COVID-19-associated diarrhea: Difference between revisions
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==Diagnosis== | ==Diagnosis== | ||
===Diagnostic Study of Choice=== | ===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. | |||
There are no established criteria for the diagnosis of | |||
===History and Symptoms=== | ===History and Symptoms=== | ||
Revision as of 19:43, 27 June 2020
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
Historical Perspective
- The etiological agent is SARS-CoV-2, named for the similarity of its symptoms to those induced by the severe acute respiratory syndrome, causing coronavirus disease 2019 (COVID-19), is a virus identified as the cause of an outbreak of respiratory illness first detected in Wuhan, China.[1][2]
- The growing number of patients however, suggest that human-to-human transmission is actively occurring.[3][4]
- The outbreak was declared a Public Health Emergency of International Concern on 30 January 2020.
- On March 12, 2020 the World Health Organization declared the COVID-19 outbreak a pandemic.
Classification
There is no established system for the classification of diarrhea in COVID-19
Pathophysiology
- SARS-CoV-2 uses the Angiotensin-converting enzyme 2 (ACE2) and the serine protease TMPRSS2 receptors for cell entry. These receptors are presently abundantly not only in the lungs but also in the enterocytes of the small intestinal.[5][6] Other sites of expression of the receptors in the gastrointestinal tract are-the upper esophagus, liver, and colon. [5]
- Entry of the virus causes disruption of the enterocytes and may lead to inflammation and alteration of intestinal permeability.
- COVID- 19 is being treated by 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. [7]
Causes
Diarrhea in a patient hospitalized due to COVID-19 may be due to-
- COVID-19 associated diarrhea
- Secondary bacterial infections
- Clostridium difficile diarrhea and recent use of antibiotics
- Other infectious causes
Differentiating COVID-19 associated diarrhea from other Diseases
COVID-19 diarrhea must be differentiated from other diseases that cause diarrhea, such as-
- Secondary bacterial infections
- E.coli
- Shigella
- Salmonella
- Clostridium difficile associated diarrhea
- Other causes of diarrhea
- Viral causes
- Parasitic causes
Epidemiology and Demographics
- Diarrhea is an uncommon gastrointestinal symptom 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%. [8]It varies widely between different studies probably due to the different criteria used to define diarrhea.
- Greater percentage of occurrence of diarrhea was noted in patients with severe COVID-19 when compared to non-severe disease.
- Likewise, patients with gastrointenstinal symptoms were more likely to have severe respiratory disease with ARDS requiring ventilatory support. [9] [10]
There is no data on predilection based on age, gender, geographical location, or race.
Risk Factors
Some gastrointestinal factors may predispose patients to infection with COVID-19.
- Inflammatory bowel disease patients- due to use to glucocorticoids, but not TNF-alpha inhibitors [11]
- Increasing age
- Other comorbidities
- Use of glucocorticoids
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].
Natural History, Complications, and Prognosis
- Greater percentage of occurrence of diarrhea was noted in patients with severe COVID-19 when compared to non-severe disease.
- Likewise, patients with gastrointenstinal symptoms were more likely to have severe respiratory disease with ARDS requiring ventilatory support. [9] [10]
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
- According to Jin et al[9], the definition of diarrhea was the passing of loose stools >3 times per day.
- According to this study, 8.1% had diarrhea 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. [12][13]
- 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. [10]
Physical examination due to diarrhea may be remarkable for
- Weak, low volume pulse
- Hypotension
- Sunken eyes
- Decreased skin turgor
Laboratory Findings
- Infectious virions released from the GI tract can be monitored by real-time reverse transcriptase polymerase chain reaction (rRT-PCR)
- A study by Xiao et al assessed the clinical significance of measuring SARS-CoV-2 RNA in the feces. [14]
- 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.
Electrocardiogram
There are no ECG findings associated with [disease name].
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
There are no x-ray findings associated with [disease name].
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].
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
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].
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
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
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].
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].
Other Diagnostic Studies
There are no other diagnostic studies associated with [disease name].
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
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].
Treatment
Medical Therapy
- Supportive management is the mainstay of treatment.
- Rehydration, fluid repletion, and potassium monitoring are essential.
- Use of probiotics may have a role if the diarrhea is being caused by alteration of the gut microbiome. This could also be potentially useful in preventing secondary bacterial infections by restoring the gut microbiota. [7]
Primary Prevention
There are no available vaccines against COVID-19 as of now, but several vaccines are under development and in trials. Standard measures for respiratory viruses are recommended-
- Use of masks
- Frequent hand hygiene (alcohol-based disinfectants or soap and water),
- Travel restrictions
- Social distancing measures
- Avoiding contact with infected patients
Prevention of transmission through gastrointenstinal tract
- Presence of the virus in the stool raises suspicion for fecal-oral transmission of SARS-CoV-2
- Appropriate PPE must be used while handling sources of contamination like feces.
