COVID-19:Gastrointestinal manifestations,liver injury and recommendations

Coronavirus disease 2019(COVID-19)has caused a pandemic that affected all countries with nearly 270 million patients and 5 million deaths,as of as of December,2021.The severe acute respiratory syndrome coronavirus 2 virus targets the receptor,angiotensin-converting enzyme 2,which is frequently found in human intestinal epithelial cells,bile duct epithelial cells,and liver cells,and all gastrointestinal system organs are affected by COVID-19 infection.The aim of this study is to review the gastrointestinal manifestations and liver damage of COVID-19 infection and investigate the severe COVID-19 infection risk in patients that have chronic gastrointestinal disease,along with current treatment guidelines.A literature search was conducted on electronic databases of PubMed,Scopus,and Cochran Library,consisting of COVID-19,liver injury,gastrointestinal system findings,and treatment.Liver and intestinal involvements are the most common manifestations.Diarrhea,anorexia,nausea/vomiting,abdominal pain are the most frequent symptoms seen in intestinal involvement.Mild hepatitis occurs with elevated levels of transaminases.Gastrointestinal involvement is associated with long hospital stay,severity of the disease,and intensive care unit necessity.Treatments and follow-up of patients with inflammatory bowel diseases,cirrhosis,hepatocellular carcinoma,or liver transplant have been negatively affected during the pandemic.Patients with cirrhosis,hepatocellular carcinoma,auto-immune diseases,or liver transplantation may have a greater risk for severe COVID-19.Diagnostic or therapeutic procedures should be restricted with specific conditions.Telemedicine should be used in non-urgent periodic patient follow up.COVID-19 treatment should not be delayed in patients at the risk group.COVID-19 vaccination should be prioritized in this group.

Gastrointestinal manifestations,risk factors,and management in patients with post-transplant lymphoproliferative disorder:A systematic review

BACKGROUND Patients with a history of solid organ transplantation(SOT)or hematopoietic stem cell transplantation(HSCT)are at an increased risk of developing post-transplant lymphoproliferative disorder(PTLD).The gastrointestinal(GI)tract is commonly affected as it has an abundance of B and T cells.AIM To determine typical GI-manifestations,risk factors for developing PTLD,and management.METHODS Major databases were searched until November 2021.RESULTS Non-case report studies that described GI manifestations of PTLD,risk factors for developing PTLD,and management of PTLD were included.Nine articles written within the last 20 years were included in the review.All articles found that patients with a history of SOT,regardless of transplanted organ,have a propensity to develop GI-PTLD.CONCLUSION GI tract manifestations may be nonspecific;therefore,consideration of risk factors is crucial for identifying GI-PTLD.Like other lymphoma variants,PTLD is very aggressive making early diagnosis key to prognosis.Initial treatment is reduction of immunosuppression which is effective in more than 50%of cases;however,additional therapy including rituximab,chemotherapy,and surgery may also be required.

Clinical characteristics,gastrointestinal manifestations and outcomes of COVID-19 patients in Iran;does the location matters?

BACKGROUND Coronavirus disease 2019(COVID-19)started in Asia,and Iran was one of its first epicenters.AIM To study the gastrointestinal(GI)symptoms and comorbidities associated with this pandemic in four different regions of Iran.METHODS We analyzed data from severe acute respiratory syndrome coronavirus 2 positive patients evaluated at four hospitals of Iran(n=91),including South(Shiraz),Southeast(Dezful),Rasht(North),and Northwest(Mashhad)between April and September 2020.Demographics,comorbidities and clinical findings including GI symptoms were collected.Statistical descriptive analysis and correlation analyses of symptoms,comorbidities,and mortality were performed.RESULTS The average age of COVID-19 patients was 51.1 years,and 56%were male.Mortality rate was 17%.Cough with 84.6%,shortness of breath with 71.4%,fever with 52.7%,and loss of appetite with 43.9%were the main symptoms.Overall cardiac disease was the most common comorbidity with an average of 28.5%followed by hypertension(28.5%)and diabetes(25.2%).The highest comorbidity in North(Rasht)was diabetes(30%)and in South(Dezful)hypertension(37%).Shiraz leads cardiac disease with 43.4%.The most reported GI symptoms included nausea,diarrhea,vomiting,and abdominal pain,with 42.8%,31.8%,26.8%,and 12%prevalence,respectively.In addition,albumin,alkaline phosphatase,aspartate aminotransferase,and alanine aminotransferase were elevated in 26.3%.CONCLUSION Our results show hypertension and diabetes as the most common comorbidities,but their distribution was different in COVID-19 patients in the four studied regions of Iran.Nausea,diarrhea,and elevated liver enzymes were the most common GI symptoms.There was also a high mortality rate that was associated with high infection rates in Iran at the beginning of the pandemic.

