspected in a patient presenting with anorexia along with other gastrointestinal symptoms.

Classification

There is no established system for the classification of anorexia in COVID-19.

Pathophysiology

The exact mechanism through which anorexia develops in COVID-19 is yet to be completely understood. The possible mechanism of anorexia in COVID-19, which is also a general response to infection is as follows:
- The relationship of the sense of taste and appetite along with the prevalence of gustatory system dysfunction in mild-moderate COVID-19 cases partly explains anorexia in COVID-19. In addition, olfactory dysfunction contributes to loss of appetite.^[5]
- According to another proposed mechanism of development of anorexia in infection, the microbial products set off the development of acute phase proteins such as cytokines (Interleukin and TNF alpha) during an infection. The acute phase proteins are known to cause anorexia. Cytokines that are locally released activate the peripheral sensory fibers causing loss of appetite. The direct effect of cytokines and microbial products on the CNS (the center of appetite) is also involved in the development of anorexia during infection.^[6]^[7] Studies have reported several pro-inflammatory cytokines and chemokines, particularly CXCL10, CXCL8, CCL2, TNFα and IFNγ to be higher in the plasma of COVID-19 patients.^[8] A relationship of cytokines and COVID-19 infection has been established.^[9]
- The detection of viral nucleocapsid protein in gastrointestinal epithelial cells and viral RNA in fecal specimens reflects the infectivity and chance of direct cytokine or chemokine response.^[10]
- The association between increased brain tryptophan availability in patients with chronic liver disease and anorexia partially explains the mechanism of anorexia in COVID-19-associated hepatic injury.^[11]

Causes

COVID-19 associated anorexia may be classified according to the COVID-19 associated entity causing the symptom:

COVID-19-associated hepatic injury^[11]
Underlying conditions such as cancer^[12]
Medications administered to treat the COVID-19 infection such as remdesivir^[13], favipiravir and chloroquine or hydroxychloroquine (anorexia is a common side effect for the three drugs mentioned)^[14]
COVID-19 associated pancreatitis^[15]
Superimposed bacterial infections^[6]^[7]
Stress associated with the COVID-19 infection itself^[16]^[17]

Differentiating COVID-19 associated anorexia 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

According to WHO the prevalence of anorexia associated with COVID-19 is 40-84%.^[18]
The pooled prevalence of COVID-19 associated anorexia is 21% according to a systematic review and meta-analysis based on the studies worldwide published between January 1st, 2020, and April 4th, 2020.^[19]
The pooled prevalence of COVID-19 associated anorexia in Hong Kong is approximately 26.8%. 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.^[20]
According to recent reviews and meta-analyses of COVID-19, patients from different parts of the world (China, Hong Kong) anorexia is the most common (40-84%) digestive symptoms associated with COVID-19.^[21]^[19]^[20]
A retrospective study from Wuhna, China describing 1,141 cases of COVID-19 reported loss of appetite in 98% patients (n=180). Anorexia was the most common presenting symptom among all GI symptoms of COVID-19.^[22]

Age

There is insufficient data to support an age group that is affected to a greater extent from COVID-19 associated anorexia.

Gender

Men more commonly presented with GI symptoms with anorexia being the most common symptom in Wuhan, China according to a retrospective study involving 1,141 cases of COVID-19.^[22]

Race

There is no racial predilection for COVID-19 associated anorexia according to a systematic review and meta-analysis of observational studies on 12,797 patients. The meta-analysis compared Chinese race (Chinese group) from all other races (non-Chinese group) as the data from China makes a major part of COVID-19 related literature.^[23]

Risk Factors

The most potent risk factor for the development of anorexia associated with COVID-19 is the infection COVID-19 itself.
Other risk factors involved in the process COVID-19 infected people presenting with anorexia have yet to be understood.

Natural History, Complications and Prognosis

The majority of COVID-19 patients develop anorexia associated with COVID-19 during hospitalization. Anorexia as an initial presentation is observed among minority of patients.^[24]
In a retrospective, single-center case series, 66.7% (n=24) of the patients treated in the ICU had anorexia versus 30.4% (n=31) who were not treated in the ICU. The data comprised of 138 hospitalized patients with confirmed COVID-19 associated pneumonia in Wuhan, China, from January 1st to January 28, 2020.^[3]
Approximately 3% of COVID-19 cases present with mere digestive symptoms and no respiratory symptoms. The observation is based upon a descriptive cross-sectional multi-center study from China.^[25]
Prognosis is variable and depends upon multiple factors. The odds of having a severe disease among patients with COVID-19 associated anorexia as one of the gastrointestinal symptoms are 2.83.^[26] *As a complication, prolonged anorexia with no supplementation may lead to hypotension, and electrolyte imbalances.

Diagnosis

Diagnostic Study of Choice

There are no established criteria to identify the cause of COVID-19 associated loss of appetite/ anorexia. COVID-19 associated anorexia/ loss of appetite is a symptom, not a disease. Anorexia may be a symptom of direct injury of an involved abdominal organ or merely one of the symptoms of COVID-19.
COVID-19 anorexia can be diagnosed based on the history, timing of the symptoms, associated symptoms and signs such as abdominal pain, nausea or vomiting (2nd and third most common symptoms) and most importantly, a positive reverse transcriptase polymerase chain reaction (rRT-PCR) for COVID-19.

History and Symptoms

History of contact with a person suspected or confirmed to have COVID-19 infection is important to suspect COVID-19 in a patient.
Anorexia is itself a symptom. Based on a retrospective observational study including 1,141 cases of COVID-19 from Wuhan, China anorexia was the most common gastrointestinal symptom of COVID-19.^[22]
The most common accompanying symptoms of COVID-19 besides anorexia were nausea, vomiting, and diarrhea.^[26]
The timing of symptoms and presence of co-morbid conditions helps differentiate the diseases with similar symptoms.

Physical Examination

Patients with COVID-19 associated anorexia may appear lethargic, fatigued or irritable. Signs of dehydration include sunken eyes and dry mucosa.

Physical examination may be remarkable for:

Vital signs:^[27]^[28]^[28]^[29]
- Heart rate/Pulse: Tachycardia may be due to fever, pain or shock. A low volume pulse is observed in severe dehydration.
- Blood pressure: Depending upon the cause of anorexia a patient with mild disease may have a normal blood pressure and others may present with shock due to infection and resulting sepsis.
- Respiratory rate: Tachypnea maybe due to high metabolic rate such as in fever and sepsis due to COVID-19 along with inefficient ventilation. Inefficient ventilation can be due to COVID-19 lung infection such as pneumonia or ARDS. Shallow breathing can be due to severe respiratory distress or associated severe abdominal pain.
- Temperature: The patient can be febrile due to COVID-19 infection, hypothermic, or have a normal temperature.
On Abdominal exam:^[30]^[31]^[32]^[15]
- Inspection: A patient with COVID-19-associated hepatic injury causing anorexia may have jaundice. (Jaundice may be observed in DILI associated with COVID-19).
- Auscultation: Accompanying gastrointestinal infection may present as increased bowel sounds due to enteritis.
- Palpation: Based on a few case reports generalized abdominal or epigastric tenderness or right iliac fossa tenderness may accompany the symptom mimicking acute appendicitis.
- Percussion: COVID-19-associated hepatic injury presenting as ascites may show a dull percussion note or shifting dullness.
Respiratory exam:
- A COVID-19 positive patient may have pulmonary manifestations depicting pneumonia or ARDS.
The physical exam findings associated with COVID-19 can be viewed by clicking here.

Laboratory Findings

There are no specific laboratory findings associated with anorexia among COVID-19 patients.
Laboratory findings consistent with the presence of infectious virions in the GI or respiratory tract detected via reverse transcriptase-polymerase chain reaction (rRT-PCR) indicate a possible direct viral infectivity of the respective organ.^[33]
Serum electrolytes: Hypokalemia is associated with anorexia, diarrhea and vomiting. Retrospective studies from Italy and China demonstrated an association between hypokalemia, hypomagnesemia and COVID-19 due to degradation of ACE 2 loss, diuretic and corticosteroid use. Hypokalemia may lead to life-threatening arrhythmias. Close monitoring of serum electrolyte levels is essential especially in ICU patients.^[34]^[35]
Complete blood count: Provides information regarding the infectious status of the patient via leukocytosis such as in COVID-19 itself. In CBC increased Hb due to hemoconcentration if dehydration accompanies.
Serum amylase and lipase: Elevated serum levels demonstrate pancreatitis.^[36]
CRP and procalcitonin: The value provides information on the inflammation and superimposed bacterial source of infection.^[28] A case of COVID-19 presenting as acute pancreatitis reports elevated procalcitonin.^[37]
Liver function tests: Biochemical markers of liver injury such as bilirubin, CRP, ALT, AST and Gamma GT may be elevated in blood tests depicting liver injury.^[28] A meta-analysis found a higher risk of raised ALT and AST among patients with severe COVID-19.^[19]

Electrocardiogram

There are no ECG findings associated with COVID-19 associated anorexia.
The electrocardiogram findings in COVID-19 can be viewed by clicking here.

X-ray

Among patients with COVID-19 associated GI symptoms with anorexia as one of the symptoms, abdominal Xrays have been reported to be normal in the few studies available.^[15]^[32]
A Chest X-ray in a COVID-19 patient may be normal or show patchy or diffuse reticular–nodular opacification and consolidation with basal and peripheral predominance bilaterally. Bilateral perihilar and interstitial opacities with air bronchograms have also been reported. These X-ray findings depict pulmonary disease COVID-19.^[38]
The signs are not related to anorexia directly. COVID-19 being primarily a pulmonary disease, the findings may serve as important tools to help strongly suspect COVID-19 even in the absence of RT PCR. A retrospective non-peer reviewed study reports the sensitivity of CXR to be 68% in detecting lung manifestations of COVID-19.^[38]
The x-ray findings in COVID-19 can be viewed by clicking here.

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with COVID-19 associated anorexia.
The echocardiographic findings in COVID-19 can be viewed by clicking here.

CT scan

Abdominal CT scan may be helpful in finding the cause of COVID-19 associated anorexia.
Findings on CT scan suggestive of gastrointestinal symptoms (anorexia one of them) associated with COVID-19 infection include peri-intestinal inflammatory reaction.^[28]
The CT scan findings in COVID-19 can be viewed by clicking here.

MRI

There are no MRI findings associated with COVID-19 associated anorexia.
The MRI findings in COVID-19 can be viewed by clicking here.

Other Imaging Findings

Bedside lung ultrasound may be helpful in the diagnosis of COVID-19 infection.
Other Imaging findings in bedside lung ultrasound to detect the signs of respiratory COVID-19 infection even when there are no respiratory symptoms.^[28]

Treatment

Medical Therapy

The mainstay of therapy for COVID-19 associated anorexia is treating the cause. Anorexia may be due to direct injury of an involved abdominal organ or merely one of the symptoms of COVID-19. The recommended medical therapy is based on expert opinion rather than randomized control trials.
Antiviral therapy for COVID-19 may be administered along with supportive treatment. The antivirals that have been used for the treatment of COVID-19 include remdesivir, lopinavir/ritonavir and darunavir/cobicistat, control and prevent inflammation and symptomatic treatment.^[39]^[40]^[41]
Treating the cause of anorexia associated with COVID-19 will treat the symptom.
Rehydration, IV fluid therapy, are essential in dehydration due to respiratory manifestations or if severe vomiting accompanies anorexia.^[41]
Associated vomiting may be treated with antiemetic drugs and diarrhea is treated with antidiarrheal drugs such as loperamide. Thorough literature on the use of antiemetics in COVID-19 was not found.
Loperamide and narcoticsare not administered if the patient has C. difficile infection or signs of infection such as fever and bloody stools.^[42]
Although the COVID-19 infection and IBDs mimic in some parameters, glucocorticoids such as prednisone treatment should not be abruptly discontinued but tapered to a possible minimum dose.
A dose above ⩾20 mg/day for prednisone should be tapered to stop if patient becomes COVID-19 positive or prevent infection.^[43]^[44]
The medical therapy used for COVID-19 can be viewed by clicking here.
There are no clear guidelines on the evaluation of response to COVID-19 associated anorexia. A review article on evidence-based management guidelines for the COVID-19 reports a raised CRP and low albumin to be associated with deterioration in patients' condition. Demonstration of viral clearance in two respiratory tract specimens (at least 24 hours apart) may also serve as a monitoring tool.^[41]

Primary Prevention

There are no available vaccines for the prevention of COVID-19. There have been rigorous efforts in order to develop a vaccine for novel coronavirus and several vaccines are in the later phases of trials.^[45]

Effective measures for the primary prevention of COVID-19 include::^[46]
- Frequent hand-washing with soap and water for at least 20 seconds or using a alcohol based hand sanitizer with at least 60% alcohol. Alcohol means ethanol here not methanol/ wood alcohol, as FDA warns against the use of methanol containing hand-wash.^[47]
- Staying at least 6 feet (approximately 2 arms’ length) from other individuals 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.

