The Covid 19 pandemic has affected the whole world. This presentation highlights the Gastrointestinal manifestations related to Covid 19

1. Gastrointestinal Manifestations of
COVID-19

2. Dr. Piyush Patwa
ConsultantGIandLaparoscopicSurgeon
GatewayClinicsCoimbatore

3. Background
In late December 2019, an outbreak of a mysterious pneumonia
characterized by fever, dry cough, and fatigue, and occasional gastrointestinal
symptoms happened in a seafood wholesale wet market, the Huanan Seafood
Wholesale Market, in Wuhan, Hubei, China.
J Chin Med Assoc (2020) 83_3
• The initial outbreak was reported in the market in
December 2019 and involved about 66% of the staff
there
• The market was shut down on January 1, 2020, after
the announcement of an epidemiologic alert by the
local health authority on December 31, 2019

4. Chronology of Events
J Chin Med Assoc (2020) 83_3

5. • Globally, as of 10:42am CEST, 12 August 2020, there have been
20,120,919 confirmed cases of COVID-19, including 736,766
deaths, reported to WHO
• In India, from Jan 30 to 10:42am CEST, 12 August 2020, there
have been 2,329,638 confirmed cases of COVID-19 with
46,091 deaths.
• After USA and Brazil, India has 3rd highest number of Covid-19
patients

6. Virology (Structure & Types)
/Journal of Advanced Research 24 (2020) 91–98
Structure of respiratory syndrome causing human coronavirus
• Coronaviruses belong to the
coronaviradae family
• Corona represents crown-like spikes on
the outer surface of the virus
• They are minute in size (65-125 nm in
diameter)
• Contain a single-stranded RNA as nucleic
material (26-32 kbs in length)
• The subgroups of coronavirus family are
alpha, beta, gamma and delta
• The novel coronavirus is reported to be
of subgroup
• It was named by the International
Committee on Taxonomy as SARS-CoV-2
and the diseases as COVID-19

7. Transmission
Cureus 12(3) e7355
J Chin Med Assoc (2020) 83_3
• Human-to-human transmission is considered the main form of transmission
• Individuals who remain asymptomatic could also transmit the virus
• The most common source of infection is symptomatic people
• Transmission occurs from the spread of respiratory droplets through coughing or sneezing
• Close contact between individuals can also result in transmission
• This also indicates possible transmission in closed spaces due to elevated aerosol concentrations
• The infectious doses not clear, but a high viral load of up to 108 copies/mL in patient’s sputum has been
reported
• The viral load increases initially and still can be detected 12 days after onset of symptoms
• Therefore, the infectivity of patients with 2019-nCoV may last for about 2 weeks.

8. Clinical Features
Based on current epidemiological investigation, the incubation period is 1–14 days, mostly 3–7
days
It is highly transmissible in humans, especially in the elderly and people with underlying
diseases
The median age of patients is 47–59 years, and 41.9–45.7% of patients were females
As it is designated SARS-CoV-2, COVID-19 patients presented certainly similar symptoms,
such as fever, malaise, and cough
Most adults or children with SARS-CoV-2 infection presented with mild flu-like symptoms and a
few patients are in critical condition and rapidly develop acute respiratory distress syndrome,
respiratory failure, multiple organ failure, even deaths
Military Medical Research (2020) 7:11

9. Clinical Presentation of COVID-19

10. Mild & Moderate Disease
Patients with mild illness may present with symptoms of an upper respiratory tract viral infection
These include dry cough, mild fever, nasal congestion, sore throat, headache, muscle pain, and
malaise
It is also characterized by the absence of serious symptoms such as dyspnea. The majority
(81%) of COVID-19 cases are mild in severity
Furthermore, radiograph features are also absent in such cases
Patients with mild disease can quickly deteriorate into severe or critical cases.
Patients with moderate disease present with respiratory symptoms of cough, shortness of breath,
and tachypnea
However,no signs and symptoms of severe disease are present
Cureus 12(3) e7355

11. Severe Disease
Patients with severe disease present with severe pneumonia. acute respiratory distress
syndrome (ARDS), sepsis, or septic shock
Diagnosis is clinical, and complications can be excluded with the help of radiographic studies
Clinical presentations include the presence of severe dyspnea, tachypnea (respiratory rate >
30/minute), respiratory distress, SpO2 ≤ 93%, PaO2/FiO2 < 300, and/or greater than 50% lung
infiltrates within 24 to 48 hours
Even in severe forms of the disease, fever can be absent or moderate
Cureus 12(3) e7355

12. Severe Disease (cont.)
• In addition, 5% of patients can develop a critical disease with features of respiratory
failure, cardiac injury, septic shock, or multiple organ dysfunction
• Data from the Chinese Centers for Disease Control and Prevention (CDC) suggest that
the case fatality rate for critical patients is 49%
• Patients with preexisting comorbidities have a higher case fatality rate; this includes
• Diabetes (7.3%)
• Respiratory disease (6.5%),
• Cardiovascular disease (10.5%),
• Hypertension (6%)
• Oncological complications (5.6%)
• Patients without comorbidities have a lower case fatality rate (0.9%)
Cureus 12(3) e7355