COVID-19 pandemic:Pathophysiology and manifestations from the gastrointestinal tract

The pandemic of coronavirus disease 2019(COVID-19),caused by a newly identifiedβ-coronavirus(SARS-CoV-2)has emerged as a dire health problem,causing a massive crisis for global health.Primary method of transmission was firstly thought to be animal to human transmission.However,it has been observed that the virus is transmitted from human to human via respiratory droplets.Interestingly,SARS-CoV-2 ribonucleic acid(RNA)has been isolated from patient stools,suggesting a possible gastrointestinal(GI)involvement.Most commonly reported clinical manifestations are fever,fatigue and dry cough.Interestingly,a small percentage of patients experience GI symptoms with the most common being anorexia,diarrhea,nausea and vomiting.The presence of viral RNA in stools is also common and fecal tests can be positive even after negative respiratory samples.The exact incidence of digestive symptoms is a matter of debate.The distribution of Angiotensin converting enzyme type 2 receptors in multiple organs in the body provides a possible explanation for the digestive symptoms’mechanism.Cases with solely GI symptoms have been reported in both adults and children.Viral RNA has also been detected in stool and blood samples,indicating the possibility of liver damage,which has been reported in COVID-19 patients.The presence of chronic liver disease appears to be a risk factor for severe complications and a poorer prognosis,however data from these cases is lacking.The aim of this review is firstly,to briefly update what is known about the origin and the transmission of SARS-CoV-2,but mainly to focus on the manifestations of the GI tract and their pathophysiological background,so that physicians on the one hand,not to underestimate or disregard digestive symptoms due to the small number of patients exhibiting exclusively this symptomatology and on the other,to have SARS-CoV-2 on their mind when the“gastroenteritis”type symptoms predominate.

COVID-19 status quo:Emphasis on gastrointestinal and liver manifestations

The coronavirus disease 2019(COVID-19)has caused one of the worst public health crises in modern history.Even though severe acute respiratory syndrome coronavirus 2 primarily affects the respiratory tract,gastrointestinal manifestations are well described in literature.This review will discuss the epidemiology,virology,manifestations,immunosuppressant states,and lessons learned from COVID-19.Observations:At the time of writing,COVID-19 had infected more than 111 million people and caused over 2.5 million deaths worldwide.Multiple medical comorbidities including obesity,pre-existing liver condition and the use of proton pump inhibitor have been described as risk factor for severe COVID-19.COVID-19 most frequently causes diarrhea(12.4%),nausea/vomiting(9%)and elevation in liver enzymes(15%-20%).The current data does not suggest that patients on immunomodulators have a significantly increased risk of mortality from COVID-19.The current guidelines from American Gastroenterological Association and American Association for the Study of Liver Diseases do not recommend pre-emptive changes in patients on immunosuppression if the patients have not been infected with COVID-19.Conclusions and relevance:The COVID-19 pandemic has prompted a change in structure and shape of gastroenterology departmental activities.Endoscopy should be performed only when necessary and with strict protective measures.Online consultations in the form of telehealth services and home drug deliveries have revolutionized the field.

COVID-19 among African Americans and Hispanics:Does gastrointestinal symptoms impact the outcome?

BACKGROUND The coronavirus disease 2019(COVID-19)disproportionately affected African Americans(AA)and Hispanics(HSP).AIM To analyze the significant effectors of outcome in African American patient population and make special emphasis on gastrointestinal(GI)symptoms,laboratory values and comorbidities METHODS We retrospectively evaluated the medical records of 386 COVID-19 positive patients admitted at Howard University Hospital between March and May 2020.We assessed the symptoms,including the GI manifestations,comorbidities,and mortality,using logistic regression analysis.RESULTS Of these 386 COVID-19 positive patients,257(63.7%)were AAs,102(25.3%)HSP,and 26(6.45%)Whites.There were 257(63.7%)AA,102(25.3%)HSP,26(6.45%)Whites.The mean age was 55.6 years(SD=18.5).However,the mean age of HSP was the lowest(43.7 years vs 61.2 for Whites vs 60 for AAs).The mortality rate was highest among the AAs(20.6%)and lowest among HSP(6.9%).Patients with shortness of breath(SOB)(OR2=3.64,CI=1.73-7.65)and elevated AST(OR2=8.01,CI=3.79-16.9)elevated Procalcitonin(OR2=8.27,CI=3.95-17.3),AST(OR2=8.01,CI=3.79-16.9),ferritin(OR2=2.69,CI=1.24-5.82),and Lymphopenia(OR2=2.77,CI=1.41-5.45)had a high mortality rate.Cough and fever were common but unrelated to the outcome.Hypertension and diabetes mellitus were the most common comorbidities.Glucocorticoid treatment was associated with higher mortality(OR2=5.40,CI=2.72-10.7).Diarrhea was prevalent(18.8%),and GI symptoms did not affect the outcome.CONCLUSION African Americans in our study had the highest mortality as they consisted of an older population and comorbidities.Age is the most important factor along with SOB in determining the mortality rate.Overall,elevated liver enzymes,ferritin,procalcitonin and C-reactive protein were associated with poor prognosis.GI symptoms did not affect the outcome.Glucocorticoids should be used judiciously,considering the poor outcomes associated with it.Attention should also be paid to monitor liver function during COVID-19,especially in AA and HSP patients with higher disease severity.