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 or visiting the patient. 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.^[48].
- Screening of fecal microbiota transplant donors for COVID-19 is also recommended.^[49]
- Contact tracing helps reduce the spread of the disease.^[50]
Oncologists from Wright State University OH, USA suggest fellow oncologists reconsider the routine use of prophylactic dexamethasone as an antiemetic among [cancer patients who are not infected with [COVID-19]]. As reported in several studies, higher lymphocyte level may be associated with better outcomes in COVID-19, avoiding dexamethasone will help avoid inducing lymphopenia.^[51]

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↑ Telias, Irene; Katira, Bhushan H.; Brochard, Laurent (2020). "Is the Prone Position Helpful During Spontaneous Breathing in Patients With COVID-19?". JAMA. 323 (22): 2265. doi:10.1001/jama.2020.8539. ISSN 0098-7484.
↑ ^28.0 ^28.1 ^28.2 ^28.3 ^28.4 ^28.5 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).
↑ Guan, Wei-jie; Ni, Zheng-yi; Hu, Yu; Liang, Wen-hua; Ou, Chun-quan; He, Jian-xing; Liu, Lei; Shan, Hong; Lei, Chun-liang; Hui, David S.C.; Du, Bin; Li, Lan-juan; Zeng, Guang; Yuen, Kwok-Yung; Chen, Ru-chong; Tang, Chun-li; Wang, Tao; Chen, Ping-yan; Xiang, Jie; Li, Shi-yue; Wang, Jin-lin; Liang, Zi-jing; Peng, Yi-xiang; Wei, Li; Liu, Yong; Hu, Ya-hua; Peng, Peng; Wang, Jian-ming; Liu, Ji-yang; Chen, Zhong; Li, Gang; Zheng, Zhi-jian; Qiu, Shao-qin; Luo, Jie; Ye, Chang-jiang; Zhu, Shao-yong; Zhong, Nan-shan (2020). "Clinical Characteristics of Coronavirus Disease 2019 in China". New England Journal of Medicine. 382 (18): 1708–1720. doi:10.1056/NEJMoa2002032. ISSN 0028-4793.
↑ Olry A, Meunier L, Délire B, Larrey D, Horsmans Y, Le Louët H (July 2020). "Drug-Induced Liver Injury and COVID-19 Infection: The Rules Remain the Same". Drug Saf. 43 (7): 615–617. doi:10.1007/s40264-020-00954-z. PMC 7279629 Check |pmc= value (help). PMID 32514859 Check |pmid= value (help).
↑ Boettler T, Newsome PN, Mondelli MU, Maticic M, Cordero E, Cornberg M, Berg T (June 2020). "Care of patients with liver disease during the COVID-19 pandemic: EASL-ESCMID position paper". JHEP Rep. 2 (3): 100113. doi:10.1016/j.jhepr.2020.100113. PMC 7128473 Check |pmc= value (help). PMID 32289115 Check |pmid= value (help).
↑ ^32.0 ^32.1 Abdalhadi A, Alkhatib M, Mismar AY, Awouda W, Albarqouni L (2020). "Can COVID 19 present like appendicitis?". IDCases. 21: e00860. doi:10.1016/j.idcr.2020.e00860. PMC 7265835 Check |pmc= value (help). PMID 32523872 Check |pmid= value (help).
↑ "CDC's Diagnostic Test for COVID-19 Only and Supplies | CDC".
↑ Chen D, Li X, Song Q, Hu C, Su F, Dai J, Ye Y, Huang J, Zhang X (June 2020). "Assessment of Hypokalemia and Clinical Characteristics in Patients With Coronavirus Disease 2019 in Wenzhou, China". JAMA Netw Open. 3 (6): e2011122. doi:10.1001/jamanetworkopen.2020.11122. PMC 7290402 Check |pmc= value (help). PMID 32525548 Check |pmid= value (help).
↑ Alfano, Gaetano; Ferrari, Annachiara; Fontana, Francesco; Perrone, Rossella; Mori, Giacomo; Ascione, Elisabetta; Riccardo, Magistroni; Venturi, Giulia; Pederzoli, Simone; Margiotta, Gianluca; Romeo, Marilina; Piccinini, Francesca; Franceschi, Giacomo; Volpi, Sara; Faltoni, Matteo; Ciusa, Giacomo; Bacca, Erica; Tutone, Marco; Raimondi, Alessandro; menozzi, marianna; Franceschini, Erica; Cuomo, Gianluca; Orlando, Gabriella; Santoro, Antonella; Di Gaetano, Margherita; Puzzolante, Cinzia; Carli, Federica; Bedini, Andrea; Milic, Jovana; Meschiari, Marianna; Mussini, Cristina; Cappelli, Gianni; Guaraldi, Giovanni (2020). doi:10.1101/2020.06.14.20131169. Missing or empty |title= (help)
↑ Wang, Fan; Wang, Haizhou; Fan, Junli; Zhang, Yongxi; Wang, Hongling; Zhao, Qiu (2020). "Pancreatic Injury Patterns in Patients With Coronavirus Disease 19 Pneumonia". Gastroenterology. 159 (1): 367–370. doi:10.1053/j.gastro.2020.03.055. ISSN 0016-5085.
↑ Aloysius MM, Thatti A, Gupta A, Sharma N, Bansal P, Goyal H (May 2020). "COVID-19 presenting as acute pancreatitis". Pancreatology. doi:10.1016/j.pan.2020.05.003. PMC 7207100 Check |pmc= value (help). PMID 32444169 Check |pmid= value (help).
↑ ^38.0 ^38.1 Cozzi D, Albanesi M, Cavigli E, Moroni C, Bindi A, Luvarà S, Lucarini S, Busoni S, Mazzoni LN, Miele V (August 2020). "Chest X-ray in new Coronavirus Disease 2019 (COVID-19) infection: findings and correlation with clinical outcome". Radiol Med. 125 (8): 730–737. doi:10.1007/s11547-020-01232-9. PMC 7282464 Check |pmc= value (help). PMID 32519256 Check |pmid= value (help).
↑ Cao, Bin; Wang, Yeming; Wen, Danning; Liu, Wen; Wang, Jingli; Fan, Guohui; Ruan, Lianguo; Song, Bin; Cai, Yanping; Wei, Ming; Li, Xingwang; Xia, Jiaan; Chen, Nanshan; Xiang, Jie; Yu, Ting; Bai, Tao; Xie, Xuelei; Zhang, Li; Li, Caihong; Yuan, Ye; Chen, Hua; Li, Huadong; Huang, Hanping; Tu, Shengjing; Gong, Fengyun; Liu, Ying; Wei, Yuan; Dong, Chongya; Zhou, Fei; Gu, Xiaoying; Xu, Jiuyang; Liu, Zhibo; Zhang, Yi; Li, Hui; Shang, Lianhan; Wang, Ke; Li, Kunxia; Zhou, Xia; Dong, Xuan; Qu, Zhaohui; Lu, Sixia; Hu, Xujuan; Ruan, Shunan; Luo, Shanshan; Wu, Jing; Peng, Lu; Cheng, Fang; Pan, Lihong; Zou, Jun; Jia, Chunmin; Wang, Juan; Liu, Xia; Wang, Shuzhen; Wu, Xudong; Ge, Qin; He, Jing; Zhan, Haiyan; Qiu, Fang; Guo, Li; Huang, Chaolin; Jaki, Thomas; Hayden, Frederick G.; Horby, Peter W.; Zhang, Dingyu; Wang, Chen (2020). "A Trial of Lopinavir–Ritonavir in Adults Hospitalized with Severe Covid-19". New England Journal of Medicine. 382 (19): 1787–1799. doi:10.1056/NEJMoa2001282. ISSN 0028-4793.
↑ Lim J, Jeon S, Shin HY, Kim MJ, Seong YM, Lee WJ, Choe KW, Kang YM, Lee B, Park SJ (February 2020). "Case of the Index Patient Who Caused Tertiary Transmission of COVID-19 Infection in Korea: the Application of Lopinavir/Ritonavir for the Treatment of COVID-19 Infected Pneumonia Monitored by Quantitative RT-PCR". J. Korean Med. Sci. 35 (6): e79. doi:10.3346/jkms.2020.35.e79. PMC 7025910 Check |pmc= value (help). PMID 32056407 Check |pmid= value (help).
↑ ^41.0 ^41.1 ^41.2 Nicola M, O'Neill N, Sohrabi C, Khan M, Agha M, Agha R (May 2020). "Evidence based management guideline for the COVID-19 pandemic - Review article". Int J Surg. 77: 206–216. doi:10.1016/j.ijsu.2020.04.001. PMC 7151371 Check |pmc= value (help). PMID 32289472 Check |pmid= value (help).
↑ Khanna S, Pardi DS (November 2012). "Clostridium difficile infection: new insights into management". Mayo Clin. Proc. 87 (11): 1106–17. doi:10.1016/j.mayocp.2012.07.016. PMC 3541870. PMID 23127735.
↑ Queiroz N, Barros LL, Azevedo M, Oba J, Sobrado CW, Carlos AS, Milani LR, Sipahi AM, Damião A (2020). "Management of inflammatory bowel disease patients in the COVID-19 pandemic era: a Brazilian tertiary referral center guidance". Clinics (Sao Paulo). 75: e1909. doi:10.6061/clinics/2020/e1909. PMC 7153358 Check |pmc= value (help). PMID 32321117 Check |pmid= value (help). Vancouver style error: initials (help)
↑ Su, Song; Shen, Jun; Zhu, Liangru; Qiu, Yun; He, Jin-Shen; Tan, Jin-Yu; Iacucci, Marietta; Ng, Siew C; Ghosh, Subrata; Mao, Ren; Liang, Jie (2020). "Involvement of digestive system in COVID-19: manifestations, pathology, management and challenges". Therapeutic Advances in Gastroenterology. 13: 175628482093462. doi:10.1177/1756284820934626. ISSN 1756-2848.
↑ "NIH clinical trial of investigational vaccine for COVID-19 begins | National Institutes of Health (NIH)".
↑ "How to Protect Yourself & Others | CDC".
↑ "Coronavirus (COVID-19) Update: FDA Takes Action to Warn, Protect Consumers from Dangerous Alcohol-Based Hand Sanitizers Containing Methanol | FDA".
↑ "Infection Control: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) | CDC".
↑ 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".
↑ Marinella MA (June 2020). "Routine antiemetic prophylaxis with dexamethasone during COVID-19: Should oncologists reconsider?". J Oncol Pharm Pract: 1078155220931921. doi:10.1177/1078155220931921. PMID 32507102 Check |pmid= value (help).

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[urlwww.who.int-1] 1.0 ^1.1 ^1.2 "www.who.int" (PDF).

[urlCoronavirus_(COVID-19)_frequently_asked_questions_|_CDC-2] "Coronavirus (COVID-19) frequently asked questions | CDC".

[WangHu2020-3] 3.0 ^3.1 ^3.2 Wang, Dawei; Hu, Bo; Hu, Chang; Zhu, Fangfang; Liu, Xing; Zhang, Jing; Wang, Binbin; Xiang, Hui; Cheng, Zhenshun; Xiong, Yong; Zhao, Yan; Li, Yirong; Wang, Xinghuan; Peng, Zhiyong (2020). "Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China". JAMA. 323 (11): 1061. doi:10.1001/jama.2020.1585. ISSN 0098-7484.

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[WangZhang2020-13] Wang, Yeming; Zhang, Dingyu; Du, Guanhua; Du, Ronghui; Zhao, Jianping; Jin, Yang; Fu, Shouzhi; Gao, Ling; Cheng, Zhenshun; Lu, Qiaofa; Hu, Yi; Luo, Guangwei; Wang, Ke; Lu, Yang; Li, Huadong; Wang, Shuzhen; Ruan, Shunan; Yang, Chengqing; Mei, Chunlin; Wang, Yi; Ding, Dan; Wu, Feng; Tang, Xin; Ye, Xianzhi; Ye, Yingchun; Liu, Bing; Yang, Jie; Yin, Wen; Wang, Aili; Fan, Guohui; Zhou, Fei; Liu, Zhibo; Gu, Xiaoying; Xu, Jiuyang; Shang, Lianhan; Zhang, Yi; Cao, Lianjun; Guo, Tingting; Wan, Yan; Qin, Hong; Jiang, Yushen; Jaki, Thomas; Hayden, Frederick G; Horby, Peter W; Cao, Bin; Wang, Chen (2020). "Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial". The Lancet. 395 (10236): 1569–1578. doi:10.1016/S0140-6736(20)31022-9. ISSN 0140-6736.

[pmid32544802-14] Di Lorenzo G, Di Trolio R, Kozlakidis Z, Busto G, Ingenito C, Buonerba L, Ferrara C, Libroia A, Ragone G, Ioio CD, Savastano B, Polverino M, De Falco F, Iaccarino S, Leo E (August 2020). "COVID 19 therapies and anti-cancer drugs: A systematic review of recent literature". Crit. Rev. Oncol. Hematol. 152: 102991. doi:10.1016/j.critrevonc.2020.102991. PMC 7239789 Check |pmc= value (help). PMID 32544802 Check |pmid= value (help).

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[urlWHO_Coronavirus_Disease_(COVID-19)_Dashboard_|_WHO_Coronavirus_Disease_(COVID-19)_Dashboard-18] "WHO Coronavirus Disease (COVID-19) Dashboard | WHO Coronavirus Disease (COVID-19) Dashboard".

