Gastrointestinal Symptoms Could Be New Focus for Coronavirus Diagnosis

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       "Gastrointestinal Symptoms Could Be New Focus for Coronavirus Diagnosis"

2020-03-09 article published on contagionlive.com
https://www.contagionlive.com/news/gastrointestinal-symptoms-could-be-new-focus-for-coronavirus-diagnosis-

++++ BEGIN HAPHAZARDLY CONDENSED ARTICLE ++++ "Novel coronavirus symptoms seem to be mostly focused on fever and cough, but gastrointestinal symptoms should be a new focus for clinicians, according to 2 new papers published online in Gastroenterology." ... "The first paper describes how investigators from Shanghai, China, sought to document the symptoms of the novel coronavirus. Although fever, dry cough, and dyspnea present in most cases, they wanted to understand what impact the virus had on symptoms such as diarrhea, nausea, vomiting, and abdominal discomfort. So far, those symptoms have varied among different study populations, the authors wrote." ... "In the second paper, investigators from Guangdong Province in China examined the viral RNA in feces from 71 patients with confirmed COVID-19 during their hospitalization between Feb. 1-14, 2020. They collected serum, nasopharyngeal and oropharyngeal swabs, urine, stool, and tissues (from endoscopy) from the patients." ... ...patients remained positive via stool tests after showing negative in respiratory samples. ... Although the first study suggests that the infectious virions can be released into the gastrointestinal tract, the second paper suggests that fecal-oral transmission could be a path for viral spread. ... “Therefore, we strongly recommend that rRT-PCR testing for coronavirus from feces should be performed routinely in coronavirus patients, and Transmission-Based Precautions for hospitalized coronavirus patients should continue if feces tests positive by rRT-PCR testing.” ++++ END HAPHAZARDLY CONDENSED ARTICLE ++++

@jmcmurry I hereby beat you to the punch on this question: "Jeepers, do we really want the anxious and cooped-up stir-crazy worried well to start fixating on their poo?" Probably not. We hope sincerely that they can find something better and more fun and less stinky on which to fixate. But on the other cheek, er... hand, this (ahem) emerging info would seem to be of some import to clinicians and/or to community medics who find themselves in a position where the nearest clinical location is swamped and they're trying to diagnose and/or treat someone in the absence of a legit test. Also possibly important for people to, perhaps while living with no toilet paper (curses, TP hoarders!), and perhaps while caring for someone who needs some type of BM-assist, as many older and sick people do, to understand, "Yo, bro--be double careful with that loaf, it's got a big viral load!" (better wording would be essential, of course). Also possibly important for people caring for themselves or others to remember that even though respiratory symptoms have cleared up, the infection may still be lingering in the ol' GI tract and the poo may still be a vector. And the possibility of fecal-oral being a significant transmission route is a potential game-changer in terms of what people need to know since virtually all the info out there for the regular public focuses only on coughing, sneezing, sputum, globules, etc. and nothing about fecal-oral

Anecdotally, a friend who's a very experienced nurse has grown increasingly suspicious that the nasty flu-like illness her husband got over a couple weeks back was in fact COVID-19. No testing available so no confirmation. He said it was far and away worse than any flu he's ever had before. Nurse friend says his symptoms, timeline, and duration were all in line with COVID-19. And for her, right as he was really coming around, she was struck with a severe GI illness that kept her from eating anything substantial for a week. Lab tests showed none of the usual suspects and lab's diagnosis was "It must have been an unknown virus". Her comment to me today was, "I've been seeing more and more on GI symptoms in COVID19...maybe he had it, gave it to me & it exhibited differently."

Someone more qualified than I should take a look at the papers cited and maybe see whether there's corroborating or conflicting info elsewhere.

Thank you for your patience with this thoroughly unprofessional writeup. Thank you for your work.

Thanks @jmcmurry I appreciate your taking a gander. The link you noted above: "COVID-19 Clinical Insights for Our Community of Gastroenterologists and Gastroenterology Care Providers" https://gi.org/2020/03/15/joint-gi-society-message-on-covid-19/ is undoubtedly helpful and necessary for all gastroenterology professionals. So to the extent they're our audience we should address them.

But for family caregivers and community medics, and (maybe especially) for clinicians making diagnoses, much more troubling is this Mar. 18, 2020 dire-sounding statement from the American College of Gastroenterology: https://gi.org/wp-content/uploads/2020/03/ACG-AJG-Media-Statement-COVID19-Hubei-Pan-et-al-FINAL-03182020.pdf

