COVID-19-associated diarrhea: Difference between revisions

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__NOTOC__
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''Main article:'' [[COVID-19]]
'''For COVID-19 frequently asked inpatient questions, click [[COVID-19 frequently asked inpatient questions|here]]'''
'''For COVID-19 frequently asked outpatient questions, click [[COVID-19 frequently asked outpatient questions|here]]'''<br>


{{CMG}}; {{AE}} {{IF}}
{{CMG}}; {{AE}} {{IF}}
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==Overview==
==Overview==
SARS-CoV-2 mainly causes severe acute respiratory syndrome but may also present with gastrointestinal symptoms like diarrhea. It invades through the [[Angiotensin-converting enzyme 2|Angiotensin-converting enzyme 2 (]]ACE2) and the serine protease [[TMPRSS2]] receptors present abundantly not only in the lungs but also in the [[Enterocyte|enterocytes]] of the [[small intestine]]. A greater prevalence of [[diarrhea]] was observed in patients with severe [[COVID-19]] when compared to non-severe disease. Likewise, patients with gastrointestinal symptoms were more likely to have a severe [[respiratory]] disease with [[Acute respiratory distress syndrome|ARDS]] requiring ventilatory support. The presence of the [[virus]] in the [[Human feces|stool]] raises suspicion for fecal-oral transmission of SARS-CoV-2. Appropriate personal protective equipment (PPE) must be used while handling sources of [[contamination]] like [[feces]].


==Historical Perspective==
==Historical Perspective==
* The etiological agent is SARS-CoV-2, named for the similarity of its symptoms to those induced by the [[severe acute respiratory syndrome]], causing coronavirus disease 2019 (COVID-19), is a [[virus]] identified as the cause of an outbreak of [[respiratory illness]] first detected in Wuhan, China.<ref>{{Cite web|url=https://www.cdc.gov/coronavirus/2019-ncov/about/index.html|title=|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref><ref name="LuCui2020">{{cite journal|last1=Lu|first1=Jian|last2=Cui|first2=Jie|last3=Qian|first3=Zhaohui|last4=Wang|first4=Yirong|last5=Zhang|first5=Hong|last6=Duan|first6=Yuange|last7=Wu|first7=Xinkai|last8=Yao|first8=Xinmin|last9=Song|first9=Yuhe|last10=Li|first10=Xiang|last11=Wu|first11=Changcheng|last12=Tang|first12=Xiaolu|title=On the origin and continuing evolution of SARS-CoV-2|journal=National Science Review|year=2020|issn=2095-5138|doi=10.1093/nsr/nwaa036}}</ref>
* The etiological agent is SARS-CoV-2, named for the similarity of its symptoms to those induced by the [[severe acute respiratory syndrome]], causing coronavirus disease 2019 (COVID-19), is a [[virus]] identified as the cause of an outbreak of [[respiratory illness]] first detected in Wuhan, China.<ref>{{Cite web|url=https://www.cdc.gov/coronavirus/2019-ncov/about/index.html|title=|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref><ref name="LuCui2020">{{cite journal|last1=Lu|first1=Jian|last2=Cui|first2=Jie|last3=Qian|first3=Zhaohui|last4=Wang|first4=Yirong|last5=Zhang|first5=Hong|last6=Duan|first6=Yuange|last7=Wu|first7=Xinkai|last8=Yao|first8=Xinmin|last9=Song|first9=Yuhe|last10=Li|first10=Xiang|last11=Wu|first11=Changcheng|last12=Tang|first12=Xiaolu|title=On the origin and continuing evolution of SARS-CoV-2|journal=National Science Review|year=2020|issn=2095-5138|doi=10.1093/nsr/nwaa036}}</ref>
*The growing number of [[patients]] however, suggest that human-to-human transmission is actively occurring.<ref name="HuangWang2020">{{cite journal|last1=Huang|first1=Chaolin|last2=Wang|first2=Yeming|last3=Li|first3=Xingwang|last4=Ren|first4=Lili|last5=Zhao|first5=Jianping|last6=Hu|first6=Yi|last7=Zhang|first7=Li|last8=Fan|first8=Guohui|last9=Xu|first9=Jiuyang|last10=Gu|first10=Xiaoying|last11=Cheng|first11=Zhenshun|last12=Yu|first12=Ting|last13=Xia|first13=Jiaan|last14=Wei|first14=Yuan|last15=Wu|first15=Wenjuan|last16=Xie|first16=Xuelei|last17=Yin|first17=Wen|last18=Li|first18=Hui|last19=Liu|first19=Min|last20=Xiao|first20=Yan|last21=Gao|first21=Hong|last22=Guo|first22=Li|last23=Xie|first23=Jungang|last24=Wang|first24=Guangfa|last25=Jiang|first25=Rongmeng|last26=Gao|first26=Zhancheng|last27=Jin|first27=Qi|last28=Wang|first28=Jianwei|last29=Cao|first29=Bin|title=Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China|journal=The Lancet|volume=395|issue=10223|year=2020|pages=497–506|issn=01406736|doi=10.1016/S0140-6736(20)30183-5}}</ref><ref>{{Cite web|url=https://www.cdc.gov/coronavirus/2019-ncov/about/transmission.html|title=|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref>
*The growing number of [[patients]] however, suggest that human-to-human [[Transmission (medicine)|transmission]] is actively occurring.<ref name="HuangWang2020">{{cite journal|last1=Huang|first1=Chaolin|last2=Wang|first2=Yeming|last3=Li|first3=Xingwang|last4=Ren|first4=Lili|last5=Zhao|first5=Jianping|last6=Hu|first6=Yi|last7=Zhang|first7=Li|last8=Fan|first8=Guohui|last9=Xu|first9=Jiuyang|last10=Gu|first10=Xiaoying|last11=Cheng|first11=Zhenshun|last12=Yu|first12=Ting|last13=Xia|first13=Jiaan|last14=Wei|first14=Yuan|last15=Wu|first15=Wenjuan|last16=Xie|first16=Xuelei|last17=Yin|first17=Wen|last18=Li|first18=Hui|last19=Liu|first19=Min|last20=Xiao|first20=Yan|last21=Gao|first21=Hong|last22=Guo|first22=Li|last23=Xie|first23=Jungang|last24=Wang|first24=Guangfa|last25=Jiang|first25=Rongmeng|last26=Gao|first26=Zhancheng|last27=Jin|first27=Qi|last28=Wang|first28=Jianwei|last29=Cao|first29=Bin|title=Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China|journal=The Lancet|volume=395|issue=10223|year=2020|pages=497–506|issn=01406736|doi=10.1016/S0140-6736(20)30183-5}}</ref><ref>{{Cite web|url=https://www.cdc.gov/coronavirus/2019-ncov/about/transmission.html|title=|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref>
*The outbreak was declared a Public Health Emergency of International Concern on 30 January 2020.
*The outbreak was declared a Public Health Emergency of International Concern on 30 January 2020.
*On March 12, 2020 the World Health Organization declared the COVID-19 outbreak a pandemic.
*On March 12, 2020, the [[World Health Organization]] declared the COVID-19 outbreak a [[pandemic]].