Digestive system involvement and clinical outcomes among COVID-19 patients:A retrospective cohort study from Qatar

BACKGROUND Coronavirus disease 2019(COVID-19)caused by the severe acute respiratory syndrome coronavirus 2 virus most commonly presents with respiratory symptoms.While gastrointestinal(GI)manifestations either at presentation or during hospitalization are also common,their impact on clinical outcomes is controversial.Some studies have described worse outcomes in COVID-19 patients with GI symptoms,while others have shown either no association or a protective effect.There is a need for consistent standards to describe GI symptoms in COVID-19 patients and to assess their effect on clinical outcomes,including mortality and disease severity.AIM To investigate the prevalence of GI symptoms in hospitalized COVID-19 patients and their correlation with disease severity and clinical outcomes.METHODS We retrospectively reviewed 601 consecutive adult COVID-19 patients requiring hospitalization between May 1-15,2020.GI symptoms were recorded at admission and during hospitalization.Demographic,clinical,laboratory,and treatment data were retrieved.Clinical outcomes included all-cause mortality,disease severity at presentation,need for intensive care unit(ICU)admission,development of acute respiratory distress syndrome,and need for mechanical ventilation.Multivariate logistic regression model was used to identify independent predictors of the adverse outcomes.RESULTS The prevalence of any GI symptom at admission was 27.1%and during hospitalization was 19.8%.The most common symptoms were nausea(98 patients),diarrhea(76 patients),vomiting(73 patients),and epigastric pain or discomfort(69 patients).There was no difference in the mortality between the two groups(6.21%vs 5.5%,P=0.7).Patients with GI symptoms were more likely to have severe disease at presentation(33.13%vs 22.5%,P<0.001)and prolonged hospital stay(15 d vs 14 d,P=0.04).There was no difference in other clinical outcomes,including ICU admission,development of acute respiratory distress syndrome,or need for mechanical ventilation.Drugs associated with the development of GI symptoms during hospitalization were ribavirin(diarrhea 26.37%P<0.001,anorexia 17.58%,P=0.02),hydroxychloroquine(vomiting 28.52%,P=0.009)and lopinavir/ritonavir(nausea 32.65%P=0.049,vomiting 31.47%P=0.004,and epigastric pain 12.65%P=0.048).In the multivariate regression analysis,age>65 years was associated with increased mortality risk[odds ratio(OR)7.53,confidence interval(CI):3.09-18.29,P<0.001],ICU admission(OR:1.79,CI:1.13-2.83,P=0.012),and need for mechanical ventilation(OR:1.89,CI:1.94-2.99,P=0.007).Hypertension was an independent risk factor for ICU admission(OR:1.82,CI:1.17-2.84,P=0.008)and need for mechanical ventilation(OR:1.66,CI:1.05-2.62,P=0.028).CONCLUSION Patients with GI symptoms are more likely to have severe disease at presentation;however,mortality and disease progression is not different between the two groups.

COVID-19 and the digestive system:A comprehensive review

The coronavirus disease 2019(COVID-19)pandemic caused by severe acute respiratory syndrome coronavirus-2(SARS-CoV-2)is spreading at an alarming rate,and it has created an unprecedented health emergency threatening tens of millions of people worldwide.Previous studies have indicated that SARS-CoV-2 ribonucleic acid could be detected in the feces of patients even after smearnegative respiratory samples.However,demonstration of confirmed fecal-oral transmission has been difficult.Clinical studies have shown an incidence rate of gastrointestinal(GI)symptoms ranging from 2%to 79.1%in patients with COVID-19.They may precede or accompany respiratory symptoms.The most common GI symptoms included nausea,diarrhea,and abdominal pain.In addition,some patients also had liver injury,pancreatic damage,and even acute mesenteric ischemia/thrombosis.Although the incidence rates reported in different centers were quite different,the digestive system was the clinical component of the COVID-19 section.Studies have shown that angiotensinconverting enzyme 2,the receptor of SARS-CoV-2,was not only expressed in the lungs,but also in the upper esophagus,small intestine,liver,and colon.The possible mechanism of GI symptoms in COVID-19 patients may include direct viral invasion into target cells,dysregulation of angiotensin-converting enzyme 2,immune-mediated tissue injury,and gut dysbiosis caused by microbiota.Additionally,numerous experiences,guidelines,recommendations,and position statements were published or released by different organizations and societies worldwide to optimize the management practice of outpatients,inpatients,and endoscopy in the era of COVID-19.In this review,based on our previous work and relevant literature,we mainly discuss potential fecal-oral transmission,GI manifestations,abdominal imaging findings,relevant pathophysiological mechanisms,and infection control and prevention measures in the time of COVID-19.