GI Symptoms Should Not Prompt Routine Screening for SARS-CoV-2, Group Says

By Will Boggs MD

May 21, 2020

NEW YORK (Reuters Health) - Gastrointestinal symptoms may be less common in COVID-19 than previously thought, so symptomatic patients without another reason for testing might not need testing for SARS-CoV-2, according to an American Gastroenterology Association (AGA) rapid review.

"GI symptoms are an important part of the spectrum of COVID; however, they rarely present as isolated symptoms," Dr. Shahnaz Sultan of the University of Minnesota, Minneapolis VA Healthcare System, told Reuters Health by email. "The data suggests that GI symptoms may precede other symptoms, but they most often occur in conjunction with COVID-related symptoms, such as dry cough, fever, fatigue, loss of taste or smell, etc."

Dr. Sultan and colleagues on the AGA Clinical Guideline Committee and Clinical Practice Update Committee evaluated the prevalence of diarrhea, nausea, vomiting, abdominal pain and liver-function test (LFT) abnormalities associated with COVID-19 in their systematic review and meta-analysis of 118 studies.

Overall, 7.7% of COVID-19 patients had diarrhea, 7.8% had nausea/vomiting, 3.6% had abdominal pain, 15% had abnormal AST or ALT, and 16.7% had abnormal bilirubin, the researchers report in Gastroenterology.

The prevalences of GI symptoms and elevations of AST/ALT were higher in studies done outside of China.

When GI symptoms were reported, it was difficult to discern if they were isolated symptoms or if patients also had concurrent, typical COVID-19 symptoms. And none of the studies reported if patients were systematically evaluated for gastrointestinal symptoms on admission. Most studies did not report on the duration of GI symptoms preceding the presentation.

Based on the limited information available, the committees developed several best-practice statements regarding the consultative management of COVID-19.

Outpatients with new-onset diarrhea or other GI symptoms should be evaluated for high-risk contact exposure and questioned about symptoms typically associated with COVID-19, they advise.

Patients hospitalized with suspected or known COVID-19 should be asked about a history of GI symptoms, including their onset, characteristics, duration and severity.

SARS-CoV-2 testing can be considered in high-prevalence settings, but there is insufficient evidence to support stool testing for diagnosis or monitoring of COVID-19 as part of routine clinical practice, the authors say.

"With testing in short supply, how do we decide who does or doesn't warrant testing?" Dr. Sultan said. "If testing was more widely available, then we would have a low threshold to test everyone even if they are not presenting with classic respiratory symptoms."

Patients with elevated LFTs in the context of suspected or known COVID-19 should be evaluated for alternative etiologies, according to the report.

Patients hospitalized with suspected or known COVID-19 should have baseline LFTs at the time of admission, and LFT monitoring throughout the hospitalization should be considered, especially for those undergoing drug treatment for COVID-19, as many of these drugs can cause liver dysfunction.

Particularly in light of the tenuous evidence base, these practices are not intended to impose a standard of care, and the authors anticipate the need to update the guideline within the next few months.

"There are still many unanswered questions about SARS-COV-2," Dr. Sultan said. "It is vital that researchers take a systematic approach in collecting data about the clinical manifestations of COVID-19 and follow patients for an appropriate period of time so we can gain a better understanding of the prognostic implications of these varying clinical findings."

Dr. Srinivas R. Vunnam and Dr. Rama R. Vunnam of the University of Nebraska, in Omaha, who also recently reviewed GI, hepatobiliary, and pancreatic manifestations of COVID-19, disagree with some of the recommended practices.

They told Reuters Health by email, "As GI symptoms may precede respiratory symptoms by a few days, COVID-19 testing should be done to identify new cases in a high-prevalence setting. We can't afford to miss any COVID-19 cases, because one COVID-19-infected person transmits the infection to 5.7 individuals."

"Stool testing should be done in all hospitalized COVID-19 patients with GI symptoms to detect live virus in addition to a test-based approach recommended by the Centers for Disease Control and Prevention (CDC) to guide disease recovery and its implications in the fecal-oral transmission," they said. "It may give insight in continuing contact isolation precautions for patients with persistent positive stool cultures after respiratory samples are negative."

"As we are getting new information every day about COVID-19, there is a lag between new information and guidelines," they conclude. "We all should be updated with the best possible evidence to provide excellent care to our patients and community."

SOURCE: Gastroenterology, online May 11, 2020.