==Classification==
==Classification==
There is no established system for the classification of diarrhea in COVID-19
There is no established system for the classification of diarrhea in COVID-19.


==Pathophysiology==
==Pathophysiology==
*SARS-CoV-2 uses the Angiotensin-converting enzyme 2 (ACE2) and the serine protease TMPRSS2 receptors for cell entry. These receptors are presently abundantly not only in the lungs but also in the enterocytes of the small intestinal.<ref name="pmid32278065">{{cite journal| author=D'Amico F, Baumgart DC, Danese S, Peyrin-Biroulet L| title=Diarrhea During COVID-19 Infection: Pathogenesis, Epidemiology, Prevention, and Management. | journal=Clin Gastroenterol Hepatol | year= 2020 | volume=  | issue=  | pages=  | pmid=32278065 | doi=10.1016/j.cgh.2020.04.001 | pmc=7141637 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32278065  }} </ref><ref name="pmid32102928">{{cite journal| author=Liang W, Feng Z, Rao S, Xiao C, Xue X, Lin Z | display-authors=etal| title=Diarrhoea may be underestimated: a missing link in 2019 novel coronavirus. | journal=Gut | year= 2020 | volume= 69 | issue= 6 | pages= 1141-1143 | pmid=32102928 | doi=10.1136/gutjnl-2020-320832 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32102928  }} </ref> Other sites of expression of the receptors in the gastrointestinal tract are-the upper esophagus, liver, and colon. <ref name="pmid32278065">{{cite journal| author=D'Amico F, Baumgart DC, Danese S, Peyrin-Biroulet L| title=Diarrhea During COVID-19 Infection: Pathogenesis, Epidemiology, Prevention, and Management. | journal=Clin Gastroenterol Hepatol | year= 2020 | volume=  | issue=  | pages=  | pmid=32278065 | doi=10.1016/j.cgh.2020.04.001 | pmc=7141637 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32278065  }} </ref>
*SARS-CoV-2 uses the [[Angiotensin-converting enzyme 2]] (ACE2) and the [[serine protease]] [[TMPRSS2]] receptors for cell entry.  
*Entry of the virus causes disruption of the enterocytes and may lead to inflammation and alteration of intestinal permeability.  
*These receptors are present abundantly not only in the [[Lung|lungs]] but also in the [[Enterocyte|enterocytes]] of the [[small intestine]].<ref name="pmid32278065">{{cite journal| author=D'Amico F, Baumgart DC, Danese S, Peyrin-Biroulet L| title=Diarrhea During COVID-19 Infection: Pathogenesis, Epidemiology, Prevention, and Management. | journal=Clin Gastroenterol Hepatol | year= 2020 | volume=  | issue=  | pages=  | pmid=32278065 | doi=10.1016/j.cgh.2020.04.001 | pmc=7141637 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32278065  }} </ref><ref name="pmid32102928">{{cite journal| author=Liang W, Feng Z, Rao S, Xiao C, Xue X, Lin Z | display-authors=etal| title=Diarrhoea may be underestimated: a missing link in 2019 novel coronavirus. | journal=Gut | year= 2020 | volume= 69 | issue= 6 | pages= 1141-1143 | pmid=32102928 | doi=10.1136/gutjnl-2020-320832 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32102928  }} </ref>
*COVID- 19 is being treated by atrial of many different antivirals and antibiotics. Diarrhea could also be a result of an alteration of the gut microbiota due to any of these. <ref name="pmid32096611">{{cite journal| author=Gao QY, Chen YX, Fang JY| title=2019 Novel coronavirus infection and gastrointestinal tract. | journal=J Dig Dis | year= 2020 | volume= 21 | issue= 3 | pages= 125-126 | pmid=32096611 | doi=10.1111/1751-2980.12851 | pmc=7162053 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32096611  }} </ref>
*Other sites of receptor expression in the gastrointestinal tract are-the upper [[esophagus]], [[liver]], and [[Colon (anatomy)|colon]]. <ref name="pmid32278065">{{cite journal| author=D'Amico F, Baumgart DC, Danese S, Peyrin-Biroulet L| title=Diarrhea During COVID-19 Infection: Pathogenesis, Epidemiology, Prevention, and Management. | journal=Clin Gastroenterol Hepatol | year= 2020 | volume=  | issue=  | pages=  | pmid=32278065 | doi=10.1016/j.cgh.2020.04.001 | pmc=7141637 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32278065  }} </ref>
*Entry of the virus causes disruption of the [[Enterocyte|enterocytes]] and may lead to inflammation and alteration of [[Intestine|intestinal]] [[permeability]].
*COVID-19 is being treated by a trial of many different antivirals and antibiotics.
*Diarrhea could also be a result of an alteration of the gut [[Microbiome|microbiota]] due to any of these. <ref name="pmid32096611">{{cite journal| author=Gao QY, Chen YX, Fang JY| title=2019 Novel coronavirus infection and gastrointestinal tract. | journal=J Dig Dis | year= 2020 | volume= 21 | issue= 3 | pages= 125-126 | pmid=32096611 | doi=10.1111/1751-2980.12851 | pmc=7162053 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32096611  }} </ref>


