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Worse outcomes were independently predicted by the initial presence of gastrointestinal (GI) symptoms in patients presenting at the hospital with suspected COVID-19 infection, according to an electronic records review of more than 1,000 patients.

Based on the number of initial GI symptoms (score 1: only one GI symptom, score 2: two or three GI symptoms), Darbaz Adnan, MBChB, of Rush University Medical Center in Chicago, and colleagues observed a stepwise increase in the likelihood of worsened outcomes compared with no GI symptoms (score 0). The effect held after adjustment for demographics, comorbidities, and all other clinical symptoms.

Presenting results for 921 patients with available data at the American College of Gastroenterology (ACG) virtual meeting, Adnan's group reported that more than one in five patients visiting the hospital for COVID-19 symptoms also had GI manifestations.

Earlier this year, researchers in China and New York City were reporting GI symptoms in COVID-19 patients. "We knew that GI symptoms could be part of the infection but we did not know if they made a difference and conferred higher risk," Adnan said in an interview with 麻豆传媒. "So we wanted to look into the impact of initial GI symptoms to see if they might coincide with more serious disease and we found that those with GI symptoms also had established risk factors for severity, such as older age, diabetes, obesity, and hypertension."

In the study, participants tested positive for the virus from March 12 to April 3, 2020. Before treatment, all were initially screened for the following symptom types:

• Constitutional: fever, loss of appetite, body aches
• Respiratory: cough, shortness of breath, smell loss, chest tightness
• GI: diarrhea, nausea/vomiting, abdominal pain

Of the patients, 206 (22.4%) reported at least one GI symptom, with nausea/vomiting being the most common complaint (61.7%).

In other findings, patients with initial GI symptoms at presentation were older, had a higher body mass index (BMI), and had a higher prevalence of diabetes and hypertension. They also showed lower mean hemoglobin, calcium, and albumin levels, and higher creatinine and aspartate aminotransferase levels. These patients had higher rates of admission to the hospital/ICU and intubation.

The study did not look at mortality rates, since most patients had been discharged or were still hospitalized, Adnan said. "The take-home message is that doctors dealing with patients presenting with COVID symptoms at intake should be sure to screen for GI symptoms," he said.

According to the authors, this is the largest U.S. study to date on the significance of GI symptoms in COVID-19 infection.

Brett Williams, MD, also of Rush University Medical Center though not involved in the study, told 麻豆传媒 the data suggest GI symptoms may be a red flag for more severe, systemic disease.

"Patients with GI symptoms quite possibly have direct viral invasion of the GI mucosa, liver, and pancreas, though in sepsis-type syndromes it's difficult to know how much the inciting pathogen, hypoperfusion, and inflammation each contribute to pathology in any one organ system," he said.

"We also know that this virus has a propensity to cause endotheliitis, which can obviously involve any organ," continued Williams. "We found that elevated lipase levels were relatively common, at 16.8% of those patients checked, and that elevated lipase levels were strongly associated with ICU admission and intubation. There appear to be receptors for the virus in the pancreas, as well as in mature enterocytes."

In another ACG presentation, a systematic review and meta-analysis found that the presence of diarrhea as a presenting symptom for COVID-19 was associated with greater disease severity and probable worse prognosis, reported Subash Ghimire, MD, of Guthrie Robert Packer Hospital in Sayre, Pennsylvania, and colleagues.

A total of 38 studies with 8,407 patients were included in the analysis. Of the total patients, 15.47% had at least one GI symptom. The pooled prevalence of nausea/vomiting was 7.53%; for diarrhea, it was 11.52%. Patients with diarrhea as one of their presenting symptoms were more likely to have severe disease (OR 1.63, 95% CI 1.11-3.38, P=0.01).

"Patients with diarrhea likely harbor increased viral load, which can potentially lead to an increased systemic response to the virus and associated respiratory complications from it," the authors wrote. "Early recognition of patients is needed for prompt management of this at-risk population."