Review Article

Gastrointestinal Features in COVID-19 and the Possibility of Faecal Transmission

Yuan Tian; Long Rong; Weidong Nian; Yan He

Disclosures

Aliment Pharmacol Ther. 2020;51(9):843-851. 

In This Article

Abstract and Introduction

Abstract

Background: There is little published evidence on the gastrointestinal features of COVID-19.

Aims: To report on the gastrointestinal manifestations and pathological findings of patients with COVID-19, and to discuss the possibility of faecal transmission.

Methods: We have reviewed gastrointestinal features of, and faecal test results in, COVID-19 from case reports and retrospective clinical studies relating to the digestive system published since the outbreak.

Results: With an incidence of 3% (1/41)-79% (159/201), gastrointestinal symptoms of COVID-19 included anorexia 39.9% (55/138)-50.2% (101/201), diarrhoea 2% (2/99)-49.5% (146/295), vomiting 3.6% (5/138)-66.7% (4/6), nausea 1% (1/99)-29.4% (59/201), abdominal pain 2.2% (3/138)-6.0% (12/201) and gastrointestinal bleeding 4% (2/52)-13.7% (10/73). Diarrhoea was the most common gastrointestinal symptom in children and adults, with a mean duration of 4.1 ± 2.5 days, and was observed before and after diagnosis. Vomiting was more prominent in children. About 3.6% (5/138)-15.9% (32/201) of adult and 6.5% (2/31)-66.7% (4/6) of children patients presented vomiting. Adult and children patients can present with digestive symptoms in the absence of respiratory symptoms. The incidence of digestive manifestations was higher in the later than in the early stage of the epidemic, but no differences in digestive symptoms among different regions were found. Among the group of patients with a higher proportion of severe cases, the proportion of gastrointestinal symptoms in severe patients was higher than that in nonsevere patients (anorexia 66.7% vs 30.4%; abdominal pain 8.3% vs 0%); while in the group of patients with a lower severe rate, the proportion with gastrointestinal symptoms was similar in severe and nonsevere cases (nausea and vomiting 6.9% vs 4.6%; diarrhoea 5.8% vs 3.5%). Angiotensin converting enzyme 2 and virus nucleocapsid protein were detected in gastrointestinal epithelial cells, and infectious virus particles were isolated from faeces. Faecal PCR testing was as accurate as respiratory specimen PCR detection. In 36% (5/14)-53% (39/73) faecal PCR became positive, 2–5 days later than sputum PCR positive. Faecal excretion persisted after sputum excretion in 23% (17/73)-82% (54/66) patients for 1–11 days.

Conclusions: Gastrointestinal symptoms are common in patients with COVID-19, and had an increased prevalence in the later stage of the recent epidemic in China. SARS-CoV-2 enters gastrointestinal epithelial cells, and the faeces of COVID-19 patients are potentially infectious.

Introduction

Up to the submission date, a novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], previously called 2019-nCoV) initially reported in Wuhan, China has been diagnosed in more than 200 000 people from 166 countries worldwide according to the World Health Organization (WHO). SARS-CoV-2 is currently the world's most pressing public health threat and has a significant impact on the lives of people around the world.

SARS-CoV-2 is an enveloped, positively charged, single-stranded RNA virus belonging to the beta coronavirus genus. SARS-CoV-2 enters cells via the angiotensin converting enzyme 2 (ACE2) receptor and is highly homologous to SARS-CoV.[1] Zhang et al[2] reported that ACE2 was highly expressed in oesophageal epithelial cells and the absorptive enterocytes from ileum and colon, suggesting possible faecal transmission. Gastrointestinal symptoms such as vomiting and diarrhoea have been reported in SARS patients[3] and in COVID-19 patients. Currently, there are few data on the gastrointestinal manifestations of COVID-19. The clinical case analyses on digestive manifestations and pathological findings of patients with COVID-19 published in China were reviewed in this paper with a view to providing reference for prevention and control, as well as diagnosis and treatment of the disease.

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