[pmid32405603-19] 19.0 ^19.1 ^19.2 Mao R, Qiu Y, He JS, Tan JY, Li XH, Liang J, Shen J, Zhu LR, Chen Y, Iacucci M, Ng SC, Ghosh S, Chen MH (July 2020). "Manifestations and prognosis of gastrointestinal and liver involvement in patients with COVID-19: a systematic review and meta-analysis". Lancet Gastroenterol Hepatol. 5 (7): 667–678. doi:10.1016/S2468-1253(20)30126-6. PMC 7217643 Check |pmc= value (help). PMID 32405603 Check |pmid= value (help).

[pmid32251668-20] 20.0 ^20.1 Cheung KS, Hung I, Chan P, Lung KC, Tso E, Liu R, Ng YY, Chu MY, Chung T, Tam AR, Yip C, Leung KH, Fung AY, Zhang RR, Lin Y, Cheng HM, Zhang A, To K, Chan KH, Yuen KY, Leung WK (April 2020). "Gastrointestinal Manifestations of SARS-CoV-2 Infection and Virus Load in Fecal Samples From a Hong Kong Cohort: Systematic Review and Meta-analysis". Gastroenterology. doi:10.1053/j.gastro.2020.03.065. PMC 7194936 Check |pmc= value (help). PMID 32251668 Check |pmid= value (help). Vancouver style error: initials (help)

[urlManagement_of_Patients_with_Confirmed_2019-nCoV_|_CDC-21] "Management of Patients with Confirmed 2019-nCoV | CDC".

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[TariqSaha2020-23] Tariq, Raseen; Saha, Srishti; Furqan, Fateeha; Hassett, Leslie; Pardi, Darrell; Khanna, Sahil (2020). "Prevalence and Mortality of COVID-19 patients with Gastrointestinal Symptoms: A Systematic Review and Meta-analysis". Mayo Clinic Proceedings. doi:10.1016/j.mayocp.2020.06.003. ISSN 0025-6196.

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[pmid32287140-25] Pan L, Mu M, Yang P, Sun Y, Wang R, Yan J, Li P, Hu B, Wang J, Hu C, Jin Y, Niu X, Ping R, Du Y, Li T, Xu G, Hu Q, Tu L (May 2020). "Clinical Characteristics of COVID-19 Patients With Digestive Symptoms in Hubei, China: A Descriptive, Cross-Sectional, Multicenter Study". Am. J. Gastroenterol. 115 (5): 766–773. doi:10.14309/ajg.0000000000000620. PMC 7172492 Check |pmc= value (help). PMID 32287140 Check |pmid= value (help).

[MaoQiu2020-26] 26.0 ^26.1 Mao, Ren; Qiu, Yun; He, Jin-Shen; Tan, Jin-Yu; Li, Xue-Hua; Liang, Jie; Shen, Jun; Zhu, Liang-Ru; Chen, Yan; Iacucci, Marietta; Ng, Siew C; Ghosh, Subrata; Chen, Min-Hu (2020). "Manifestations and prognosis of gastrointestinal and liver involvement in patients with COVID-19: a systematic review and meta-analysis". The Lancet Gastroenterology & Hepatology. 5 (7): 667–678. doi:10.1016/S2468-1253(20)30126-6. ISSN 2468-1253.

[TeliasKatira2020-27] Telias, Irene; Katira, Bhushan H.; Brochard, Laurent (2020). "Is the Prone Position Helpful During Spontaneous Breathing in Patients With COVID-19?". JAMA. 323 (22): 2265. doi:10.1001/jama.2020.8539. ISSN 0098-7484.

[pmid32309266-28] 28.0 ^28.1 ^28.2 ^28.3 ^28.4 ^28.5 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).

[GuanNi2020-29] Guan, Wei-jie; Ni, Zheng-yi; Hu, Yu; Liang, Wen-hua; Ou, Chun-quan; He, Jian-xing; Liu, Lei; Shan, Hong; Lei, Chun-liang; Hui, David S.C.; Du, Bin; Li, Lan-juan; Zeng, Guang; Yuen, Kwok-Yung; Chen, Ru-chong; Tang, Chun-li; Wang, Tao; Chen, Ping-yan; Xiang, Jie; Li, Shi-yue; Wang, Jin-lin; Liang, Zi-jing; Peng, Yi-xiang; Wei, Li; Liu, Yong; Hu, Ya-hua; Peng, Peng; Wang, Jian-ming; Liu, Ji-yang; Chen, Zhong; Li, Gang; Zheng, Zhi-jian; Qiu, Shao-qin; Luo, Jie; Ye, Chang-jiang; Zhu, Shao-yong; Zhong, Nan-shan (2020). "Clinical Characteristics of Coronavirus Disease 2019 in China". New England Journal of Medicine. 382 (18): 1708–1720. doi:10.1056/NEJMoa2002032. ISSN 0028-4793.

[pmid32514859-30] Olry A, Meunier L, Délire B, Larrey D, Horsmans Y, Le Louët H (July 2020). "Drug-Induced Liver Injury and COVID-19 Infection: The Rules Remain the Same". Drug Saf. 43 (7): 615–617. doi:10.1007/s40264-020-00954-z. PMC 7279629 Check |pmc= value (help). PMID 32514859 Check |pmid= value (help).

[pmid32289115-31] Boettler T, Newsome PN, Mondelli MU, Maticic M, Cordero E, Cornberg M, Berg T (June 2020). "Care of patients with liver disease during the COVID-19 pandemic: EASL-ESCMID position paper". JHEP Rep. 2 (3): 100113. doi:10.1016/j.jhepr.2020.100113. PMC 7128473 Check |pmc= value (help). PMID 32289115 Check |pmid= value (help).

[pmid32523872-32] 32.0 ^32.1 Abdalhadi A, Alkhatib M, Mismar AY, Awouda W, Albarqouni L (2020). "Can COVID 19 present like appendicitis?". IDCases. 21: e00860. doi:10.1016/j.idcr.2020.e00860. PMC 7265835 Check |pmc= value (help). PMID 32523872 Check |pmid= value (help).

[urlCDC’s_Diagnostic_Test_for_COVID-19_Only_and_Supplies_|_CDC-33] "CDC's Diagnostic Test for COVID-19 Only and Supplies | CDC".

[pmid32525548-34] Chen D, Li X, Song Q, Hu C, Su F, Dai J, Ye Y, Huang J, Zhang X (June 2020). "Assessment of Hypokalemia and Clinical Characteristics in Patients With Coronavirus Disease 2019 in Wenzhou, China". JAMA Netw Open. 3 (6): e2011122. doi:10.1001/jamanetworkopen.2020.11122. PMC 7290402 Check |pmc= value (help). PMID 32525548 Check |pmid= value (help).

[AlfanoFerrari2020-35] Alfano, Gaetano; Ferrari, Annachiara; Fontana, Francesco; Perrone, Rossella; Mori, Giacomo; Ascione, Elisabetta; Riccardo, Magistroni; Venturi, Giulia; Pederzoli, Simone; Margiotta, Gianluca; Romeo, Marilina; Piccinini, Francesca; Franceschi, Giacomo; Volpi, Sara; Faltoni, Matteo; Ciusa, Giacomo; Bacca, Erica; Tutone, Marco; Raimondi, Alessandro; menozzi, marianna; Franceschini, Erica; Cuomo, Gianluca; Orlando, Gabriella; Santoro, Antonella; Di Gaetano, Margherita; Puzzolante, Cinzia; Carli, Federica; Bedini, Andrea; Milic, Jovana; Meschiari, Marianna; Mussini, Cristina; Cappelli, Gianni; Guaraldi, Giovanni (2020). doi:10.1101/2020.06.14.20131169. Missing or empty |title= (help)

[WangWang2020-36] Wang, Fan; Wang, Haizhou; Fan, Junli; Zhang, Yongxi; Wang, Hongling; Zhao, Qiu (2020). "Pancreatic Injury Patterns in Patients With Coronavirus Disease 19 Pneumonia". Gastroenterology. 159 (1): 367–370. doi:10.1053/j.gastro.2020.03.055. ISSN 0016-5085.

[pmid32444169-37] Aloysius MM, Thatti A, Gupta A, Sharma N, Bansal P, Goyal H (May 2020). "COVID-19 presenting as acute pancreatitis". Pancreatology. doi:10.1016/j.pan.2020.05.003. PMC 7207100 Check |pmc= value (help). PMID 32444169 Check |pmid= value (help).

[pmid32519256-38] 38.0 ^38.1 Cozzi D, Albanesi M, Cavigli E, Moroni C, Bindi A, Luvarà S, Lucarini S, Busoni S, Mazzoni LN, Miele V (August 2020). "Chest X-ray in new Coronavirus Disease 2019 (COVID-19) infection: findings and correlation with clinical outcome". Radiol Med. 125 (8): 730–737. doi:10.1007/s11547-020-01232-9. PMC 7282464 Check |pmc= value (help). PMID 32519256 Check |pmid= value (help).

