Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2021 Jul;19(7):1355-1365.e4.
doi: 10.1016/j.cgh.2020.09.041. Epub 2020 Oct 1.

Digestive Manifestations in Patients Hospitalized With Coronavirus Disease 2019

B Joseph Elmunzer  1 , Rebecca L Spitzer  2 , Lydia D Foster  3 , Ambreen A Merchant  4 , Eric F Howard  5 , Vaishali A Patel  4 , Mary K West  5 , Emad Qayed  6 , Rosemary Nustas  6 , Ali Zakaria  7 , Marc S Piper  7 , Jason R Taylor  8 , Lujain Jaza  8 , Nauzer Forbes  9 , Millie Chau  9 , Luis F Lara  10 , Georgios I Papachristou  10 , Michael L Volk  11 , Liam G Hilson  12 , Selena Zhou  12 , Vladimir M Kushnir  13 , Alexandria M Lenyo  13 , Caroline G McLeod  2 , Sunil Amin  14 , Gabriela N Kuftinec  14 , Dhiraj Yadav  15 , Charlie Fox  16 , Jennifer M Kolb  16 , Swati Pawa  17 , Rishi Pawa  17 , Andrew Canakis  18 , Christopher Huang  18 , Laith H Jamil  19 , Andrew M Aneese  20 , Benita K Glamour  21 , Zachary L Smith  21 , Katherine A Hanley  22 , Jordan Wood  22 , Harsh K Patel  23 , Janak N Shah  23 , Emil Agarunov  24 , Amrita Sethi  24 , Evan L Fogel  25 , Gail McNulty  25 , Abdul Haseeb  26 , Judy A Trieu  26 , Rebekah E Dixon  27 , Jeong Yun Yang  27 , Robin B Mendelsohn  28 , Delia Calo  28 , Olga C Aroniadis  29 , Joseph F LaComb  29 , James M Scheiman  30 , Bryan G Sauer  30 , Duyen T Dang  31 , Cyrus R Piraka  31 , Eric D Shah  32 , Heiko Pohl  33 , William M Tierney  34 , Stephanie Mitchell  34 , Ashwinee Condon  35 , Adrienne Lenhart  35 , Kulwinder S Dua  36 , Vikram S Kanagala  36 , Ayesha Kamal  37 , Vikesh K Singh  37 , Maria Ines Pinto-Sanchez  38 , Joy M Hutchinson  38 , Richard S Kwon  39 , Sheryl J Korsnes  39 , Harminder Singh  40 , Zahra Solati  40 , Field F Willingham  4 , Patrick S Yachimski  5 , Darwin L Conwell  10 , Evan Mosier  11 , Mohamed Azab  11 , Anish Patel  11 , James Buxbaum  12 , Sachin Wani  16 , Amitabh Chak  21 , Amy E Hosmer  21 , Rajesh N Keswani  22 , Christopher J DiMaio  27 , Michael S Bronze  34 , Raman Muthusamy  35 , Marcia I Canto  37 , V Mihajlo Gjeorgjievski  20 , Zaid Imam  20 , Fadi Odish  20 , Ahmed I Edhi  20 , Molly Orosey  20 , Abhinav Tiwari  20 , Soumil Patwardhan  20 , Nicholas G Brown  24 , Anish A Patel  24 , Collins O Ordiah  2 , Ian P Sloan  13 , Lilian Cruz  29 , Casey L Koza  5 , Uchechi Okafor  10 , Thomas Hollander  13 , Nancy Furey  21 , Olga Reykhart  29 , Natalia H Zbib  32 , John A Damianos  32 , James Esteban  36 , Nick Hajidiacos  40 , Melissa Saul  15 , Melanie Mays  15 , Gulsum Anderson  15 , Kelley Wood  15 , Laura Mathews  15 , Galina Diakova  30 , Molly Caisse  32 , Lauren Wakefield  2 , Haley Nitchie  2 , Akbar K Waljee  39 , Weijing Tang  41 , Yueyang Zhang  41 , Ji Zhu  41 , Amar R Deshpande  14 , Don C Rockey  2 , Teldon B Alford  2 , Valerie Durkalski  3 ; North American Alliance for the Study of Digestive Manifestations of COVID-19
Affiliations

Digestive Manifestations in Patients Hospitalized With Coronavirus Disease 2019

B Joseph Elmunzer et al. Clin Gastroenterol Hepatol. 2021 Jul.

Abstract

Background & aims: The prevalence and significance of digestive manifestations in coronavirus disease 2019 (COVID-19) remain uncertain. We aimed to assess the prevalence, spectrum, severity, and significance of digestive manifestations in patients hospitalized with COVID-19.

