COVID-19-associated nausea and vomiting

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

Synonyms and keywords:

Overview

SARS-CoV-2 mainly causes severe acute respiratory syndrome but may also present with gastrointestinal symptoms like diarrhea. It invades through the Angiotensin-converting enzyme 2 (ACE2) and the serine protease TMPRSS2 receptors present abundantly not only in the lungs but also in the enterocytes of the small intestine. Nausea and vomiting are the less common gastrointestinal symptoms seen. Anorexia and diarrhea are more common.

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.
• The growing number of patients however, suggest that human-to-human transmission is actively occurring.
• 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 nausea and vomiting 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 intestine. Other sites of expression of the receptors in the gastrointestinal tract are-the upper esophagus, liver, and colon.
• Entry of the virus causes disruption of the enterocytes and may lead to inflammation and alteration of intestinal permeability.
• The gastrointestinal symptoms of COVID-19 are thought to arise due to the invasion of enterocytes.

Causes

Disease name] may be caused by [cause1], [cause2], or [cause3].

OR

Common causes of [disease] include [cause1], [cause2], and [cause3].

OR

The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].

OR

The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click 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

• According to a study by Redd et al, the prevalence of nausea in COVID-19 patients was 26%.

The more common GI symptoms were-

• Anorexia- 35 %
• Diarrhea- 34 %

• Another study by Luo et al reported that 16% of patients presented with GI symptoms like diarrhea, nausea, vomiting without any respiratory symptoms.

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
• Increasing age
• Other comorbidities
• Use of glucocorticoids

Screening

There is insufficient evidence to recommend routine screening.

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

Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.

Diagnosis

Diagnostic Study of Choice

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

History and Symptoms

• According to a study by Redd et al, the prevalence of nausea in COVID-19 patients was 26%.

The more common GI symptoms were-

• Anorexia- 35 %
• Diarrhea- 34 %

• Another study by Luo et al reported that 16% of patients presented with GI symptoms like diarrhea, nausea, vomiting without any respiratory symptoms.

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

The presence of [finding(s)] on physical examination is highly suggestive of [disease name].

Laboratory Findings

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

Electrocardiogram

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

X-ray

• The chest x ray findings in a suspected case of coronavirus infection can mimic the findings in pneumonia, which can include:

• Consolidation
• Interstitial infiltration

Echocardiography or Ultrasound

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

CT scan

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

MRI

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

Other Imaging Findings

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

Other Diagnostic Studies

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

Treatment

Medical Therapy

• Supportive management is the mainstay of treatment of nausea and vomiting.
• Antiemetic drugs are used for symptomatic relief. 5-HT3 antagonists like ondansetron, granisetron, dolasetron, and palonosetron are commonly used.
• Rehydration, fluid repletion, and potassium monitoring are essential.

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

References

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