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@@ Line 4: / Line 4: @@
 '''For COVID-19 frequently asked inpatient questions, click [[COVID-19 frequently asked inpatient questions|here]]'''<br>
 {{SI}}
-{{CMG}} {{AE}} [[User:Javaria Anwer|Javaria Anwer M.D.]][mailto:javaria.anwer@gmail.com]
+{{CMG}} {{AE}} {{JA}}
-{{SK}}[[COVID-19 associated loss of appetite]], [[COVID-19 and hunger]], [[appetite and COVID-19]], [[loss of appetite in COVID]], [[COVID and hunger]], [[SARS-Cov-2 associated anorexia]], [[SARS-Cov-2 associated loss of appetite]], [[SARS CoV2 and hunger]], [[Coronavirus and hunger]], [[appetite and COVID-19]].
+{{SK}}[[COVID-19 associated loss of appetite]], [[COVID-19 and hunger]], [[appetite and COVID-19]], [[loss of appetite in COVID]], [[COVID and hunger]], [[SARS-Cov-2 associated anorexia]], [[SARS-Cov-2 associated loss of appetite]], [[SARS CoV2 and hunger]], [[Coronavirus and hunger]], [[appetite and COVID-19]], [[covid19 associated anorexia]].
 ==Overview==
-[[COVID-19]] is primarily known to be a respiratory disease. [[Anorexia]] associated with [[COVID-19]] is the most common digestive symptom among patients with [[COVID-19]]. The exact mechanism of [[anorexia|loss of appetite]] associated with the infection is unknown, but the symptom may be due to various causes. Several diseases share [[anorexia|loss of appetite]] symptom and it is important to suspect [[COVI-19|COVID-19]] and perform [[RT-PCR]] to detect the infection or [[CXR]] to detect possible lung manifestations. Patients with loss of appetite may present with associated symptoms such as [[nausea]] or [[vomiting]] and [[diarrhea]]. The mainstay of treatment in [[COVID-19]] infection is supportive therapy and [[Antiviral Therapy|antiviral therapy]]. [[Hygiene|Hand hygiene]] and social distancing are important [[primary prevention|primary]] prevention tools. [[Contact tracing]] is an important tool of [[secondary prevention]].
+[[COVID-19]] is primarily known to be a respiratory disease. [[Anorexia]] associated with [[COVID-19]] is the most common digestive symptom among patients with [[COVID-19]]. The exact mechanism of [[anorexia|loss of appetite]] associated with the infection is unknown, but the symptom may be due to various causes. Several diseases share [[anorexia|loss of appetite]] symptom, so it is important to suspect [[COVI-19|COVID-19]] and perform [[RT-PCR]] to detect the infection or [[CXR]] to detect possible lung manifestations. Patients with loss of appetite may present with associated symptoms such as [[nausea]] or [[vomiting]] and [[diarrhea]]. The mainstay of treatment in [[COVID-19]] infection is supportive therapy and [[Antiviral Therapy|antiviral therapy]]. [[Hygiene|Hand hygiene]] and social distancing are important [[primary prevention|primary]] prevention tools. [[Contact tracing]] is an important tool of [[secondary prevention]].
 ==Historical Perspective==
-*[[COVID-19]] was first discovered in Wuhan, China. On 30th December 2019, three [[bronchoalveolar lavage]] samples collected from a [[patient]] with [[pneumonia]] of unknown [[etiology]] – a surveillance definition established following the [[SARS]] [[outbreak ]]of 2002-2003 – in Wuhan Jinyintan Hospital. Real-time [[PCR]] (RT-PCR) assays on these samples were positive for pan-Beta[[coronavirus]].<ref name="urlwww.who.int">{{cite web |url=https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf |title=www.who.int |format= |work= |accessdate=}}</ref>
+*[[COVID-19]] was first discovered in Wuhan, China. On 30th December 2019, three [[bronchoalveolar lavage]] samples were collected from a [[patient]] with [[pneumonia]] of unknown [[etiology]] – a surveillance definition established following the [[SARS]] [[outbreak ]]of 2002-2003 – in Wuhan Jinyintan Hospital. Real-time [[PCR]] (RT-PCR) assays on these samples were positive for pan-Beta[[coronavirus]].<ref name="urlwww.who.int">{{cite web |url=https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf |title=www.who.int |format= |work= |accessdate=}}</ref>
 *Nanopore sequencing and bioinformatic analyses indicated that the virus had features typical of the [[coronavirus]] family and belonged to the Beta[[coronavirus]] 2B lineage.<ref name="urlwww.who.int">{{cite web |url=https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf |title=www.who.int |format= |work= |accessdate=}}</ref>
-*[[COVID-19]] was primarily known as a [[respiratory disease]]. In the initial reports from [[WHO]], the mode of transmission of [[COVID-19]] was droplets and fomites during close unprotected contact between an infector and the infectee. Airborne transmission was not reported initially.
+*[[COVID-19]] was primarily known as a [[respiratory disease]]. In the initial reports from the World Health Organization  ([[WHO|WHO)]], the mode of transmission of [[COVID-19]] was reported to spread through droplets and fomites during close unprotected contact between an infector and an infectee. Airborne transmission was not reported initially.
-*Fecal shedding was reported to be demonstrated from some [[patients]], with viable virus identified in a limited number of case reports. However, fecal-oral route did not appear to drive [[COVID-19]] transmission.<ref name="urlwww.who.int">{{cite web |url=https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf |title=www.who.int |format= |work= |accessdate=}}</ref><ref name="urlCoronavirus (COVID-19) frequently asked questions | CDC">{{cite web |url=https://www.cdc.gov/coronavirus/2019-ncov/faq.html |title=Coronavirus (COVID-19) frequently asked questions &#124; CDC |format= |work= |accessdate=}}</ref>
+*Fecal shedding was demonstrated from [[patients]], with viable virus identified in a limited number of case reports. However, fecal-oral route did not appear to drive [[COVID-19]] transmission.<ref name="urlwww.who.int">{{cite web |url=https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf |title=www.who.int |format= |work= |accessdate=}}</ref><ref name="urlCoronavirus (COVID-19) frequently asked questions | CDC">{{cite web |url=https://www.cdc.gov/coronavirus/2019-ncov/faq.html |title=Coronavirus (COVID-19) frequently asked questions &#124; CDC |format= |work= |accessdate=}}</ref>
 *[[COVID-19]] associated [[anorexia]] was first described as one of the less common symptoms of [[COVID-19]] in a retrospective, single-center case series by Wang D et al. published on Feb 7th, 2020. The [[patient]] data was derived from January 1st-Jan 28th,2020 at Zhongnan Hospital in Wuhan, China.<ref name="WangHu2020">{{cite journal|last1=Wang|first1=Dawei|last2=Hu|first2=Bo|last3=Hu|first3=Chang|last4=Zhu|first4=Fangfang|last5=Liu|first5=Xing|last6=Zhang|first6=Jing|last7=Wang|first7=Binbin|last8=Xiang|first8=Hui|last9=Cheng|first9=Zhenshun|last10=Xiong|first10=Yong|last11=Zhao|first11=Yan|last12=Li|first12=Yirong|last13=Wang|first13=Xinghuan|last14=Peng|first14=Zhiyong|title=Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China|journal=JAMA|volume=323|issue=11|year=2020|pages=1061|issn=0098-7484|doi=10.1001/jama.2020.1585}}</ref>
 *[[COVID-19]] associated [[anorexia]] was not only described as one of the common [[symptom]]s at the illness onset, it was reported to be more common among [[ICU]] [[patients]].<ref name="WangHu2020">{{cite journal|last1=Wang|first1=Dawei|last2=Hu|first2=Bo|last3=Hu|first3=Chang|last4=Zhu|first4=Fangfang|last5=Liu|first5=Xing|last6=Zhang|first6=Jing|last7=Wang|first7=Binbin|last8=Xiang|first8=Hui|last9=Cheng|first9=Zhenshun|last10=Xiong|first10=Yong|last11=Zhao|first11=Yan|last12=Li|first12=Yirong|last13=Wang|first13=Xinghuan|last14=Peng|first14=Zhiyong|title=Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China|journal=JAMA|volume=323|issue=11|year=2020|pages=1061|issn=0098-7484|doi=10.1001/jama.2020.1585}}</ref>
 *On March 11th, 2020, [[WHO]] declared the COVID-19 [[outbreak]] a [[pandemic]].<ref name="urlWHO Director-Generals opening remarks at the media briefing on COVID-19 - 11 March 2020">{{cite web |url=https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020 |title=WHO Director-General's opening remarks at the media briefing on COVID-19 - 11 March 2020 |format= |work= |accessdate=}}</ref>
-*With the increasing evidence and ongoing research, [[anorexia]] associated with [[COVID-19]] is now reported to be a common symptom in patients with [[COVID-19]], and the viral infection is suspected in a patient presenting with [[anorexia]] along with other [[gastrointestinal]] symptoms.
+*With the increasing evidence and ongoing research, [[anorexia]] associated with [[COVID-19]] is now reported to be a common symptom among patients with [[COVID-19]], and the viral infection is suspected in a patient presenting with [[anorexia]] along with other [[gastrointestinal]] symptoms.
 ==Classification==
@@ Line 25: / Line 25: @@
 ==Pathophysiology==
 *The exact mechanism through which [[anorexia]] develops in [[COVID-19]] is yet to be completely understood. The possible mechanism of [[anorexia]] in [[COVID-19]], which is also a general response to [[infection]] is as follows:
-**The relationship of the [[taste|sense of taste]] and [[appetite]] alongwith the prevalence of [[gustatory system]] dysfunction in mild-moderate [[COVID-19]] cases partly explains [[anorexia]] in [[COVID-19]]. In addition, [[olfactory]] dysfunction also contributes [[anorexia|to loss of appetite]].<ref name="pmid32253535">{{cite journal |vauthors=Lechien JR, Chiesa-Estomba CM, De Siati DR, Horoi M, Le Bon SD, Rodriguez A, Dequanter D, Blecic S, El Afia F, Distinguin L, Chekkoury-Idrissi Y, Hans S, Delgado IL, Calvo-Henriquez C, Lavigne P, Falanga C, Barillari MR, Cammaroto G, Khalife M, Leich P, Souchay C, Rossi C, Journe F, Hsieh J, Edjlali M, Carlier R, Ris L, Lovato A, De Filippis C, Coppee F, Fakhry N, Ayad T, Saussez S |title=Olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (COVID-19): a multicenter European study |journal=Eur Arch Otorhinolaryngol |volume= |issue= |pages= |date=April 2020 |pmid=32253535 |pmc=7134551 |doi=10.1007/s00405-020-05965-1 |url=}}</ref>
+**The relationship of the [[taste|sense of taste]] and [[appetite]] along with the prevalence of [[gustatory system]] dysfunction in mild-moderate [[COVID-19]] cases partly explains [[anorexia]] in [[COVID-19]]. In addition, [[olfactory]] dysfunction contributes [[anorexia|to loss of appetite]].<ref name="pmid32253535">{{cite journal |vauthors=Lechien JR, Chiesa-Estomba CM, De Siati DR, Horoi M, Le Bon SD, Rodriguez A, Dequanter D, Blecic S, El Afia F, Distinguin L, Chekkoury-Idrissi Y, Hans S, Delgado IL, Calvo-Henriquez C, Lavigne P, Falanga C, Barillari MR, Cammaroto G, Khalife M, Leich P, Souchay C, Rossi C, Journe F, Hsieh J, Edjlali M, Carlier R, Ris L, Lovato A, De Filippis C, Coppee F, Fakhry N, Ayad T, Saussez S |title=Olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (COVID-19): a multicenter European study |journal=Eur Arch Otorhinolaryngol |volume= |issue= |pages= |date=April 2020 |pmid=32253535 |pmc=7134551 |doi=10.1007/s00405-020-05965-1 |url=}}</ref>