==Causes==
==Causes==
Disease name] may be caused by [cause1], [cause2], or [cause3].
Diarrhea in a patient hospitalized due to COVID-19 may be due to:
 
* COVID-19 associated [[diarrhea]]
OR
* Secondary [[Bacteria|bacterial]] infections
*[[Clostridium difficile diarrhea resident survival guide|Clostridium difficile diarrhea]] and recent use of [[antibiotics]]
* Other [[Infection|infectious]] causes


Common causes of [disease] include [cause1], [cause2], and [cause3].
==Differentiating COVID-19 associated diarrhea from other Diseases==
COVID-19 diarrhea must be differentiated from other diseases that cause diarrhea, such as:<ref name="pmid32314792">{{cite journal| author=Occhipinti V, Pastorelli L| title=Challenges in the Care of IBD Patients During the CoViD-19 Pandemic: Report From a "Red Zone" Area in Northern Italy. | journal=Inflamm Bowel Dis | year= 2020 | volume= 26 | issue= 6 | pages= 793-796 | pmid=32314792 | doi=10.1093/ibd/izaa084 | pmc=7188155 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32314792  }} </ref>


OR
* Secondary [[bacterial]] [[Infection|infections]]
*[[Clostridium difficile-associated diarrhea|Clostridium difficile]] associated diarrhea
*[[Virus|Viral]] causes
*[[Parasitic]] causes


The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].
*[[Crohn's disease (patient information)|Crohn's disease]]
*[[Ulcerative colitis|Ulcerative Colitis]]
*[[Autoimmune hepatitis]]


OR
To review the differential diagnosis of diarrhea due to various organisms, click [[COVID-19 associated diarrhea differential diagnosis|here]].


The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click [[Pericarditis causes#Overview|here]].
To review the differential diagnosis of diarrhea, click [[Diarrhea#Differential Diagnosis of Diarrhea of other diseases|here]].
 
==Differentiating ((Page name)) from other Diseases==
[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
 
OR
 
[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].


==Epidemiology and Demographics==
==Epidemiology and Demographics==
*Diarrhea is an uncommon gastrointestinal symptom in patients with COVID-19, but may be the presenting symptom in a few patients.  
*Diarrhea is an uncommon gastrointestinal symptom ([[anorexia]], [[Nausea and vomiting|nausea]], and [[Nausea and vomiting|vomiting]] are more common) in patients with [[COVID-19]] but may be the presenting symptom in a few patients.
*The frequency of occurrence of diarrhea varies between 1%-35%. <ref name="pmid32253163">{{cite journal| author=Li XY, Dai WJ, Wu SN, Yang XZ, Wang HG| title=The occurrence of diarrhea in COVID-19 patients. | journal=Clin Res Hepatol Gastroenterol | year= 2020 | volume=  | issue=  | pages=  | pmid=32253163 | doi=10.1016/j.clinre.2020.03.017 | pmc=7270575 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32253163  }} </ref>It varies widely between different studies probably due to the different criteria used to define diarrhea.
*The frequency of occurrence of diarrhea varies between 1%-35%. <ref name="pmid32253163">{{cite journal| author=Li XY, Dai WJ, Wu SN, Yang XZ, Wang HG| title=The occurrence of diarrhea in COVID-19 patients. | journal=Clin Res Hepatol Gastroenterol | year= 2020 | volume=  | issue=  | pages=  | pmid=32253163 | doi=10.1016/j.clinre.2020.03.017 | pmc=7270575 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32253163  }} </ref>
* Greater percentage of occurrence of diarrhea was noted in patients with severe COVID-19 when compared to non-severe disease.  
*It varies widely between different studies, likely due to the different [[Criterion|criteria]] used to define [[diarrhea]].
*Likewise, patients with gastrointenstinal symptoms were more likely to have severe respiratory disease with ARDS requiring ventilatory support. <ref name="pmid32213556">{{cite journal| author=Jin X, Lian JS, Hu JH, Gao J, Zheng L, Zhang YM | display-authors=etal| title=Epidemiological, clinical and virological characteristics of 74 cases of coronavirus-infected disease 2019 (COVID-19) with gastrointestinal symptoms. | journal=Gut | year= 2020 | volume= 69 | issue= 6 | pages= 1002-1009 | pmid=32213556 | doi=10.1136/gutjnl-2020-320926 | pmc=7133387 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32213556  }} </ref> <ref name="pmid32109013">{{cite journal| author=Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX | display-authors=etal| title=Clinical Characteristics of Coronavirus Disease 2019 in China. | journal=N Engl J Med | year= 2020 | volume= 382 | issue= 18 | pages= 1708-1720 | pmid=32109013 | doi=10.1056/NEJMoa2002032 | pmc=7092819 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32109013  }} </ref>
* Greater prevalence of [[diarrhea]] was noted in patients with severe [[COVID-19]] when compared to non-severe disease.
*Likewise, patients with [[Stomach|gastrointenstinal]] symptoms were more likely to have severe respiratory disease with [[Acute respiratory distress syndrome|ARDS]] requiring [[Ventilation|ventilatory]] support. <ref name="pmid32213556">{{cite journal| author=Jin X, Lian JS, Hu JH, Gao J, Zheng L, Zhang YM | display-authors=etal| title=Epidemiological, clinical and virological characteristics of 74 cases of coronavirus-infected disease 2019 (COVID-19) with gastrointestinal symptoms. | journal=Gut | year= 2020 | volume= 69 | issue= 6 | pages= 1002-1009 | pmid=32213556 | doi=10.1136/gutjnl-2020-320926 | pmc=7133387 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32213556  }} </ref> <ref name="pmid32109013">{{cite journal| author=Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX | display-authors=etal| title=Clinical Characteristics of Coronavirus Disease 2019 in China. | journal=N Engl J Med | year= 2020 | volume= 382 | issue= 18 | pages= 1708-1720 | pmid=32109013 | doi=10.1056/NEJMoa2002032 | pmc=7092819 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32109013  }} </ref>


There is no data on predilection based on age, gender, geographical location, or race.
* There is no data on predilection based on age, gender, geographical location, or race.