Methods: Consecutive patients hospitalized with COVID-19 were identified across a geographically diverse alliance of medical centers in North America. Data pertaining to baseline characteristics, symptomatology, laboratory assessment, imaging, and endoscopic findings from the time of symptom onset until discharge or death were abstracted manually from electronic health records to characterize the prevalence, spectrum, and severity of digestive manifestations. Regression analyses were performed to evaluate the association between digestive manifestations and severe outcomes related to COVID-19.

Results: A total of 1992 patients across 36 centers met eligibility criteria and were included. Overall, 53% of patients experienced at least 1 gastrointestinal symptom at any time during their illness, most commonly diarrhea (34%), nausea (27%), vomiting (16%), and abdominal pain (11%). In 74% of cases, gastrointestinal symptoms were judged to be mild. In total, 35% of patients developed an abnormal alanine aminotransferase or total bilirubin level; these were increased to less than 5 times the upper limit of normal in 77% of cases. After adjusting for potential confounders, the presence of gastrointestinal symptoms at any time (odds ratio, 0.93; 95% CI, 0.76-1.15) or liver test abnormalities on admission (odds ratio, 1.31; 95% CI, 0.80-2.12) were not associated independently with mechanical ventilation or death.

Conclusions: Among patients hospitalized with COVID-19, gastrointestinal symptoms and liver test abnormalities were common, but the majority were mild and their presence was not associated with a more severe clinical course.

Keywords: COVID-19; Digestive Manifestations; Gastrointestinal Symptoms; Hepatic Manifestations; SARS-CoV-2.

PubMed Disclaimer

Figures

Figure 1
Figure 1
Gastrointestinal symptoms in patients hospitalized with coronavirus disease 2019 (COVID-19).
Figure 2
Figure 2
Prevalence and distribution of gastrointestinal symptoms by study site.
Figure 3
Figure 3
Liver test abnormalities in patients hospitalized with coronavirus disease 2019 (COVID-19), at admission and at any time during hospitalization. Proportions were calculated using the full cohort as the denominator (N = 1992). Alk phos, alkaline phosphatase; ALT, alanine aminotransferase; AST, aspartate aminotransferase; IQR, interquartile range; TB, total bilirubin.
Supplementary Figure 1
Supplementary Figure 1
Prevalence and distribution of gastrointestinal symptoms in 1860 patients without pre-existing luminal gastrointestinal or pancreaticobiliary disease, compared with the full cohort.
Supplementary Figure 2
Supplementary Figure 2
Prevalence and distribution of gastrointestinal symptoms in 875 patients who were not known to have received any of the following medications that are associated with potential gastrointestinal side effects: hydroxychloroquine, chloroquine, remdesivir, oseltamivir, lopinavir/ritonavir, and interferon alpha, compared with the full cohort. COVID-19, coronavirus disease 2019.
Supplementary Figure 3
Supplementary Figure 3
Prevalence and distribution of liver test abnormalities in 1876 patients without pre-existing liver disease, compared with the full cohort. ALT, alanine aminotransferase; TB, total bilirubin.
Supplementary Figure 4
Supplementary Figure 4
Prevalence and distribution of abnormal liver tests in 1825 patients who were not known to have received any of the following medications with potential hepatotoxicity: remdesivir, oseltamivir, lopinavir/ritonavir, and interferon alpha, compared with the full cohort. ALT, alanine aminotransferase; COVID-19, coronavirus disease 2019; TB, total bilirubin.
See this image and copyright information in PMC

References

    1. Xiao F., Tang M., Zheng X. Evidence for gastrointestinal infection of SARS-CoV-2. Gastroenterology. 2020;158:1831–1833. - PMC - PubMed
    1. Du M., Cai G., Chen F. Multi-omics evaluation of gastrointestinal and other clinical characteristics of SARS-CoV-2 and COVID-19. Gastroenterology. 2020;158 2298–2230. - PMC - PubMed
    1. ACE2 angiotensin I converting enzyme 2 [Homo sapiens (human)]. Gene ID: 59272. https://www.ncbi.nlm.nih.gov/gene/59272 Available from: Accessed May 9, 2020.
    1. Han C., Duan C., Zhang S. Digestive symptoms in COVID-19 patients with mild disease severity: clinical presentation, stool viral RNA testing, and outcomes. Am J Gastroenterol. 2020;115:916–923. - PMC - PubMed
    1. Wu Y., Guo C., Tang L. Prolonged presence of SARS-CoV-2 viral RNA in faecal samples. Lancet Gastroenterol Hepatol. 2020;5:434–435. - PMC - PubMed