-** According to another proposed mechanism of development of [[anorexia]] in [[infection]], the [[microbial]] products set off the development of [[acute phase protein]]s such as [[cytokines]] ([[Interleukin]] and [[Tumor necrosis factor-alpha|TNF alpha]]) during an [[infection]]. The [[acute phase protein]]s are known to cause [[anorexia]]. [[Cytokines]] locally released activate the [[peripheral]] [[sensory fibers]] causing loss of appetite. The direct effect of [[cytokines]] and [[microbial]] products on the [[CNS]] (the [[Hypothalamus|center of appetite]]) is also involved in the development of [[anorexia]] during [[infection]].<ref name="pmid17290560">{{cite journal |vauthors=Kanra GY, Ozen H, Kara A |title=Infection and anorexia |journal=Turk. J. Pediatr. |volume=48 |issue=4 |pages=279–87 |date=2006 |pmid=17290560 |doi= |url=}}</ref><ref name="pmid10657519">{{cite journal |vauthors=Langhans W, Hrupka B |title=Interleukins and tumor necrosis factor as inhibitors of food intake |journal=Neuropeptides |volume=33 |issue=5 |pages=415–24 |date=October 1999 |pmid=10657519 |doi=10.1054/npep.1999.0048 |url=}}</ref> Studies have reported several pro-inflammatory [[cytokines]] and [[chemokines]], particularly [[CXCL10]], CXCL8, [[CCL2]], [[Tumor necrosis factor-alpha|TNFα]] and IFNγ to be higher in the [[plasma]] of [[COVID-19]] patients.<ref name="pmid32270184">{{cite journal |vauthors=Chu H, Chan JF, Wang Y, Yuen TT, Chai Y, Hou Y, Shuai H, Yang D, Hu B, Huang X, Zhang X, Cai JP, Zhou J, Yuan S, Kok KH, To KK, Chan IH, Zhang AJ, Sit KY, Au WK, Yuen KY |title=Comparative replication and immune activation profiles of SARS-CoV-2 and SARS-CoV in human lungs: an ex vivo study with implications for the pathogenesis of COVID-19 |journal=Clin. Infect. Dis. |volume= |issue= |pages= |date=April 2020 |pmid=32270184 |pmc=7184390 |doi=10.1093/cid/ciaa410 |url=}}</ref> A relationship of [[cytokines]] and [[COVID-19]] infection has been established.<ref name="pmid32446778">{{cite journal |vauthors=Coperchini F, Chiovato L, Croce L, Magri F, Rotondi M |title=The cytokine storm in COVID-19: An overview of the involvement of the chemokine/chemokine-receptor system |journal=Cytokine Growth Factor Rev. |volume=53 |issue= |pages=25–32 |date=June 2020 |pmid=32446778 |pmc=7211650 |doi=10.1016/j.cytogfr.2020.05.003 |url=}}</ref>
+** According to another proposed mechanism of development of [[anorexia]] in [[infection]], the [[microbial]] products set off the development of [[acute phase protein]]s such as [[cytokines]] ([[Interleukin]] and [[Tumor necrosis factor-alpha|TNF alpha]]) during an [[infection]]. The [[acute phase protein]]s are known to cause [[anorexia]]. [[Cytokines]] that are locally released activate the [[peripheral]] [[sensory fibers]] causing loss of appetite. The direct effect of [[cytokines]] and [[microbial]] products on the [[CNS]] (the [[Hypothalamus|center of appetite]]) is also involved in the development of [[anorexia]] during [[infection]].<ref name="pmid17290560">{{cite journal |vauthors=Kanra GY, Ozen H, Kara A |title=Infection and anorexia |journal=Turk. J. Pediatr. |volume=48 |issue=4 |pages=279–87 |date=2006 |pmid=17290560 |doi= |url=}}</ref><ref name="pmid10657519">{{cite journal |vauthors=Langhans W, Hrupka B |title=Interleukins and tumor necrosis factor as inhibitors of food intake |journal=Neuropeptides |volume=33 |issue=5 |pages=415–24 |date=October 1999 |pmid=10657519 |doi=10.1054/npep.1999.0048 |url=}}</ref> Studies have reported several pro-inflammatory [[cytokines]] and [[chemokines]], particularly [[CXCL10]], CXCL8, [[CCL2]], [[Tumor necrosis factor-alpha|TNFα]] and IFNγ to be higher in the [[plasma]] of [[COVID-19]] patients.<ref name="pmid32270184">{{cite journal |vauthors=Chu H, Chan JF, Wang Y, Yuen TT, Chai Y, Hou Y, Shuai H, Yang D, Hu B, Huang X, Zhang X, Cai JP, Zhou J, Yuan S, Kok KH, To KK, Chan IH, Zhang AJ, Sit KY, Au WK, Yuen KY |title=Comparative replication and immune activation profiles of SARS-CoV-2 and SARS-CoV in human lungs: an ex vivo study with implications for the pathogenesis of COVID-19 |journal=Clin. Infect. Dis. |volume= |issue= |pages= |date=April 2020 |pmid=32270184 |pmc=7184390 |doi=10.1093/cid/ciaa410 |url=}}</ref> A relationship of [[cytokines]] and [[COVID-19]] infection has been established.<ref name="pmid32446778">{{cite journal |vauthors=Coperchini F, Chiovato L, Croce L, Magri F, Rotondi M |title=The cytokine storm in COVID-19: An overview of the involvement of the chemokine/chemokine-receptor system |journal=Cytokine Growth Factor Rev. |volume=53 |issue= |pages=25–32 |date=June 2020 |pmid=32446778 |pmc=7211650 |doi=10.1016/j.cytogfr.2020.05.003 |url=}}</ref>
 **The detection of viral [[nucleocapsid]] protein in gastrointestinal [[epithelial cells]] and viral RNA in [[fecal]] [[specimens]] reflects the infectivity and chance of direct [[cytokine]] or [[chemokine]] response.<ref name="ZouChen2020">{{cite journal|last1=Zou|first1=Xin|last2=Chen|first2=Ke|last3=Zou|first3=Jiawei|last4=Han|first4=Peiyi|last5=Hao|first5=Jie|last6=Han|first6=Zeguang|title=Single-cell RNA-seq data analysis on the receptor ACE2 expression reveals the potential risk of different human organs vulnerable to 2019-nCoV infection|journal=Frontiers of Medicine|volume=14|issue=2|year=2020|pages=185–192|issn=2095-0217|doi=10.1007/s11684-020-0754-0}}</ref>
 **The association between increased brain [[tryptophan]] availability in patients with [[chronic liver disease]] and [[anorexia]] partially explains the mechanism of [[anorexia]] in [[COVID-19-associated hepatic injury]].<ref name="pmid9062842">{{cite journal |vauthors=Laviano A, Cangiano C, Preziosa I, Riggio O, Conversano L, Cascino A, Ariemma S, Rossi Fanelli F |title=Plasma tryptophan levels and anorexia in liver cirrhosis |journal=Int J Eat Disord |volume=21 |issue=2 |pages=181–6 |date=March 1997 |pmid=9062842 |doi=10.1002/(sici)1098-108x(199703)21:2<181::aid-eat9>3.0.co;2-h |url=}}</ref>
@@ Line 44: / Line 44: @@
 ==Epidemiology and Demographics==
+*According to [[WHO]] the prevalence of [[anorexia]] associated with [[COVID-19]] is 40-84%.<ref name="urlWHO Coronavirus Disease (COVID-19) Dashboard | WHO Coronavirus Disease (COVID-19) Dashboard">{{cite web |url=https://covid19.who.int/?gclid=EAIaIQobChMIydTH1rrh6wIVsRkGAB32zQYgEAAYASAAEgJv5vD_BwE |title=WHO Coronavirus Disease (COVID-19) Dashboard &#124; WHO Coronavirus Disease (COVID-19) Dashboard |format= |work= |accessdate=}}</ref>
 *The pooled prevalence of [[COVID-19]] associated [[anorexia]] is 21% according to a systematic review and meta-analysis based on the studies worldwide published between January 1st, 2020, and April 4th, 2020.<ref name="pmid32405603">{{cite journal |vauthors=Mao R, Qiu Y, He JS, Tan JY, Li XH, Liang J, Shen J, Zhu LR, Chen Y, Iacucci M, Ng SC, Ghosh S, Chen MH |title=Manifestations and prognosis of gastrointestinal and liver involvement in patients with COVID-19: a systematic review and meta-analysis |journal=Lancet Gastroenterol Hepatol |volume=5 |issue=7 |pages=667–678 |date=July 2020 |pmid=32405603 |pmc=7217643 |doi=10.1016/S2468-1253(20)30126-6 |url=}}</ref>
 *The pooled prevalence of [[COVID-19]] associated [[anorexia]] in Hong Kong is approximately 26.8%. 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 [[gastrointestinal|GI]] symptoms associated with [[COVID-19]].<ref name="pmid32251668">{{cite journal |vauthors=Cheung KS, Hung IFN, Chan PPY, Lung KC, Tso E, Liu R, Ng YY, Chu MY, Chung TWH, Tam AR, Yip CCY, Leung KH, Fung AY, Zhang RR, Lin Y, Cheng HM, Zhang AJX, To KKW, Chan KH, Yuen KY, Leung WK |title=Gastrointestinal Manifestations of SARS-CoV-2 Infection and Virus Load in Fecal Samples From a Hong Kong Cohort: Systematic Review and Meta-analysis |journal=Gastroenterology |volume= |issue= |pages= |date=April 2020 |pmid=32251668 |pmc=7194936 |doi=10.1053/j.gastro.2020.03.065 |url=}}</ref>
-*According to recent reviews and meta-analyses of [[COVID-19]] patients from different parts of the world (China, Hong Kong) [[anorexia]] is the most common (40-84%) digestive symptoms associated with [[COVID-19]].<ref name="urlManagement of Patients with Confirmed 2019-nCoV | CDC">{{cite web |url=https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html |title=Management of Patients with Confirmed 2019-nCoV &#124; CDC |format= |work= |accessdate=}}</ref><ref name="pmid32405603">{{cite journal |vauthors=Mao R, Qiu Y, He JS, Tan JY, Li XH, Liang J, Shen J, Zhu LR, Chen Y, Iacucci M, Ng SC, Ghosh S, Chen MH |title=Manifestations and prognosis of gastrointestinal and liver involvement in patients with COVID-19: a systematic review and meta-analysis |journal=Lancet Gastroenterol Hepatol |volume=5 |issue=7 |pages=667–678 |date=July 2020 |pmid=32405603 |pmc=7217643 |doi=10.1016/S2468-1253(20)30126-6 |url=}}</ref><ref name="pmid32251668">{{cite journal |vauthors=Cheung KS, Hung IFN, Chan PPY, Lung KC, Tso E, Liu R, Ng YY, Chu MY, Chung TWH, Tam AR, Yip CCY, Leung KH, Fung AY, Zhang RR, Lin Y, Cheng HM, Zhang AJX, To KKW, Chan KH, Yuen KY, Leung WK |title=Gastrointestinal Manifestations of SARS-CoV-2 Infection and Virus Load in Fecal Samples From a Hong Kong Cohort: Systematic Review and Meta-analysis |journal=Gastroenterology |volume= |issue= |pages= |date=April 2020 |pmid=32251668 |pmc=7194936 |doi=10.1053/j.gastro.2020.03.065 |url=}}</ref>
+*According to recent reviews and meta-analyses of [[COVID-19]], patients from different parts of the world (China, Hong Kong) [[anorexia]] is the most common (40-84%) digestive symptoms associated with [[COVID-19]].<ref name="urlManagement of Patients with Confirmed 2019-nCoV | CDC">{{cite web |url=https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html |title=Management of Patients with Confirmed 2019-nCoV &#124; CDC |format= |work= |accessdate=}}</ref><ref name="pmid32405603">{{cite journal |vauthors=Mao R, Qiu Y, He JS, Tan JY, Li XH, Liang J, Shen J, Zhu LR, Chen Y, Iacucci M, Ng SC, Ghosh S, Chen MH |title=Manifestations and prognosis of gastrointestinal and liver involvement in patients with COVID-19: a systematic review and meta-analysis |journal=Lancet Gastroenterol Hepatol |volume=5 |issue=7 |pages=667–678 |date=July 2020 |pmid=32405603 |pmc=7217643 |doi=10.1016/S2468-1253(20)30126-6 |url=}}</ref><ref name="pmid32251668">{{cite journal |vauthors=Cheung KS, Hung IFN, Chan PPY, Lung KC, Tso E, Liu R, Ng YY, Chu MY, Chung TWH, Tam AR, Yip CCY, Leung KH, Fung AY, Zhang RR, Lin Y, Cheng HM, Zhang AJX, To KKW, Chan KH, Yuen KY, Leung WK |title=Gastrointestinal Manifestations of SARS-CoV-2 Infection and Virus Load in Fecal Samples From a Hong Kong Cohort: Systematic Review and Meta-analysis |journal=Gastroenterology |volume= |issue= |pages= |date=April 2020 |pmid=32251668 |pmc=7194936 |doi=10.1053/j.gastro.2020.03.065 |url=}}</ref>
-*A retrospective study from Wuhna, China describing 1141 cases of [[COVID-19]] reported [[anorexia|loss of appetite]] in 98% patients (n=180). Anorexia was the most common presenting symptom among all [[gastrointestinall|GI]] symptoms of [[COVID-19]].<ref name="LuoZhang2020">{{cite journal|last1=Luo|first1=Shihua|last2=Zhang|first2=Xiaochun|last3=Xu|first3=Haibo|title=Don't Overlook Digestive Symptoms in Patients With 2019 Novel Coronavirus Disease (COVID-19)|journal=Clinical Gastroenterology and Hepatology|volume=18|issue=7|year=2020|pages=1636–1637|issn=15423565|doi=10.1016/j.cgh.2020.03.043}}</ref>
+*A retrospective study from Wuhna, China describing 1,141 cases of [[COVID-19]] reported [[anorexia|loss of appetite]] in 98% patients (n=180). Anorexia was the most common presenting symptom among all [[gastrointestinall|GI]] symptoms of [[COVID-19]].<ref name="pmid32205220">{{cite journal |vauthors=Luo S, Zhang X, Xu H |title=Don't Overlook Digestive Symptoms in Patients With 2019 Novel Coronavirus Disease (COVID-19) |journal=Clin. Gastroenterol. Hepatol. |volume=18 |issue=7 |pages=1636–1637 |date=June 2020 |pmid=32205220 |pmc=7154217 |doi=10.1016/j.cgh.2020.03.043 |url=}}</ref>
 ===Age===
@@ Line 54: / Line 54: @@
 ===Gender===
-Men more commonly presented with [[gastrointestinal|GI]] symptoms with [[anorexia]] being the most common symptom in Wuhan, China according to a retrospective study involving 1141 cases of [[COVID-19]].<ref name="LuoZhang2020">{{cite journal|last1=Luo|first1=Shihua|last2=Zhang|first2=Xiaochun|last3=Xu|first3=Haibo|title=Don't Overlook Digestive Symptoms in Patients With 2019 Novel Coronavirus Disease (COVID-19)|journal=Clinical Gastroenterology and Hepatology|volume=18|issue=7|year=2020|pages=1636–1637|issn=15423565|doi=10.1016/j.cgh.2020.03.043}}</ref>