==Risk Factors==
==Risk Factors==
There are no established risk factors for [disease name].
Common risk factors in the development of gastrointestinal symptoms in patients with  COVID-19 infection include:
 
*[[Inflammatory bowel disease]] patients- due to use to [[glucocorticoids]], but not [[TNF-alpha|TNF-alpha inhibitors]] <ref name="pmid32425234">{{cite journal| author=Brenner EJ, Ungaro RC, Gearry RB, Kaplan GG, Kissous-Hunt M, Lewis JD | display-authors=etal| title=Corticosteroids, but not TNF Antagonists, are Associated with Adverse COVID-19 Outcomes in Patients With Inflammatory Bowel Diseases: Results from an International Registry. | journal=Gastroenterology | year= 2020 | volume=  | issue=  | pages=  | pmid=32425234 | doi=10.1053/j.gastro.2020.05.032 | pmc=7233252 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32425234  }} </ref>
OR
* Increasing [[age]]
 
* Other [[Comorbidity|comorbidities]] such as [[Hypertension|HTN]], [[DM]]  
The most potent risk factor in the development of [disease name] is [risk factor 1]. Other risk factors include [risk factor 2], [risk factor 3], and [risk factor 4].
* Use of [[glucocorticoids]]
 
OR
 
Common risk factors in the development of [disease name] include [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].
 
OR
 
Common risk factors in the development of [disease name] may be occupational, environmental, genetic, and viral.


==Screening==
==Screening==
There is insufficient evidence to recommend routine screening for [disease/malignancy].
OR
According to the [guideline name], screening for [disease name] is not recommended.
OR


According to the [guideline name], screening for [disease name] by [test 1] is recommended every [duration] among patients with [condition 1], [condition 2], and [condition 3].
* There is insufficient evidence to recommend routine screening in detecting covid associated diarrhea.  


==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
OR
Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].


OR
*Presence of diarrheal symptoms in covid-19 infection is associated with severe form of disease.
 
*Severe or poor prognostic form of disease can be described as [[Acute respiratory distress syndrome|ARDS]] requiring [[Mechanical ventilation|ventilatory support]].<ref name="pmid32213556">{{cite journal| author=Jin X, Lian JS, Hu JH, Gao J, Zheng L, Zhang YM | display-authors=etal| title=Epidemiological, clinical and virological characteristics of 74 cases of coronavirus-infected disease 2019 (COVID-19) with gastrointestinal symptoms. | journal=Gut | year= 2020 | volume= 69 | issue= 6 | pages= 1002-1009 | pmid=32213556 | doi=10.1136/gutjnl-2020-320926 | pmc=7133387 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32213556  }} </ref><ref name="pmid32109013">{{cite journal| author=Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX | display-authors=etal| title=Clinical Characteristics of Coronavirus Disease 2019 in China. | journal=N Engl J Med | year= 2020 | volume= 382 | issue= 18 | pages= 1708-1720 | pmid=32109013 | doi=10.1056/NEJMoa2002032 | pmc=7092819 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32109013  }} </ref>
Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.


==Diagnosis==
==Diagnosis==
===Diagnostic Study of Choice===
===Diagnostic Study of Choice===
The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
*[[COVID-19]] [[diarrhea]] can be diagnosed based on the history of diarrhea and a positive [[Human feces|stool]] test for SARS-CoV-2
 
* There are no established [[Criterion|criteria]] for the diagnosis of diarrhea in COVID-19.
OR
 
The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
 
OR
 
The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].
 
OR
 
There are no established criteria for the diagnosis of [disease name].


===History and Symptoms===
===History and Symptoms===
* According to Jin et al<ref name="pmid32213556">{{cite journal| author=Jin X, Lian JS, Hu JH, Gao J, Zheng L, Zhang YM | display-authors=etal| title=Epidemiological, clinical and virological characteristics of 74 cases of coronavirus-infected disease 2019 (COVID-19) with gastrointestinal symptoms. | journal=Gut | year= 2020 | volume= 69 | issue= 6 | pages= 1002-1009 | pmid=32213556 | doi=10.1136/gutjnl-2020-320926 | pmc=7133387 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32213556  }} </ref>, the definition of diarrhea was the passing of loose stools >3 times per day.
* Diarrhea can be defined as passing of >3 loose [[Human feces|stools]] per day.<ref name="pmid32213556" />
* According to this study, 8.1% had diarrhea at onset and the symptoms lasted for approximately 4 days.  
* Diarrhea was the primary symptom at the onset of COVID-19 infection at onset and the symptoms lasted for approximately 4 days.
* The duration of diarrhea ranged from 2-4 days with 3-8 bowel movements per day, according to various studies. <ref name="pmid32139552">{{cite journal| author=Song Y, Liu P, Shi XL, Chu YL, Zhang J, Xia J | display-authors=etal| title=SARS-CoV-2 induced diarrhoea as onset symptom in patient with COVID-19. | journal=Gut | year= 2020 | volume= 69 | issue= 6 | pages= 1143-1144 | pmid=32139552 | doi=10.1136/gutjnl-2020-320891 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32139552  }} </ref><ref name="pmid31986261">{{cite journal| author=Chan JF, Yuan S, Kok KH, To KK, Chu H, Yang J | display-authors=etal| title=A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. | journal=Lancet | year= 2020 | volume= 395 | issue= 10223 | pages= 514-523 | pmid=31986261 | doi=10.1016/S0140-6736(20)30154-9 | pmc=7159286 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31986261  }} </ref>
* The duration of diarrhea ranged from 2-4 days with 3-8 [[bowel]] movements per day, according to various studies. <ref name="pmid32139552">{{cite journal| author=Song Y, Liu P, Shi XL, Chu YL, Zhang J, Xia J | display-authors=etal| title=SARS-CoV-2 induced diarrhoea as onset symptom in patient with COVID-19. | journal=Gut | year= 2020 | volume= 69 | issue= 6 | pages= 1143-1144 | pmid=32139552 | doi=10.1136/gutjnl-2020-320891 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32139552  }} </ref><ref name="pmid31986261">{{cite journal| author=Chan JF, Yuan S, Kok KH, To KK, Chu H, Yang J | display-authors=etal| title=A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. | journal=Lancet | year= 2020 | volume= 395 | issue= 10223 | pages= 514-523 | pmid=31986261 | doi=10.1016/S0140-6736(20)30154-9 | pmc=7159286 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31986261  }} </ref>
* There is not enough data from other studies on the number of evacuations, consistency of stool, and duration of [[Symptom|symptoms]].


