Gastrointestinal Symptoms Could Signal Severity of COVID-19

The presence of gastrointestinal symptoms in patients with COVID-19 was associated with a more severe course of illness and greater likelihood of mortality, in a prospective study of a population with little exposure to drugs with adverse GI effects.

"Infection with SARS-CoV-2 is increasingly recognized to cause GI symptoms in addition to the respiratory symptoms," noted Uday Ghoshal, MD, Departments of Gastroenterology and Microbiology, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow, India, and colleagues.

"The prevalence of GI symptoms reported in our study may be a true reflection of the frequency (with COVID-19) because most of these patients were not hospitalized and were not on drugs that might be associated with GI symptoms,"the investigators indicated.

Ghoshal and colleagues conducted the prospective study of 252 consecutive patients with laboratory-confirmed SARS-CoV-2 infection in a referral clinic of a university hospital in northern India during a 1-month period between April and May 2020.Demographic and clinical data were obtained directly from patients presenting to the clinic, and with an electronic online questionnaire and telephone follow-up for remote patients.

In the cohort, 82.5% (n=208) were asymptomatic.Of the 44 patients with symptoms, 40.9% (n=18) had non-GI symptoms, 34.1% (n=15) had a combination of GI and non-GI symptoms, and 25% (n=11) had GI symptoms only.The symptoms included anorexia, nausea, vomiting, abdominal pain and diarrhea.The investigators reported that, among the 26 patient with GI symptoms, 5% had severe disease and 2% had fatal outcomes.

"We not only did the univariate analysis, but we also did a multivariable analysis and found that the presence of GI symptoms was associated with severe COVID-19 and worse outcome even on multivariate analysis," Ghoshal told ContagionLive."Hence, healthcare personnel taking care of COVID-19 patients must be vigilant about the presence of GI symptoms."

Possible mechanisms for GI symptoms in COVID-19, include SARS-CoV-2 infection in the GI tract, Ghoshal noted, citing a meta-analysis which determined that patients with diarrhea were more likely to have viral RNA in the feces.

"SARS-CoV-2 infection of the GI tract occurs because the receptor, angiotensin converting enzyme-2, through which the virus enters into the cells are not only present in the nasopharyngeal and respiratory mucusa but also GI tract mucosa," Ghoshal explained.

Ghoshal also noted that elevated serotonin levels can occur in COVID-19, which can lead to increased GI motility and secretion."High level of serotonin has been shown in GI mucosa in patients with COVID-19," he said.

The investigators noted the higher proportion of asymptomatic patients or those with mild illness in their cohortthan is reported in the US, and suggested several possible factors.Less hygenic conditions in tropical and subtropical counties have been associated with fewer autoimmune and allergic diseases, and they suggest this could also contribute to reducing the host immune response to SARS-CoV-2 and the occurrence of cytokine storm.Other possible factors, they indicated, include a younger demographic in developing countries, with fewer comorbid illnesses.

"It is (also) possible that the SARS-CoV-2 genome is different in India," Ghoshal commented."We know now that there is a UK strain of SARS-CoV-2, which is more infectious or may be more lethal than the other strain.Difference in SARS-CoV-2 genome might be another reason for less severe disease in India.However, more studies from India are needed to evaluate this hypothesis."

Ghoshal and colleagues characterize their study as the first to address the association between severity of COVID-19 and the presence of GI symptoms; and indicate that efforts to identifydeterminants and correlates of severity and outcome are particularly important while vaccination against the infection remains limited.