+Men more commonly presented with [[gastrointestinal|GI]] symptoms with [[anorexia]] being the most common symptom in Wuhan, China according to a retrospective study involving 1,141 cases of [[COVID-19]].<ref name="pmid32205220">{{cite journal |vauthors=Luo S, Zhang X, Xu H |title=Don't Overlook Digestive Symptoms in Patients With 2019 Novel Coronavirus Disease (COVID-19) |journal=Clin. Gastroenterol. Hepatol. |volume=18 |issue=7 |pages=1636–1637 |date=June 2020 |pmid=32205220 |pmc=7154217 |doi=10.1016/j.cgh.2020.03.043 |url=}}</ref>
 ===Race===
-*There is no racial predilection for [[COVID-19]] associated [[anorexia]] according to a systematic review and meta-analysis of observational studies on 12797 [[patients]]. The meta-analysis compared Chinese race (Chinese group) from all other races (non-Chinese group) as the data from China makes a major part of [[COVID-19]] related literature.<ref name="TariqSaha2020">{{cite journal|last1=Tariq|first1=Raseen|last2=Saha|first2=Srishti|last3=Furqan|first3=Fateeha|last4=Hassett|first4=Leslie|last5=Pardi|first5=Darrell|last6=Khanna|first6=Sahil|title=Prevalence and Mortality of COVID-19 patients with Gastrointestinal Symptoms: A Systematic Review and Meta-analysis|journal=Mayo Clinic Proceedings|year=2020|issn=00256196|doi=10.1016/j.mayocp.2020.06.003}}</ref>
+*There is no racial predilection for [[COVID-19]] associated [[anorexia]] according to a systematic review and meta-analysis of observational studies on 12,797 [[patients]]. The meta-analysis compared Chinese race (Chinese group) from all other races (non-Chinese group) as the data from China makes a major part of [[COVID-19]] related literature.<ref name="TariqSaha2020">{{cite journal|last1=Tariq|first1=Raseen|last2=Saha|first2=Srishti|last3=Furqan|first3=Fateeha|last4=Hassett|first4=Leslie|last5=Pardi|first5=Darrell|last6=Khanna|first6=Sahil|title=Prevalence and Mortality of COVID-19 patients with Gastrointestinal Symptoms: A Systematic Review and Meta-analysis|journal=Mayo Clinic Proceedings|year=2020|issn=00256196|doi=10.1016/j.mayocp.2020.06.003}}</ref>
 ==Risk Factors==
@@ Line 71: / Line 71: @@
 ==Diagnosis==
 ===Diagnostic Study of Choice===
-*There are no established criteria to identify the cause of [[COVID-19]] associated loss of appetite/ anorexia. [[COVID-19]] associated anorexia/ loss of appetite is a symptom, not a disease. [[Anorexia]] may be a symptom of direct injury of an involved abdominal organ or merely one of the symptoms of [[COVID-19]].
+*There are no established criteria to identify the cause of [[COVID-19]] associated loss of appetite/ anorexia. [[COVID-19]] associated [[anorexia]]/ loss of appetite is a symptom, not a disease. [[Anorexia]] may be a symptom of direct injury of an involved abdominal organ or merely one of the symptoms of [[COVID-19]].
 *COVID-19 [[anorexia]] can be diagnosed based on the history, timing of the symptoms, associated symptoms and signs such as [[abdominal pain]], [[nausea]] or [[vomiting]] (2nd and third most common symptoms) and most importantly, a positive [[Reverse transcription polymerase chain reaction|reverse transcriptase polymerase chain reaction]] (rRT-PCR) for [[COVID-19]].
 === History and Symptoms ===
 * History of contact with a person suspected or confirmed to have [[COVID-19]] infection is important to suspect [[COVID-19]] in a patient.
-*Based on a retrospective observational study including 1141 cases of [[COVID-19]] from Wuhan, China [[anorexia]] was the most common [[gastrointestinal]] symptom of [[COVID-19]].<ref name="pmid32205220">{{cite journal |vauthors=Luo S, Zhang X, Xu H |title=Don't Overlook Digestive Symptoms in Patients With 2019 Novel Coronavirus Disease (COVID-19) |journal=Clin. Gastroenterol. Hepatol. |volume=18 |issue=7 |pages=1636–1637 |date=June 2020 |pmid=32205220 |pmc=7154217 |doi=10.1016/j.cgh.2020.03.043 |url=}}</ref>
+*[[Anorexia]] is itself a symptom. Based on a retrospective observational study including 1,141 cases of [[COVID-19]] from Wuhan, China [[anorexia]] was the most common [[gastrointestinal]] symptom of [[COVID-19]].<ref name="pmid32205220">{{cite journal |vauthors=Luo S, Zhang X, Xu H |title=Don't Overlook Digestive Symptoms in Patients With 2019 Novel Coronavirus Disease (COVID-19) |journal=Clin. Gastroenterol. Hepatol. |volume=18 |issue=7 |pages=1636–1637 |date=June 2020 |pmid=32205220 |pmc=7154217 |doi=10.1016/j.cgh.2020.03.043 |url=}}</ref>
 *The most common accompanying symptoms of [[COVID-19]] besides [[anorexia]] were [[nausea]], [[vomiting]], and [[diarrhea]].<ref name="MaoQiu2020">{{cite journal|last1=Mao|first1=Ren|last2=Qiu|first2=Yun|last3=He|first3=Jin-Shen|last4=Tan|first4=Jin-Yu|last5=Li|first5=Xue-Hua|last6=Liang|first6=Jie|last7=Shen|first7=Jun|last8=Zhu|first8=Liang-Ru|last9=Chen|first9=Yan|last10=Iacucci|first10=Marietta|last11=Ng|first11=Siew C|last12=Ghosh|first12=Subrata|last13=Chen|first13=Min-Hu|title=Manifestations and prognosis of gastrointestinal and liver involvement in patients with COVID-19: a systematic review and meta-analysis|journal=The Lancet Gastroenterology & Hepatology|volume=5|issue=7|year=2020|pages=667–678|issn=24681253|doi=10.1016/S2468-1253(20)30126-6}}</ref>
 *The timing of symptoms and presence of co-morbid conditions helps differentiate the diseases with similar symptoms.
 ===Physical Examination===
-*Patients with [[COVID-19]] associated [[anorexia]] may appear [[lethargic]], [[fatigue]]d or [[irritable]].
+*Patients with [[COVID-19]] associated [[anorexia]] may appear [[lethargic]], [[fatigue]]d or [[irritable]]. Signs of [[dehydration]] include [[sunken eyes]] and dry [[mucosa]].
-*Signs of [[dehydration]] such as [[sunken eyes]] and dry [[mucosa]].
+Physical examination may be remarkable for:
-*[[Vital signs]]:<ref name="TeliasKatira2020">{{cite journal|last1=Telias|first1=Irene|last2=Katira|first2=Bhushan H.|last3=Brochard|first3=Laurent|title=Is the Prone Position Helpful During Spontaneous Breathing in Patients With COVID-19?|journal=JAMA|volume=323|issue=22|year=2020|pages=2265|issn=0098-7484|doi=10.1001/jama.2020.8539}}</ref><ref name="pmid32309266">{{cite journal |vauthors=Poggiali E, Ramos PM, Bastoni D, Vercelli A, Magnacavallo A |title=Abdominal Pain: A Real Challenge in Novel COVID-19 Infection |journal=Eur J Case Rep Intern Med |volume=7 |issue=4 |pages=001632 |date=2020 |pmid=32309266 |pmc=7162568 |doi=10.12890/2020_001632 |url=}}</ref>
+*[[Vital signs]]:<ref name="TeliasKatira2020">{{cite journal|last1=Telias|first1=Irene|last2=Katira|first2=Bhushan H.|last3=Brochard|first3=Laurent|title=Is the Prone Position Helpful During Spontaneous Breathing in Patients With COVID-19?|journal=JAMA|volume=323|issue=22|year=2020|pages=2265|issn=0098-7484|doi=10.1001/jama.2020.8539}}</ref><ref name="pmid32309266">{{cite journal |vauthors=Poggiali E, Ramos PM, Bastoni D, Vercelli A, Magnacavallo A |title=Abdominal Pain: A Real Challenge in Novel COVID-19 Infection |journal=Eur J Case Rep Intern Med |volume=7 |issue=4 |pages=001632 |date=2020 |pmid=32309266 |pmc=7162568 |doi=10.12890/2020_001632 |url=}}</ref><ref name="pmid32309266">{{cite journal |vauthors=Poggiali E, Ramos PM, Bastoni D, Vercelli A, Magnacavallo A |title=Abdominal Pain: A Real Challenge in Novel COVID-19 Infection |journal=Eur J Case Rep Intern Med |volume=7 |issue=4 |pages=001632 |date=2020 |pmid=32309266 |pmc=7162568 |doi=10.12890/2020_001632 |url=}}</ref><ref name="GuanNi2020">{{cite journal|last1=Guan|first1=Wei-jie|last2=Ni|first2=Zheng-yi|last3=Hu|first3=Yu|last4=Liang|first4=Wen-hua|last5=Ou|first5=Chun-quan|last6=He|first6=Jian-xing|last7=Liu|first7=Lei|last8=Shan|first8=Hong|last9=Lei|first9=Chun-liang|last10=Hui|first10=David S.C.|last11=Du|first11=Bin|last12=Li|first12=Lan-juan|last13=Zeng|first13=Guang|last14=Yuen|first14=Kwok-Yung|last15=Chen|first15=Ru-chong|last16=Tang|first16=Chun-li|last17=Wang|first17=Tao|last18=Chen|first18=Ping-yan|last19=Xiang|first19=Jie|last20=Li|first20=Shi-yue|last21=Wang|first21=Jin-lin|last22=Liang|first22=Zi-jing|last23=Peng|first23=Yi-xiang|last24=Wei|first24=Li|last25=Liu|first25=Yong|last26=Hu|first26=Ya-hua|last27=Peng|first27=Peng|last28=Wang|first28=Jian-ming|last29=Liu|first29=Ji-yang|last30=Chen|first30=Zhong|last31=Li|first31=Gang|last32=Zheng|first32=Zhi-jian|last33=Qiu|first33=Shao-qin|last34=Luo|first34=Jie|last35=Ye|first35=Chang-jiang|last36=Zhu|first36=Shao-yong|last37=Zhong|first37=Nan-shan|title=Clinical Characteristics of Coronavirus Disease 2019 in China|journal=New England Journal of Medicine|volume=382|issue=18|year=2020|pages=1708–1720|issn=0028-4793|doi=10.1056/NEJMoa2002032}}</ref>
 **[[Heart rate]]/[[Pulse]]: [[Tachycardia]] may be due to [[fever]], [[pain]] or [[shock]]. A low volume [[pulse]] is observed in severe [[dehydration]].
 **[[Blood pressure]]: Depending upon the cause of [[anorexia]] a patient with mild disease may have a normal [[blood pressure]] and others may present with [[shock]] due to [[infection]] and resulting [[sepsis]].
 **[[Respiratory rate]]: [[Tachypnea]] maybe due to high metabolic rate such as in [[fever]] and [[sepsis]] due to [[COVID-19]] along with inefficient [[ventilation]]. Inefficient ventilation can be due to [[COVID-19]] lung infection  such as [[pneumonia]] or [[ARDS]]. Shallow breathing can be due to severe [[respiratory distress]] or associated severe [[abdominal pain]].
 **[[Temperature]]: The patient can be [[fever|febrile]] due to [[COVID-19]] infection, hypothermic, or have a normal temperature.
-*On [[Abdominal exam]]:<ref name="pmid32523872">{{cite journal |vauthors=Abdalhadi A, Alkhatib M, Mismar AY, Awouda W, Albarqouni L |title=Can COVID 19 present like appendicitis? |journal=IDCases |volume=21 |issue= |pages=e00860 |date=2020 |pmid=32523872 |pmc=7265835 |doi=10.1016/j.idcr.2020.e00860 |url=}}</ref><ref name="pmid32387082">{{cite journal |vauthors=Hadi A, Werge M, Kristiansen KT, Pedersen UG, Karstensen JG, Novovic S, Gluud LL |title=Coronavirus Disease-19 (COVID-19) associated with severe acute pancreatitis: Case report on three family members |journal=Pancreatology |volume=20 |issue=4 |pages=665–667 |date=June 2020 |pmid=32387082 |pmc=7199002 |doi=10.1016/j.pan.2020.04.021 |url=}}</ref>
+*On [[Abdominal exam]]:<ref name="pmid32514859">{{cite journal |vauthors=Olry A, Meunier L, Délire B, Larrey D, Horsmans Y, Le Louët H |title=Drug-Induced Liver Injury and COVID-19 Infection: The Rules Remain the Same |journal=Drug Saf |volume=43 |issue=7 |pages=615–617 |date=July 2020 |pmid=32514859 |pmc=7279629 |doi=10.1007/s40264-020-00954-z |url=}}</ref><ref name="pmid32289115">{{cite journal |vauthors=Boettler T, Newsome PN, Mondelli MU, Maticic M, Cordero E, Cornberg M, Berg T |title=Care of patients with liver disease during the COVID-19 pandemic: EASL-ESCMID position paper |journal=JHEP Rep |volume=2 |issue=3 |pages=100113 |date=June 2020 |pmid=32289115 |pmc=7128473 |doi=10.1016/j.jhepr.2020.100113 |url=}}</ref><ref name="pmid32523872">{{cite journal |vauthors=Abdalhadi A, Alkhatib M, Mismar AY, Awouda W, Albarqouni L |title=Can COVID 19 present like appendicitis? |journal=IDCases |volume=21 |issue= |pages=e00860 |date=2020 |pmid=32523872 |pmc=7265835 |doi=10.1016/j.idcr.2020.e00860 |url=}}</ref><ref name="pmid32387082">{{cite journal |vauthors=Hadi A, Werge M, Kristiansen KT, Pedersen UG, Karstensen JG, Novovic S, Gluud LL |title=Coronavirus Disease-19 (COVID-19) associated with severe acute pancreatitis: Case report on three family members |journal=Pancreatology |volume=20 |issue=4 |pages=665–667 |date=June 2020 |pmid=32387082 |pmc=7199002 |doi=10.1016/j.pan.2020.04.021 |url=}}</ref>
-**Inspection: A patient with [[COVID-19-associated hepatic injury]] causing [[anorexia]] may have [[jaundice]].
+**Inspection: A patient with [[COVID-19-associated hepatic injury]] causing [[anorexia]] may have [[jaundice]]. (Jaundice may be observed in [[DILI]] associated with [[COVID-19]]).
 **Auscultation: Accompanying [[gastrointestinal]] infection may present as [[increased bowel sounds]] due to [[enteritis]].
-**Palpation: Based of a few case reports generalized abdominal or [[epigastric]] [[tenderness]] or [[right iliac fossa]] [[tenderness]] may accompany the symptom mimicking [[acute appendicitis]].