===Physical Examination===
===Physical Examination===
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
OR
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
The presence of [finding(s)] on physical examination is diagnostic of [disease name].


OR
* Patients with diarrhea due to [[COVID-19]] usually appear very sick, since diarrhea is seen in a greater percentage of patients with severe [[respiratory]] disease than non-severe disease. <ref name="pmid32109013">{{cite journal| author=Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX | display-authors=etal| title=Clinical Characteristics of Coronavirus Disease 2019 in China. | journal=N Engl J Med | year= 2020 | volume= 382 | issue= 18 | pages= 1708-1720 | pmid=32109013 | doi=10.1056/NEJMoa2002032 | pmc=7092819 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32109013  }} </ref>


The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
* Physical examination due to diarrhea may be remarkable for:
** Weak, low [[volume]] [[pulse]]
**[[Hypotension]]
**[[Eyes|Sunken eyes]]
** Decreased [[Turgor|skin turgor]]


===Laboratory Findings===
===Laboratory Findings===
An elevated/reduced concentration of serum/blood/urinary/CSF/other [lab test] is diagnostic of [disease name].
Laboratory findings consistent with the diagnosis of covid-19 associated diarrhea include [[complete blood count]], [[glucose]] levels, [[white blood cells]] ([[WBC]]) detection, urine analysis, [[calcium]] levels, [[Thyroid stimulating hormone]] ([[TSH]]) levels, complete metabolic panel and [[stool examination]].
 
OR
 
Laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].
 
OR
 
[Test] is usually normal among patients with [disease name].
 
OR
 
Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication].
 
OR


There are no diagnostic laboratory findings associated with [disease name].
*[[Stool examination]] includes the following:
**[[Stool culture]]
**Stool [[electrolyte]]s
**Stool osmolality
**Ova and parasites
**[[Lactoferrin|Fecal lactoferrin]]
**[[White blood cells|Fecal leukocytes]]


===Electrocardiogram===
===Electrocardiogram===
There are no ECG findings associated with [disease name].
*An ECG may be helpful in the diagnosis of COVID-19 associated diarrhea. Findings on an ECG suggestive of diarrhea include [[sinus tachycardia]].
 
OR
 
An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].


===X-ray===
===X-ray===
There are no x-ray findings associated with [disease name].
*The [[Chest X-ray|chest x ray]] findings in a suspected case of coronavirus [[infection]] can mimic the findings in [[pneumonia]], which can include:
 
OR


An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
:*[[Consolidation (medicine)|Consolidation]]<ref name="pmid31986264">{{cite journal |vauthors=Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, Cheng Z, Yu T, Xia J, Wei Y, Wu W, Xie X, Yin W, Li H, Liu M, Xiao Y, Gao H, Guo L, Xie J, Wang G, Jiang R, Gao Z, Jin Q, Wang J, Cao B |title=Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China |journal=Lancet |volume= |issue= |pages= |date=January 2020 |pmid=31986264 |doi=10.1016/S0140-6736(20)30183-5 |url=}}</ref>
 
:*[[Interstitial]] [[Infiltration (medical)|infiltration]]
OR
 
There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].


===Echocardiography or Ultrasound===
===Echocardiography or Ultrasound===
There are no echocardiography/ultrasound  findings associated with [disease name].
OR
Echocardiography/ultrasound  may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR


There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound  may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
* There are no [[echocardiography]]/[[ultrasound]] findings associated with diarrhea in COVID-19.


===CT scan===
===CT scan===
There are no CT scan findings associated with [disease name].
OR
[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].


OR
*Abdominal CT scan may be helpful in the diagnosis of COVID-19 associated diarrhea.
 
*Findings on CT scan suggestive of diarrhea associated with COVID-19 infection include peri-intestinal inflammatory reaction.<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>
There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].


===MRI===
===MRI===
There are no MRI findings associated with [disease name].
OR
[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR


There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
* There are no [[Magnetic resonance imaging|MRI]] findings associated with diarrhea in COVID-19


===Other Imaging Findings===
===Other Imaging Findings===
There are no other imaging findings associated with [disease name].
OR


[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
* There are no other imaging findings associated with [[diarrhea]] in COVID-19.


===Other Diagnostic Studies===
===Other Diagnostic Studies===
There are no other diagnostic studies associated with [disease name].
Other diagnostic studies for COVID-19 associated diarrhea include:
 
OR
 
[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].