++++ BEGIN CLUMSY EXCERPT ++++ TITLE: Experience with COVID-19 in Wuhan, China shows up to half of patients present with a digestive symptom as chief complaint ... Most patients with COVID-19 present with typical respiratory symptoms and signs. However, early experience with the outbreak in Wuhan, China revealed that many patients experienced digestive symptoms as their chief complaint. “Clinicians must bear in mind that digestive symptoms, such as diarrhea, may be a presenting feature of COVID-19, and that the index of suspicion may need to be raised earlier in these cases rather than waiting for respiratory symptoms to emerge,” ... In this study, COVID-19 patients with digestive symptoms have a worse clinical outcome and higher risk of mortality compared to those without digestive symptoms, emphasizing the importance of including symptoms like diarrhea to suspect COVID-19 early in the disease course before respiratory symptoms develop,” said Brennan M.R. Spiegel, MD, MSHS, FACG, Co-Editor-in-Chief of The American Journal of Gastroenterology. ... if clinicians solely monitor for respiratory symptoms to establish case definitions for COVID-19, they may miss cases initially presenting with extra-pulmonary symptoms, or the disease may not be diagnosed later until respiratory symptoms emerge.” ... Compared to COVID-19 patients without digestive symptoms, those with digestive symptoms have a longer time from onset to admission and a worse clinical outcome ... ... Diagnosis was confirmed by real-time RT-PCR. Clinical characteristics, laboratory data and treatment information for the patients were included in the final analysis. • Of the 204 patients, the average age of the patients was 54.9 years (SD +15.4), including 107 men and 97 women. The average time from symptom onset to hospital admission was 8.1 days (SD +4.9) • Patients with digestive symptoms had a significantly longer time from onset to admission than patients without digestive symptoms (9.0 daysversus 7.3 days). This may indicate that patients presenting with digestive symptoms sought care later because they did not yet suspect COVID-19 in the absence of respiratory symptoms, like cough or shortness of breath • Patients with digestive symptoms had a variety of manifestations, such as anorexia (83 [83.8%] cases), diarrhea (29 [29.3%] cases), vomiting (8 [0.8%] cases), and abdominal pain (4 [0.4%] cases). • Seven patients with COVID-19 presented with digestive symptoms but no respiratory symptoms. • As the severity of the disease increased, digestive symptoms became more pronounced. • Patients without digestive symptoms were more likely to be cured and discharged than patients with digestive symptoms (60% versus 34.3%). • Laboratory data revealed no significant liver injury, although other studies have shown signs of liver involvement; more research is required to understand the impact of COVID-19 on liver function ++++ END CLUMSY EXCERPT ++++

Medscape Medical News notes an interesting clarification by Brennan M.R. Spiegel, MD, MSHS, FACG, Co-Editor-in-Chief of The American Journal of Gastroenterology. [same person quoted above] ""If you leave out anorexia, which is very nonspecific, the percentage of COVID-19 patients with GI symptoms is about 30%," Spiegel told Medscape Medical News.

That's in this article: "Digestive Symptoms Tied to Worse COVID-19 Outcomes" https://www.medscape.com/viewarticle/927112

I do understand that this is in reference to a single study with what might be considered a small sample size (someone more qualified than I should determine what's an adequate sample size). But what I ask myself is, "Okay, what if that study is off by a lot? What if instead of 30-50% of COVID-19 cases presenting with GI issues as first and foremost symptom, and correlation with significantly worse clinical outcome, it's only 15-25% of cases?" And I answer myself, "Well, that's still a high percentage of cases, too high to ignore, particularly if GI issues as first and foremost symptom portends worse clinical outcomes." And I further answer myself, "The American College of Gastroenterology is certainly taking this very seriously."

In my mind I keep going back and identifying with the many many people who are or will be caring for someone(s) at home. The possibility that GI symptoms, even when really bad, might be incorrectly written off as "not COVID-19", with the result that people forgo vital medical attention in error and wind up being part of the "worse clinical outcome" subset. Equally bad would seem to be the situation where one infected household member comes down with notable GI issues but everyone assumes that since they have no respiratory symptoms they're not infected, and then the GI-symptom person goes on to infect mom, grandpa, and the cousin who's sheltering with them because the local college is shut, and whoever else they might come into contact with.

Anecdotally, previously I mentioned my friend the RN who was stricken with severe GI symptoms on the heels of with her husband's getting over severe respiratory symptoms. As it turned out, when after some days she went to the ER, they didn't assess her at all for COVID-19, and when the next day she was told to send in a stool specimen, I went to her house and picked it up and drove it an hour to the nearest lab (we live out in the sticks of coastal NorCal). But what she didn't do, and what I didn't do either, was to assume that she had COVID-19, and it appears now in retrospect that we would've been wiser to assume that she did, and to take all the precautions that would be in line with that assumption. Knock wood I'm not feeling sick, at least not yet, but I'm definitely counting the number of days that have passed since I picked up and delivered her specimen. If we agree with the American College of Gastroenterology, this is a scenario that is to be heartily avoided, and if unavoidable, full precautions should be taken. And without guidance on this topic many people will neither try to avoid this situation nor take adequate precautions with this situation.

I don't know off the top of my head the best way to address this topic in the Guide. Maybe a short and sweet section that covers fecal-oral transmission, toilet flushing, adult and/or baby diaper changing, and the importance of assuming at least to some extent that GI symptoms are noteworthy and possibly indicate COVID-19 infection.

Thank you for your work and for the care you are demonstrating to others.

flattenthecurve / guide

Gastrointestinal Symptoms Could Be New Focus for Coronavirus Diagnosis #160