+**Palpation: Based on a few case reports generalized abdominal or [[epigastric]] [[tenderness]] or [[right iliac fossa]] [[tenderness]] may accompany the symptom mimicking [[acute appendicitis]].
 **Percussion: [[COVID-19-associated hepatic injury]] presenting as [[ascites]] may show a dull percussion note or [[shifting dullness]].
 *[[Respiratory examination|Respiratory exam]]:
@@ Line 98: / Line 98: @@
 ===Laboratory Findings===
-*Infectious [[virions]] in the [[gastrointestinal|GI]] or [[respiratory tract]] can be detected via [[Reverse transcription polymerase chain reaction|reverse transcriptase polymerase chain reaction]] (rRT-PCR).
+*There are no specific laboratory findings associated with [[anorexia]] among [[COVID-19]] patients.
-*[[Electrolyte disturbance]]s such as [[hypokalemia]] especially if [[diarrhea]] or [[vomiting]] accompanies. [[Hypovolemia|Hypovolemic]] [[Hyponatremia]] may occur in severe cases.
+*Laboratory findings consistent with the presence of infectious virions in the [[gastrointestinal|GI]] or [[respiratory tract]] detected via [[Reverse transcription polymerase chain reaction|reverse transcriptase-polymerase chain reaction]] (rRT-PCR) indicate a possible direct viral infectivity of the respective organ.<ref name="urlCDC’s Diagnostic Test for COVID-19 Only and Supplies | CDC">{{cite web |url=https://www.cdc.gov/coronavirus/2019-ncov/lab/virus-requests.html |title=CDC’s Diagnostic Test for COVID-19 Only and Supplies &#124; CDC |format= |work= |accessdate=}}</ref>
-*In [[CBC]] increased [[hemoglobin|Hb]] due to [[hemoconcentration]] if [[dehydration]] accompanies.
+*'''[[Serum electrolytes]]''': [[Hypokalemia]] is associated with [[anorexia]], [[diarrhea]] and [[vomiting]]. Retrospective studies from Italy and China demonstrated an association between [[hypokalemia]], [[hypomagnesemia]] and [[COVID-19]] due to degradation of [[angiotensin-converting enzyme|ACE 2]] loss, [[diuretic]] and [[corticosteroid]] use. [[Hypokalemia]] may lead to life-threatening [[arrhythmias]]. Close monitoring of serum electrolyte levels is essential especially in [[ICU]] patients.<ref name="pmid32525548">{{cite journal |vauthors=Chen D, Li X, Song Q, Hu C, Su F, Dai J, Ye Y, Huang J, Zhang X |title=Assessment of Hypokalemia and Clinical Characteristics in Patients With Coronavirus Disease 2019 in Wenzhou, China |journal=JAMA Netw Open |volume=3 |issue=6 |pages=e2011122 |date=June 2020 |pmid=32525548 |pmc=7290402 |doi=10.1001/jamanetworkopen.2020.11122 |url=}}</ref><ref name="AlfanoFerrari2020">{{cite journal|last1=Alfano|first1=Gaetano|last2=Ferrari|first2=Annachiara|last3=Fontana|first3=Francesco|last4=Perrone|first4=Rossella|last5=Mori|first5=Giacomo|last6=Ascione|first6=Elisabetta|last7=Riccardo|first7=Magistroni|last8=Venturi|first8=Giulia|last9=Pederzoli|first9=Simone|last10=Margiotta|first10=Gianluca|last11=Romeo|first11=Marilina|last12=Piccinini|first12=Francesca|last13=Franceschi|first13=Giacomo|last14=Volpi|first14=Sara|last15=Faltoni|first15=Matteo|last16=Ciusa|first16=Giacomo|last17=Bacca|first17=Erica|last18=Tutone|first18=Marco|last19=Raimondi|first19=Alessandro|last20=menozzi|first20=marianna|last21=Franceschini|first21=Erica|last22=Cuomo|first22=Gianluca|last23=Orlando|first23=Gabriella|last24=Santoro|first24=Antonella|last25=Di Gaetano|first25=Margherita|last26=Puzzolante|first26=Cinzia|last27=Carli|first27=Federica|last28=Bedini|first28=Andrea|last29=Milic|first29=Jovana|last30=Meschiari|first30=Marianna|last31=Mussini|first31=Cristina|last32=Cappelli|first32=Gianni|last33=Guaraldi|first33=Giovanni|year=2020|doi=10.1101/2020.06.14.20131169}}</ref>
-*Value of [[CRP]] and [[procalcitonin]] provide information on the inflammation and superimposed bacterial source of infection.<ref name="pmid32309266">{{cite journal |vauthors=Poggiali E, Ramos PM, Bastoni D, Vercelli A, Magnacavallo A |title=Abdominal Pain: A Real Challenge in Novel COVID-19 Infection |journal=Eur J Case Rep Intern Med |volume=7 |issue=4 |pages=001632 |date=2020 |pmid=32309266 |pmc=7162568 |doi=10.12890/2020_001632 |url=}}</ref>
+*'''[[Complete blood count]]''': Provides information regarding the infectious status of the patient via [[leukocytosis]] such as in [[COVID-19]] itself. In [[CBC]] increased [[hemoglobin|Hb]] due to [[hemoconcentration]] if [[dehydration]] accompanies.
+*'''[[Serum amylase]] and [[lipase]]''': Elevated serum levels demonstrate [[pancreatitis]].<ref name="WangWang2020">{{cite journal|last1=Wang|first1=Fan|last2=Wang|first2=Haizhou|last3=Fan|first3=Junli|last4=Zhang|first4=Yongxi|last5=Wang|first5=Hongling|last6=Zhao|first6=Qiu|title=Pancreatic Injury Patterns in Patients With Coronavirus Disease 19 Pneumonia|journal=Gastroenterology|volume=159|issue=1|year=2020|pages=367–370|issn=00165085|doi=10.1053/j.gastro.2020.03.055}}</ref>
+*'''[[CRP]] and [[procalcitonin]]''': The value provides information on the [[inflammation]] and superimposed bacterial source of infection.<ref name="pmid32309266">{{cite journal |vauthors=Poggiali E, Ramos PM, Bastoni D, Vercelli A, Magnacavallo A |title=Abdominal Pain: A Real Challenge in Novel COVID-19 Infection |journal=Eur J Case Rep Intern Med |volume=7 |issue=4 |pages=001632 |date=2020 |pmid=32309266 |pmc=7162568 |doi=10.12890/2020_001632 |url=}}</ref> A case of [[COVID-19]]  presenting as [[acute pancreatitis]] reports elevated procalcitonin.<ref name="pmid32444169">{{cite journal |vauthors=Aloysius MM, Thatti A, Gupta A, Sharma N, Bansal P, Goyal H |title=COVID-19 presenting as acute pancreatitis |journal=Pancreatology |volume= |issue= |pages= |date=May 2020 |pmid=32444169 |pmc=7207100 |doi=10.1016/j.pan.2020.05.003 |url=}}</ref>
+*'''[[Liver function tests]]''': Biochemical markers of liver injury such as [[bilirubin]], [[C-reactive protein|CRP]], [[alanine aminotransferase|ALT]], [[aspartate aminotransferase|AST]] and [[Gamma-glutamyltransferase|Gamma GT]] may be elevated in blood tests depicting [[COVID-19 associated hepatic injury|liver injury]].<ref name="pmid32309266">{{cite journal |vauthors=Poggiali E, Ramos PM, Bastoni D, Vercelli A, Magnacavallo A |title=Abdominal Pain: A Real Challenge in Novel COVID-19 Infection |journal=Eur J Case Rep Intern Med |volume=7 |issue=4 |pages=001632 |date=2020 |pmid=32309266 |pmc=7162568 |doi=10.12890/2020_001632 |url=}}</ref> A meta-analysis found a higher risk of raised [[ALT]] and [[AST]] among patients with severe [[COVID-19]].<ref name="pmid32405603">{{cite journal |vauthors=Mao R, Qiu Y, He JS, Tan JY, Li XH, Liang J, Shen J, Zhu LR, Chen Y, Iacucci M, Ng SC, Ghosh S, Chen MH |title=Manifestations and prognosis of gastrointestinal and liver involvement in patients with COVID-19: a systematic review and meta-analysis |journal=Lancet Gastroenterol Hepatol |volume=5 |issue=7 |pages=667–678 |date=July 2020 |pmid=32405603 |pmc=7217643 |doi=10.1016/S2468-1253(20)30126-6 |url=}}</ref>
 ===Electrocardiogram===
-*There are no ECG findings associated with [[COVID-19]] associated [[anorexia].
+*There are no ECG findings associated with [[COVID-19]] associated [[anorexia]].
 *The electrocardiogram findings in [[COVID-19]] can be viewed by [[COVID-19 electrocardiogram|clicking here]].
 ===X-ray===
-*In patients with [[COVID-19]] associated [[gastrointestinal|GI]] symptoms with [[anorexia]] as one of the symptoms, abdominal [[X-ray|Xrays]] have been reported to be normal in a few studies available.<ref name="pmid32387082">{{cite journal |vauthors=Hadi A, Werge M, Kristiansen KT, Pedersen UG, Karstensen JG, Novovic S, Gluud LL |title=Coronavirus Disease-19 (COVID-19) associated with severe acute pancreatitis: Case report on three family members |journal=Pancreatology |volume=20 |issue=4 |pages=665–667 |date=June 2020 |pmid=32387082 |pmc=7199002 |doi=10.1016/j.pan.2020.04.021 |url=}}</ref><ref name="pmid32523872">{{cite journal |vauthors=Abdalhadi A, Alkhatib M, Mismar AY, Awouda W, Albarqouni L |title=Can COVID 19 present like appendicitis? |journal=IDCases |volume=21 |issue= |pages=e00860 |date=2020 |pmid=32523872 |pmc=7265835 |doi=10.1016/j.idcr.2020.e00860 |url=}}</ref>
+*Among patients with [[COVID-19]] associated [[gastrointestinal|GI]] symptoms with [[anorexia]] as one of the symptoms, abdominal [[X-ray|Xrays]] have been reported to be normal in the few studies available.<ref name="pmid32387082">{{cite journal |vauthors=Hadi A, Werge M, Kristiansen KT, Pedersen UG, Karstensen JG, Novovic S, Gluud LL |title=Coronavirus Disease-19 (COVID-19) associated with severe acute pancreatitis: Case report on three family members |journal=Pancreatology |volume=20 |issue=4 |pages=665–667 |date=June 2020 |pmid=32387082 |pmc=7199002 |doi=10.1016/j.pan.2020.04.021 |url=}}</ref><ref name="pmid32523872">{{cite journal |vauthors=Abdalhadi A, Alkhatib M, Mismar AY, Awouda W, Albarqouni L |title=Can COVID 19 present like appendicitis? |journal=IDCases |volume=21 |issue= |pages=e00860 |date=2020 |pmid=32523872 |pmc=7265835 |doi=10.1016/j.idcr.2020.e00860 |url=}}</ref>
 *A [[Chest X-ray]] in a [[COVID-19]] patient may be normal or show patchy or diffuse reticular–nodular opacification and [[Pulmonary consolidation|consolidation]] with basal and peripheral predominance bilaterally. [[Bilateral]]  [[perihilar]] and [[interstitial]] opacities with [[Chest X-ray#Limitations|air bronchograms]] have also been reported. These X-ray findings  depict pulmonary disease [[COVID-19]].<ref name="pmid32519256">{{cite journal |vauthors=Cozzi D, Albanesi M, Cavigli E, Moroni C, Bindi A, Luvarà S, Lucarini S, Busoni S, Mazzoni LN, Miele V |title=Chest X-ray in new Coronavirus Disease 2019 (COVID-19) infection: findings and correlation with clinical outcome |journal=Radiol Med |volume=125 |issue=8 |pages=730–737 |date=August 2020 |pmid=32519256 |pmc=7282464 |doi=10.1007/s11547-020-01232-9 |url=}}</ref>
 * The signs are not related to [[anorexia]] directly. [[COVID-19]] being primarily a pulmonary disease, the findings may serve as important tools to help strongly suspect [[COVID-19]] even in the absence of [[RT PCR]]. A retrospective non-peer reviewed study reports the sensitivity of [[CXR]] to be 68% in detecting lung manifestations of [[COVID-19]].<ref name="pmid32519256">{{cite journal |vauthors=Cozzi D, Albanesi M, Cavigli E, Moroni C, Bindi A, Luvarà S, Lucarini S, Busoni S, Mazzoni LN, Miele V |title=Chest X-ray in new Coronavirus Disease 2019 (COVID-19) infection: findings and correlation with clinical outcome |journal=Radiol Med |volume=125 |issue=8 |pages=730–737 |date=August 2020 |pmid=32519256 |pmc=7282464 |doi=10.1007/s11547-020-01232-9 |url=}}</ref>
 *The x-ray findings in [[COVID-19]] can be viewed by [[COVID-19 x ray|clicking here]].
 ===Echocardiography or Ultrasound===
@@ Line 125: / Line 127: @@
 ===MRI===
 *There are no MRI findings associated with [[COVID-19]] associated [[anorexia]].
-*The MRI findings in [[COVID-19]] can be viewed by [[COVID-19 MRI|clicking here]].<br />
+*The MRI findings in [[COVID-19]] can be viewed by [[COVID-19 MRI|clicking here]].
 ===Other Imaging Findings===
@@ Line 133: / Line 135: @@
 ==Treatment==
 ===Medical Therapy===
-*The mainstay of treatment in COVID-19 infection is [[antiviral therapy]] such as lopinavir and ritonavir tablets and supportive therapy.
+*The mainstay of therapy for [[COVID-19]] associated [[anorexia]] is treating the cause. Anorexia may be due to direct injury of an involved abdominal organ or merely one of the symptoms of [[COVID-19]]. The recommended medical therapy is based on expert opinion rather than randomized control trials.
-*[[Rehydration]], [[Intravenous therapy#IV fluids|IV fluid therapy]], are essential if [[vomiting]] accompanies [[anorexia]].