OR
*Infectious [[virions]] released from the GI tract can be monitored by real-time [[Reverse transcription polymerase chain reaction|reverse transcriptase polymerase chain reaction]] (rRT-PCR)
 
* A study by Xiao et al assessed the clinical significance of measuring [[SARS-CoV-2]] RNA in the [[feces]]. <ref name="pmid32142773">{{cite journal| author=Xiao F, Tang M, Zheng X, Liu Y, Li X, Shan H| title=Evidence for Gastrointestinal Infection of SARS-CoV-2. | journal=Gastroenterology | year= 2020 | volume= 158 | issue= 6 | pages= 1831-1833.e3 | pmid=32142773 | doi=10.1053/j.gastro.2020.02.055 | pmc=7130181 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32142773  }} </ref>
Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [finding 1], [finding 2], and [finding 3].
* The fecal test remained positive until 12 days after the disease onset in patients with diarrhea.
* Notably, stool test for [[RNA|viral RNA]] remained positive despite negative respiratory tests. This suggests the possibility of gastrointestinal transmission via the [[fecal-oral route]] despite clearance from the [[Respiratory system|respiratory]] tract.
* It was recommended [[Transmission (medicine)|transmission]]-based precautions for hospitalized [[COVID-19]] patients should be continued till the rRT-[[Polymerase chain reaction|PCR]] for [[SARS-CoV-2]] turns negative.


==Treatment==
==Treatment==
===Medical Therapy===
===Medical Therapy===
* Supportive management is the mainstay of treatment.
* Supportive management is the mainstay of treatment.
* Rehydration, fluid repletion, and potassium monitoring are essential.
*[[Rehydration]], fluid repletion, and [[potassium]] monitoring are essential.
* Use of probiotics may have a role if the diarrhea is being caused by alteration of the gut microbiome. This could also be potentially useful in preventing secondary bacterial infections by restoring the gut microbiota. <ref name="pmid32096611">{{cite journal| author=Gao QY, Chen YX, Fang JY| title=2019 Novel coronavirus infection and gastrointestinal tract. | journal=J Dig Dis | year= 2020 | volume= 21 | issue= 3 | pages= 125-126 | pmid=32096611 | doi=10.1111/1751-2980.12851 | pmc=7162053 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32096611  }} </ref>
* Use of [[Probiotic|probiotics]] may have a role if the [[diarrhea]] is being caused by alteration of the [[Microbiome|gut microbiome]].  
*This could also be potentially useful in preventing [[secondary]] [[Bacteria|bacterial]] [[Infection|infections]] by restoring the gut [[Microbiome|microbiota]]. <ref name="pmid32096611">{{cite journal| author=Gao QY, Chen YX, Fang JY| title=2019 Novel coronavirus infection and gastrointestinal tract. | journal=J Dig Dis | year= 2020 | volume= 21 | issue= 3 | pages= 125-126 | pmid=32096611 | doi=10.1111/1751-2980.12851 | pmc=7162053 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32096611  }} </ref>


===Primary Prevention===
===Primary Prevention===


There are no available vaccines against COVID-19 as of now, but several vaccines are under development and in trials.
*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>
Standard measures for respiratory viruses are recommended-  
**Frequent handwashing with soap and water for at least 20 seconds or using a [[Alcohol rub|alcohol based hand sanitizer]] with at least 60% alcohol
* Use of masks
**Staying at least 6 feet (about 2 arms’ length) from other people who do not live with you
* Frequent hand hygiene (alcohol-based disinfectants or soap and water),
**Covering your mouth and nose with a cloth face cover when around others and covering sneezes and coughs
* Travel restrictions
**Cleaning and [[disinfect]]ing
* Social distancing measures
*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>
* Avoiding contact with infected patients
 
====Prevention of transmission through gastrointenstinal tract====
 
* Presence of the virus in the stool raises suspicion for [[fecal-oral route|fecal-oral transmission]] of SARS-CoV-2.
* Appropriate personal protective equipment (PPE) must be used while handling sources of contamination like feces.
*[[Elective]] appointments and [[Endoscopy|endoscopies]] should be rescheduled and extreme care must be taken by health care professionals of the [[endoscopy]] units to avoid spreading the virus from one patient to another. <ref name="pmid32197957">{{cite journal| author=Ungaro RC, Sullivan T, Colombel JF, Patel G| title=What Should Gastroenterologists and Patients Know About COVID-19? | journal=Clin Gastroenterol Hepatol | year= 2020 | volume= 18 | issue= 7 | pages= 1409-1411 | pmid=32197957 | doi=10.1016/j.cgh.2020.03.020 | pmc=7156804 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32197957  }} </ref>
* Patients listed for fecal [[Microbiome|microbiota]] transplantation and donors should be screened for the SARS-CoV-2.
 
===Secondary prevention===


'''Prevention of transmission through gastrointenstinal tract'''
*Effective measures for the [[secondary prevention]] of COVID-19 include:
* Presence of the virus in the stool raises suspicion for fecal-oral transmission of SARS-CoV-2
**Use of [[personal protective equipment]] (PPE) by the personnel handling the fecal matter.
* Appropriate PPE must be used while handling sources of contamination like feces.
**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>
* Elective appointments and endoscopies should be rescheduled and extreme care must be taken by health care professionals of the endoscopy units to avoid spreading the virus from one patient to another.
**[[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>
* Patients listed for fecal microbiota transplantation and donors should be screened for the SARS-CoV-2.


==References==
==References==

Latest revision as of 01:05, 26 August 2020

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Main article: COVID-19

For COVID-19 frequently asked inpatient questions, click here

For COVID-19 frequently asked outpatient questions, click here

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

Synonyms and keywords:

Overview

SARS-CoV-2 mainly causes severe acute respiratory syndrome but may also present with gastrointestinal symptoms like diarrhea. It invades through the Angiotensin-converting enzyme 2 (ACE2) and the serine protease TMPRSS2 receptors present abundantly not only in the lungs but also in the enterocytes of the small intestine. A greater prevalence of diarrhea was observed in patients with severe COVID-19 when compared to non-severe disease. Likewise, patients with gastrointestinal symptoms were more likely to have a severe respiratory disease with ARDS requiring ventilatory support. The presence of the virus in the stool raises suspicion for fecal-oral transmission of SARS-CoV-2. Appropriate personal protective equipment (PPE) must be used while handling sources of contamination like feces.