- Elective appointments and endoscopies should be rescheduled and extreme care must be taken by health care professionals of the endoscopy units to avoid spreading the virus from one patient to another. [15]
- Patients listed for fecal microbiota transplantation and donors should be screened for the SARS-CoV-2.
References
- ↑ https://www.cdc.gov/coronavirus/2019-ncov/about/index.html. Missing or empty
|title=(help) - ↑ Lu, Jian; Cui, Jie; Qian, Zhaohui; Wang, Yirong; Zhang, Hong; Duan, Yuange; Wu, Xinkai; Yao, Xinmin; Song, Yuhe; Li, Xiang; Wu, Changcheng; Tang, Xiaolu (2020). "On the origin and continuing evolution of SARS-CoV-2". National Science Review. doi:10.1093/nsr/nwaa036. ISSN 2095-5138.
- ↑ Huang, Chaolin; Wang, Yeming; Li, Xingwang; Ren, Lili; Zhao, Jianping; Hu, Yi; Zhang, Li; Fan, Guohui; Xu, Jiuyang; Gu, Xiaoying; Cheng, Zhenshun; Yu, Ting; Xia, Jiaan; Wei, Yuan; Wu, Wenjuan; Xie, Xuelei; Yin, Wen; Li, Hui; Liu, Min; Xiao, Yan; Gao, Hong; Guo, Li; Xie, Jungang; Wang, Guangfa; Jiang, Rongmeng; Gao, Zhancheng; Jin, Qi; Wang, Jianwei; Cao, Bin (2020). "Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China". The Lancet. 395 (10223): 497–506. doi:10.1016/S0140-6736(20)30183-5. ISSN 0140-6736.
- ↑ https://www.cdc.gov/coronavirus/2019-ncov/about/transmission.html. Missing or empty
|title=(help) - ↑ 5.0 5.1 D'Amico F, Baumgart DC, Danese S, Peyrin-Biroulet L (2020). "Diarrhea During COVID-19 Infection: Pathogenesis, Epidemiology, Prevention, and Management". Clin Gastroenterol Hepatol. doi:10.1016/j.cgh.2020.04.001. PMC 7141637 Check
|pmc=value (help). PMID 32278065 Check|pmid=value (help). - ↑ Liang W, Feng Z, Rao S, Xiao C, Xue X, Lin Z; et al. (2020). "Diarrhoea may be underestimated: a missing link in 2019 novel coronavirus". Gut. 69 (6): 1141–1143. doi:10.1136/gutjnl-2020-320832. PMID 32102928 Check
|pmid=value (help). - ↑ 7.0 7.1 Gao QY, Chen YX, Fang JY (2020). "2019 Novel coronavirus infection and gastrointestinal tract". J Dig Dis. 21 (3): 125–126. doi:10.1111/1751-2980.12851. PMC 7162053 Check
|pmc=value (help). PMID 32096611 Check|pmid=value (help). - ↑ 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). - ↑ 9.0 9.1 9.2 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). - ↑ 10.0 10.1 10.2 Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX; et al. (2020). "Clinical Characteristics of Coronavirus Disease 2019 in China". N Engl J Med. 382 (18): 1708–1720. doi:10.1056/NEJMoa2002032. PMC 7092819 Check
|pmc=value (help). PMID 32109013 Check|pmid=value (help). - ↑ Brenner EJ, Ungaro RC, Gearry RB, Kaplan GG, Kissous-Hunt M, Lewis JD; et al. (2020). "Corticosteroids, but not TNF Antagonists, are Associated with Adverse COVID-19 Outcomes in Patients With Inflammatory Bowel Diseases: Results from an International Registry". Gastroenterology. doi:10.1053/j.gastro.2020.05.032. PMC 7233252 Check
|pmc=value (help). PMID 32425234 Check|pmid=value (help). - ↑ Song Y, Liu P, Shi XL, Chu YL, Zhang J, Xia J; et al. (2020). "SARS-CoV-2 induced diarrhoea as onset symptom in patient with COVID-19". Gut. 69 (6): 1143–1144. doi:10.1136/gutjnl-2020-320891. PMID 32139552 Check
|pmid=value (help). - ↑ Chan JF, Yuan S, Kok KH, To KK, Chu H, Yang J; et al. (2020). "A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster". Lancet. 395 (10223): 514–523. doi:10.1016/S0140-6736(20)30154-9. PMC 7159286 Check
|pmc=value (help). PMID 31986261. - ↑ 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). - ↑ 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).