+*[[COVID-19 medical therapy|Antiviral therapy]] for [[COVID-19]] may be administered along with supportive treatment. The [[antivirals]] that have been used for the treatment of [[COVID-19]] include [[Remdesivir|remdesivir]], [[lopinavir]]/[[ritonavir]] and [[darunavir]]/[[cobicistat]], control and prevent [[inflammation]] and symptomatic treatment.<ref name="CaoWang2020">{{cite journal|last1=Cao|first1=Bin|last2=Wang|first2=Yeming|last3=Wen|first3=Danning|last4=Liu|first4=Wen|last5=Wang|first5=Jingli|last6=Fan|first6=Guohui|last7=Ruan|first7=Lianguo|last8=Song|first8=Bin|last9=Cai|first9=Yanping|last10=Wei|first10=Ming|last11=Li|first11=Xingwang|last12=Xia|first12=Jiaan|last13=Chen|first13=Nanshan|last14=Xiang|first14=Jie|last15=Yu|first15=Ting|last16=Bai|first16=Tao|last17=Xie|first17=Xuelei|last18=Zhang|first18=Li|last19=Li|first19=Caihong|last20=Yuan|first20=Ye|last21=Chen|first21=Hua|last22=Li|first22=Huadong|last23=Huang|first23=Hanping|last24=Tu|first24=Shengjing|last25=Gong|first25=Fengyun|last26=Liu|first26=Ying|last27=Wei|first27=Yuan|last28=Dong|first28=Chongya|last29=Zhou|first29=Fei|last30=Gu|first30=Xiaoying|last31=Xu|first31=Jiuyang|last32=Liu|first32=Zhibo|last33=Zhang|first33=Yi|last34=Li|first34=Hui|last35=Shang|first35=Lianhan|last36=Wang|first36=Ke|last37=Li|first37=Kunxia|last38=Zhou|first38=Xia|last39=Dong|first39=Xuan|last40=Qu|first40=Zhaohui|last41=Lu|first41=Sixia|last42=Hu|first42=Xujuan|last43=Ruan|first43=Shunan|last44=Luo|first44=Shanshan|last45=Wu|first45=Jing|last46=Peng|first46=Lu|last47=Cheng|first47=Fang|last48=Pan|first48=Lihong|last49=Zou|first49=Jun|last50=Jia|first50=Chunmin|last51=Wang|first51=Juan|last52=Liu|first52=Xia|last53=Wang|first53=Shuzhen|last54=Wu|first54=Xudong|last55=Ge|first55=Qin|last56=He|first56=Jing|last57=Zhan|first57=Haiyan|last58=Qiu|first58=Fang|last59=Guo|first59=Li|last60=Huang|first60=Chaolin|last61=Jaki|first61=Thomas|last62=Hayden|first62=Frederick G.|last63=Horby|first63=Peter W.|last64=Zhang|first64=Dingyu|last65=Wang|first65=Chen|title=A Trial of Lopinavir–Ritonavir in Adults Hospitalized with Severe Covid-19|journal=New England Journal of Medicine|volume=382|issue=19|year=2020|pages=1787–1799|issn=0028-4793|doi=10.1056/NEJMoa2001282}}</ref><ref name="pmid32056407">{{cite journal |vauthors=Lim J, Jeon S, Shin HY, Kim MJ, Seong YM, Lee WJ, Choe KW, Kang YM, Lee B, Park SJ |title=Case of the Index Patient Who Caused Tertiary Transmission of COVID-19 Infection in Korea: the Application of Lopinavir/Ritonavir for the Treatment of COVID-19 Infected Pneumonia Monitored by Quantitative RT-PCR |journal=J. Korean Med. Sci. |volume=35 |issue=6 |pages=e79 |date=February 2020 |pmid=32056407 |pmc=7025910 |doi=10.3346/jkms.2020.35.e79 |url=}}</ref><ref name="pmid32289472">{{cite journal |vauthors=Nicola M, O'Neill N, Sohrabi C, Khan M, Agha M, Agha R |title=Evidence based management guideline for the COVID-19 pandemic - Review article |journal=Int J Surg |volume=77 |issue= |pages=206–216 |date=May 2020 |pmid=32289472 |pmc=7151371 |doi=10.1016/j.ijsu.2020.04.001 |url=}}</ref>
-*Associated [[vomiting]] is treated with [[antiemetic]] drugs and [[diarrhea]] is treated with [[antidiarrheal]] drugs such as [[loperamide]].
+*Treating the cause of [[anorexia]] associated with [[COVID-19]] will treat the symptom.
-*[[Loperamide]] is not administered if the patient has [[C. difficile]] infection or signs of infection such as [[fever]], [[Hematochezia|bloody stools]].
+*[[Rehydration]], [[Intravenous therapy#IV fluids|IV fluid therapy]], are essential in [[dehydration]] due to respiratory manifestations or if severe [[vomiting]] accompanies [[anorexia]].<ref name="pmid32289472">{{cite journal |vauthors=Nicola M, O'Neill N, Sohrabi C, Khan M, Agha M, Agha R |title=Evidence based management guideline for the COVID-19 pandemic - Review article |journal=Int J Surg |volume=77 |issue= |pages=206–216 |date=May 2020 |pmid=32289472 |pmc=7151371 |doi=10.1016/j.ijsu.2020.04.001 |url=}}</ref>
+*Associated [[vomiting]] may be treated with [[antiemetic]] drugs and [[diarrhea]] is treated with [[antidiarrheal]] drugs such as [[loperamide]]. Thorough literature on the use of [[antiemetics]] in [[COVID-19]] was not found.
+*[[Loperamide]] and [[narcotics]]are not administered if the patient has [[C. difficile]] infection or signs of infection such as [[fever]] and [[Hematochezia|bloody stools]].<ref name="pmid23127735">{{cite journal |vauthors=Khanna S, Pardi DS |title=Clostridium difficile infection: new insights into management |journal=Mayo Clin. Proc. |volume=87 |issue=11 |pages=1106–17 |date=November 2012 |pmid=23127735 |pmc=3541870 |doi=10.1016/j.mayocp.2012.07.016 |url=}}</ref>
 *Although the [[COVID-19]] infection and [[inflammatory bowel disease|IBDs]] mimic in some parameters, [[glucocorticoids]] such as [[prednisone]] treatment should not be abruptly discontinued but tapered to a possible minimum dose.
-*A dose above ⩾20 mg/day for prednisone should be tapered to stop if patient becomesCOVID-19 positive or prevent infection.<ref name="pmid32321117">{{cite journal |vauthors=Queiroz NSF, Barros LL, Azevedo MFC, Oba J, Sobrado CW, Carlos AS, Milani LR, Sipahi AM, Damião AOMC |title=Management of inflammatory bowel disease patients in the COVID-19 pandemic era: a Brazilian tertiary referral center guidance |journal=Clinics (Sao Paulo) |volume=75 |issue= |pages=e1909 |date=2020 |pmid=32321117 |pmc=7153358 |doi=10.6061/clinics/2020/e1909 |url=}}</ref><ref name="SuShen2020">{{cite journal|last1=Su|first1=Song|last2=Shen|first2=Jun|last3=Zhu|first3=Liangru|last4=Qiu|first4=Yun|last5=He|first5=Jin-Shen|last6=Tan|first6=Jin-Yu|last7=Iacucci|first7=Marietta|last8=Ng|first8=Siew C|last9=Ghosh|first9=Subrata|last10=Mao|first10=Ren|last11=Liang|first11=Jie|title=Involvement of digestive system in COVID-19: manifestations, pathology, management and challenges|journal=Therapeutic Advances in Gastroenterology|volume=13|year=2020|pages=175628482093462|issn=1756-2848|doi=10.1177/1756284820934626}}</ref>
+*A dose above ⩾20 mg/day for prednisone should be tapered to stop if patient becomes COVID-19 positive or prevent infection.<ref name="pmid32321117">{{cite journal |vauthors=Queiroz NSF, Barros LL, Azevedo MFC, Oba J, Sobrado CW, Carlos AS, Milani LR, Sipahi AM, Damião AOMC |title=Management of inflammatory bowel disease patients in the COVID-19 pandemic era: a Brazilian tertiary referral center guidance |journal=Clinics (Sao Paulo) |volume=75 |issue= |pages=e1909 |date=2020 |pmid=32321117 |pmc=7153358 |doi=10.6061/clinics/2020/e1909 |url=}}</ref><ref name="SuShen2020">{{cite journal|last1=Su|first1=Song|last2=Shen|first2=Jun|last3=Zhu|first3=Liangru|last4=Qiu|first4=Yun|last5=He|first5=Jin-Shen|last6=Tan|first6=Jin-Yu|last7=Iacucci|first7=Marietta|last8=Ng|first8=Siew C|last9=Ghosh|first9=Subrata|last10=Mao|first10=Ren|last11=Liang|first11=Jie|title=Involvement of digestive system in COVID-19: manifestations, pathology, management and challenges|journal=Therapeutic Advances in Gastroenterology|volume=13|year=2020|pages=175628482093462|issn=1756-2848|doi=10.1177/1756284820934626}}</ref>
+*The medical therapy used for [[COVID-19]] can be viewed by [[COVID-19 medical therapy|clicking here]].
+*There are no clear guidelines on the evaluation of response to [[COVID-19]] associated [[anorexia]]. A review article on evidence-based management guidelines for the [[COVID-19]] reports a raised [[CRP]] and low [[albumin]] to be associated with deterioration in [[patient]]s' condition. Demonstration of viral clearance in two respiratory tract specimens (at least 24 hours apart) may also serve as a monitoring tool.<ref name="pmid32289472">{{cite journal |vauthors=Nicola M, O'Neill N, Sohrabi C, Khan M, Agha M, Agha R |title=Evidence based management guideline for the COVID-19 pandemic - Review article |journal=Int J Surg |volume=77 |issue= |pages=206–216 |date=May 2020 |pmid=32289472 |pmc=7151371 |doi=10.1016/j.ijsu.2020.04.001 |url=}}</ref>
 ===Primary Prevention===
-*
+*There are no available [[vaccine]]s for the prevention of [[COVID-19]]. There have been rigorous efforts in order to develop a [[vaccine]] for [[COVID-10|novel coronavirus]] and several vaccines are in the later phases of trials.<ref name="urlNIH clinical trial of investigational vaccine for COVID-19 begins | National Institutes of Health (NIH)">{{cite web |url=https://www.nih.gov/news-events/news-releases/nih-clinical-trial-investigational-vaccine-covid-19-begins |title=NIH clinical trial of investigational vaccine for COVID-19 begins &#124; National Institutes of Health (NIH) |format= |work= |accessdate=}}</ref>
 *Effective measures for the [[primary prevention]] of COVID-19 include::<ref name="urlHow to Protect Yourself & Others | CDC">{{cite web |url=https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html |title=How to Protect Yourself & Others &#124; CDC |format= |work= |accessdate=}}</ref>
 **Frequent hand-washing with soap and water for at least 20 seconds or using a [[alcohol rub|alcohol based hand sanitizer]] with at least 60% alcohol. [[Alcohol]] means [[ethanol]] here not [[methanol]]/ wood alcohol, as [[FDA]] warns against the use of [[methanol]] containing hand-wash.<ref name="urlCoronavirus (COVID-19) Update: FDA Takes Action to Warn, Protect Consumers from Dangerous Alcohol-Based Hand Sanitizers Containing Methanol | FDA">{{cite web |url=https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-takes-action-warn-protect-consumers-dangerous-alcohol-based-hand |title=Coronavirus (COVID-19) Update: FDA Takes Action to Warn, Protect Consumers from Dangerous Alcohol-Based Hand Sanitizers Containing Methanol &#124; FDA |format= |work= |accessdate=}}</ref>
@@ Line 147: / Line 155: @@
 **Covering your mouth and nose with a cloth face cover when around others and covering [[sneeze]]s and [[cough]]s.
 **Cleaning and [[disinfect]]ing.
-*There have been rigorous efforts in order to develop a [[vaccine]] for [[COVID-10|novel coronavirus]] and several vaccines are in the later phases of trials.<ref name="urlNIH clinical trial of investigational vaccine for COVID-19 begins | National Institutes of Health (NIH)">{{cite web |url=https://www.nih.gov/news-events/news-releases/nih-clinical-trial-investigational-vaccine-covid-19-begins |title=NIH clinical trial of investigational vaccine for COVID-19 begins &#124; National Institutes of Health (NIH) |format= |work= |accessdate=}}</ref>
 ===Secondary prevention===
@@ Line 155: / Line 162: @@
 **Screening of fecal [[Microbiome|microbiota]] [[transplant]] donors for [[COVID-19]] is also recommended.<ref name="pmid32240618">{{cite journal |vauthors=Green CA, Quraishi MN, Shabir S, Sharma N, Hansen R, Gaya DR, Hart AL, Loman NJ, Iqbal TH |title=Screening faecal microbiota transplant donors for SARS-CoV-2 by molecular testing of stool is the safest way forward |journal=Lancet Gastroenterol Hepatol |volume=5 |issue=6 |pages=531 |date=June 2020 |pmid=32240618 |pmc=7225406 |doi=10.1016/S2468-1253(20)30089-3 |url=}}</ref>
 **[[Contact tracing]] helps reduce the spread of the disease.<ref name="urlContact Tracing for COVID-19 | CDC">{{cite web |url=https://www.cdc.gov/coronavirus/2019-ncov/php/contact-tracing/contact-tracing-plan/contact-tracing.html |title=Contact Tracing for COVID-19 &#124; CDC |format= |work= |accessdate=}}</ref>
+*Oncologists from Wright State University OH, USA suggest fellow oncologists reconsider the routine use of prophylactic [[dexamethasone]] as an [[antiemetic]] among [cancer patients who are not infected with [COVID-19]]. As reported in several studies, higher [[lymphocyte]] level may be associated with better outcomes in [[COVID-19]], avoiding [[dexamethasone]] will help avoid inducing [[lymphopenia]].<ref name="pmid32507102">{{cite journal |vauthors=Marinella MA |title=Routine antiemetic prophylaxis with dexamethasone during COVID-19: Should oncologists reconsider? |journal=J Oncol Pharm Pract |volume= |issue= |pages=1078155220931921 |date=June 2020 |pmid=32507102 |doi=10.1177/1078155220931921 |url=}}</ref>
 ==References==