Historical Perspective

Classification

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

Pathophysiology

Causes

Diarrhea in a patient hospitalized due to COVID-19 may be due to:

Differentiating COVID-19 associated diarrhea from other Diseases

COVID-19 diarrhea must be differentiated from other diseases that cause diarrhea, such as:[8]

To review the differential diagnosis of diarrhea due to various organisms, click here.

To review the differential diagnosis of diarrhea, click here.

Epidemiology and Demographics

  • Diarrhea is an uncommon gastrointestinal symptom (anorexia, nausea, and vomiting are more common) in patients with COVID-19 but may be the presenting symptom in a few patients.
  • The frequency of occurrence of diarrhea varies between 1%-35%. [9]
  • It varies widely between different studies, likely due to the different criteria used to define diarrhea.
  • Greater prevalence of diarrhea was noted in patients with severe COVID-19 when compared to non-severe disease.
  • Likewise, patients with gastrointenstinal symptoms were more likely to have severe respiratory disease with ARDS requiring ventilatory support. [10] [11]
  • There is no data on predilection based on age, gender, geographical location, or race.

Risk Factors

Common risk factors in the development of gastrointestinal symptoms in patients with COVID-19 infection include:

Screening

  • There is insufficient evidence to recommend routine screening in detecting covid associated diarrhea.

Natural History, Complications, and Prognosis

  • Presence of diarrheal symptoms in covid-19 infection is associated with severe form of disease.
  • Severe or poor prognostic form of disease can be described as ARDS requiring ventilatory support.[10][11]

Diagnosis

Diagnostic Study of Choice

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

History and Symptoms

  • Diarrhea can be defined as passing of >3 loose stools per day.[10]
  • Diarrhea was the primary symptom at the onset of COVID-19 infection at onset and the symptoms lasted for approximately 4 days.
  • The duration of diarrhea ranged from 2-4 days with 3-8 bowel movements per day, according to various studies. [13][14]
  • There is not enough data from other studies on the number of evacuations, consistency of stool, and duration of symptoms.

Physical Examination

  • Patients with diarrhea due to COVID-19 usually appear very sick, since diarrhea is seen in a greater percentage of patients with severe respiratory disease than non-severe disease. [11]

Laboratory Findings

Laboratory findings consistent with the diagnosis of covid-19 associated diarrhea include complete blood count, glucose levels, white blood cells (WBC) detection, urine analysis, calcium levels, Thyroid stimulating hormone (TSH) levels, complete metabolic panel and stool examination.

Electrocardiogram

  • An ECG may be helpful in the diagnosis of COVID-19 associated diarrhea. Findings on an ECG suggestive of diarrhea include sinus tachycardia.

X-ray

Echocardiography or Ultrasound

CT scan

  • Abdominal CT scan may be helpful in the diagnosis of COVID-19 associated diarrhea.
  • Findings on CT scan suggestive of diarrhea associated with COVID-19 infection include peri-intestinal inflammatory reaction.[16]

MRI

  • There are no MRI findings associated with diarrhea in COVID-19

Other Imaging Findings

  • There are no other imaging findings associated with diarrhea in COVID-19.

Other Diagnostic Studies

Other diagnostic studies for COVID-19 associated diarrhea include:

  • Infectious virions released from the GI tract can be monitored by real-time reverse transcriptase polymerase chain reaction (rRT-PCR)
  • A study by Xiao et al assessed the clinical significance of measuring SARS-CoV-2 RNA in the feces. [17]
  • The fecal test remained positive until 12 days after the disease onset in patients with diarrhea.
  • Notably, stool test for viral RNA remained positive despite negative respiratory tests. This suggests the possibility of gastrointestinal transmission via the fecal-oral route despite clearance from the respiratory tract.
  • It was recommended transmission-based precautions for hospitalized COVID-19 patients should be continued till the rRT-PCR for SARS-CoV-2 turns negative.

Treatment

Medical Therapy

Primary Prevention

  • Effective measures for the primary prevention of COVID-19 include::[18]
    • Frequent handwashing with soap and water for at least 20 seconds or using a alcohol based hand sanitizer with at least 60% alcohol
    • Staying at least 6 feet (about 2 arms’ length) from other people who do not live with you
    • Covering your mouth and nose with a cloth face cover when around others and covering sneezes and coughs
    • Cleaning and disinfecting
  • There have been rigorous efforts in order to develop a vaccine for novel coronavirus and several vaccines are in the later phases of trials.[19]

Prevention of transmission through gastrointenstinal tract

  • Presence of the virus in the stool raises suspicion for fecal-oral transmission of SARS-CoV-2.
  • Appropriate personal protective equipment (PPE) must be used while handling sources of contamination like feces.
  • Elective appointments and endoscopies should be rescheduled and extreme care must be taken by health care professionals of the endoscopy units to avoid spreading the virus from one patient to another. [20]
  • Patients listed for fecal microbiota transplantation and donors should be screened for the SARS-CoV-2.

Secondary prevention

References

  1. ↑ https://www.cdc.gov/coronavirus/2019-ncov/about/index.html. Missing or empty |title= (help)
  2. ↑ Lu, Jian; Cui, Jie; Qian, Zhaohui; Wang, Yirong; Zhang, Hong; Duan, Yuange; Wu, Xinkai; Yao, Xinmin; Song, Yuhe; Li, Xiang; Wu, Changcheng; Tang, Xiaolu (2020). "On the origin and continuing evolution of SARS-CoV-2". National Science Review. doi:10.1093/nsr/nwaa036. ISSN 2095-5138.
  3. ↑ Huang, Chaolin; Wang, Yeming; Li, Xingwang; Ren, Lili; Zhao, Jianping; Hu, Yi; Zhang, Li; Fan, Guohui; Xu, Jiuyang; Gu, Xiaoying; Cheng, Zhenshun; Yu, Ting; Xia, Jiaan; Wei, Yuan; Wu, Wenjuan; Xie, Xuelei; Yin, Wen; Li, Hui; Liu, Min; Xiao, Yan; Gao, Hong; Guo, Li; Xie, Jungang; Wang, Guangfa; Jiang, Rongmeng; Gao, Zhancheng; Jin, Qi; Wang, Jianwei; Cao, Bin (2020). "Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China". The Lancet. 395 (10223): 497–506. doi:10.1016/S0140-6736(20)30183-5. ISSN 0140-6736.
  4. ↑ https://www.cdc.gov/coronavirus/2019-ncov/about/transmission.html. Missing or empty |title= (help)
  5. ↑ 5.0 5.1 D'Amico F, Baumgart DC, Danese S, Peyrin-Biroulet L (2020). "Diarrhea During COVID-19 Infection: Pathogenesis, Epidemiology, Prevention, and Management". Clin Gastroenterol Hepatol. doi:10.1016/j.cgh.2020.04.001. PMC 7141637 Check |pmc= value (help). PMID 32278065 Check |pmid= value (help).
  6. ↑ Liang W, Feng Z, Rao S, Xiao C, Xue X, Lin Z; et al. (2020). "Diarrhoea may be underestimated: a missing link in 2019 novel coronavirus". Gut. 69 (6): 1141–1143. doi:10.1136/gutjnl-2020-320832. PMID 32102928 Check |pmid= value (help).
  7. ↑ 7.0 7.1 Gao QY, Chen YX, Fang JY (2020). "2019 Novel coronavirus infection and gastrointestinal tract". J Dig Dis. 21 (3): 125–126. doi:10.1111/1751-2980.12851. PMC 7162053 Check |pmc= value (help). PMID 32096611 Check |pmid= value (help).
  8. ↑ Occhipinti V, Pastorelli L (2020). "Challenges in the Care of IBD Patients During the CoViD-19 Pandemic: Report From a "Red Zone" Area in Northern Italy". Inflamm Bowel Dis. 26 (6): 793–796. doi:10.1093/ibd/izaa084. PMC 7188155 Check |pmc= value (help). PMID 32314792 Check |pmid= value (help).
  9. ↑ Li XY, Dai WJ, Wu SN, Yang XZ, Wang HG (2020). "The occurrence of diarrhea in COVID-19 patients". Clin Res Hepatol Gastroenterol. doi:10.1016/j.clinre.2020.03.017. PMC 7270575 Check |pmc= value (help). PMID 32253163 Check |pmid= value (help).
  10. ↑ 10.0 10.1 10.2 Jin X, Lian JS, Hu JH, Gao J, Zheng L, Zhang YM; et al. (2020). "Epidemiological, clinical and virological characteristics of 74 cases of coronavirus-infected disease 2019 (COVID-19) with gastrointestinal symptoms". Gut. 69 (6): 1002–1009. doi:10.1136/gutjnl-2020-320926. PMC 7133387 Check |pmc= value (help). PMID 32213556 Check |pmid= value (help).
  11. ↑ 11.0 11.1 11.2 Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX; et al. (2020). "Clinical Characteristics of Coronavirus Disease 2019 in China". N Engl J Med. 382 (18): 1708–1720. doi:10.1056/NEJMoa2002032. PMC 7092819 Check |pmc= value (help). PMID 32109013 Check |pmid= value (help).
  12. ↑ Brenner EJ, Ungaro RC, Gearry RB, Kaplan GG, Kissous-Hunt M, Lewis JD; et al. (2020). "Corticosteroids, but not TNF Antagonists, are Associated with Adverse COVID-19 Outcomes in Patients With Inflammatory Bowel Diseases: Results from an International Registry". Gastroenterology. doi:10.1053/j.gastro.2020.05.032. PMC 7233252 Check |pmc= value (help). PMID 32425234 Check |pmid= value (help).
  13. ↑ Song Y, Liu P, Shi XL, Chu YL, Zhang J, Xia J; et al. (2020). "SARS-CoV-2 induced diarrhoea as onset symptom in patient with COVID-19". Gut. 69 (6): 1143–1144. doi:10.1136/gutjnl-2020-320891. PMID 32139552 Check |pmid= value (help).
  14. ↑ Chan JF, Yuan S, Kok KH, To KK, Chu H, Yang J; et al. (2020). "A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster". Lancet. 395 (10223): 514–523. doi:10.1016/S0140-6736(20)30154-9. PMC 7159286 Check |pmc= value (help). PMID 31986261.
  15. ↑ Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, Cheng Z, Yu T, Xia J, Wei Y, Wu W, Xie X, Yin W, Li H, Liu M, Xiao Y, Gao H, Guo L, Xie J, Wang G, Jiang R, Gao Z, Jin Q, Wang J, Cao B (January 2020). "Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China". Lancet. doi:10.1016/S0140-6736(20)30183-5. PMID 31986264.
  16. ↑ 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).
  17. ↑ Xiao F, Tang M, Zheng X, Liu Y, Li X, Shan H (2020). "Evidence for Gastrointestinal Infection of SARS-CoV-2". Gastroenterology. 158 (6): 1831–1833.e3. doi:10.1053/j.gastro.2020.02.055. PMC 7130181 Check |pmc= value (help). PMID 32142773 Check |pmid= value (help).
  18. ↑ "How to Protect Yourself & Others | CDC".
  19. ↑ "NIH clinical trial of investigational vaccine for COVID-19 begins | National Institutes of Health (NIH)".
  20. ↑ Ungaro RC, Sullivan T, Colombel JF, Patel G (2020). "What Should Gastroenterologists and Patients Know About COVID-19?". Clin Gastroenterol Hepatol. 18 (7): 1409–1411. doi:10.1016/j.cgh.2020.03.020. PMC 7156804 Check |pmc= value (help). PMID 32197957 Check |pmid= value (help).
  21. ↑ 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).
  22. ↑ "Contact Tracing for COVID-19 | CDC".


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