13. Gastrointestinal Symptomology
The most characterized symptoms of COVID-19 include fever, cough, fatigue, dyspnea, sore
throat, headache, and myalgias or arthralgias
Approximately 80 % of patients demonstrate mild symptoms; 20 % have severe disease
About 5 % of patients exhibit critical disease symptoms such as respiratory arrest,
septic shock, or multiple organ failure
ThemedianincubationperiodforCOVID-19 is five days
As SARS-CoV-2 has widely been studied as a respiratory tract pathogen, its extent of
involvement in the gastrointestinal system is currently under investigation
A multicenter and cross-sectional study demonstrated that approximately 50% of patients
experienced symptoms such as diarrhea, nausea, vomiting, abdominal pain
Journal of Clinical Virology 128 (2020) 10438

14. Percentageof2019coronavirusdiseaseCOVID-19
patientsexhibitinggastrointestinalmanifestationsin
variousstudiescompletedfromChina
Journal of Clinical Virology 128 (2020) 104386

15. Incidenceof specificgastrointestinalsymptoms
by COVID-19patients in variousstudies
completedfrom China
Journal of Clinical Virology 128 (2020) 104386

16. Hepatobiliary Implications
• An increasing number of COVID-19 patients have been noted to experience hepatic
injury, ranging on a spectrum of mild to severe damage
• Hepatic injury has been evident in specific laboratory abnormalities in these patients
– the pathophysiology behind SARSCoV-2 infection may suggest the injury is due to
the disease process.
Journal of Clinical Virology 128 (2020) 10438

17. Hepatobiliary Implications
• According to the American College of Gastroenterology (ACG), abnormal liver
enzymes are observed in 20–30 % of persons with confirmed COVID-19 infection
• In a study examining 148 confirmed SARS-CoV-2 infected patients in China, 50.7% of
patients were found to have abnormal liver functions at admission
• Additional studies have demonstrated similar results with abnormalities in liver
enzymes and total bilirubin
• Patients with elevated liver function tests were more likely to have a moderate-high
degree fever, and these elevations were significantly more prevalent in male patients
(68.67%vs.38.36%).
Journal of Clinical Virology 128 (2020) 10438

18. Various gastrointestinal and hepatic manifestations among patients with coronavirus
disease-2019. ALT: Alanine transferase; AST: Aspartate transferase.

19. PercentageofCOVID-19patientsexhibitinghepatobiliary
laboratoryabnormalitiesincludingAST (aspartate
aminotransferase),ALT(alaninetransaminase),&total
bilirubininvariousstudiescompletedfromChina
Journal of Clinical Virology 128 (2020) 104386

20. Pancreas
In a recent study by Wang et al. Examining 52 patients with COVID19 pneumonia, 17% of patients
experienced pancreatic injury defined by any abnormality in amylase or lipase
They did not exhibit clinical symptoms of severe pancreatitis, however.
The ACE2 receptor is also highly expressed in pancreatic islet cells, therefore SARS-CoV-2 infection can
theoretically cause islet damage resulting in acute diabetes.
Of the nine patients with pancreatic injury, six had abnormal blood glucose levels.
Mechanisms by which pancreatic injury could occur include the direct cytopathic effects of SARS-CoV-2,
or indirect systemic inflammatory and immune-mediated cellular responses, resulting in organ damage or
secondary enzyme abnormalities
Antipyretics, which most of the patients in this study took prior to admission, could also cause drug-
related pancreatic injury
Journal of Clinical Virology 128 (2020) 10438

21. Routes of Transmission
• SARS-CoV-2 can be found in the respiratory secretions of patients 1–2 days before
onset of clinical symptoms and for up to two weeks after symptoms subside
• The virus has previously been found in whole blood, serum, urine, and fecal samples
• A study by Cai et al. demonstrated that some pediatric patients were noted to have a
high frequency of SARS-CoV-2 RNA detection in feces.
• It also confirmed prolonged viral RNA shedding in feces for at least two weeks and
upwards of more than a month, raising suspicion that the gastrointestinal tract acts as
another site of viral replication
Journal of Clinical Virology 128 (2020) 10438

22. FecalRT-PCRtestinpatientswithSARS-CoV-2infection
Aliment Pharmacol Ther. 2020;51:843–851

23. Diagnostic testing & Laboratory
Abnormalities
Currently, nasopharyngeal samples are used for the testing of suspected COVID-19
However, with the occurrence of gastrointestinal manifestations, the use of fecal
testing may be beneficial as well.
Additionally, recognizing that gastrointestinal symptoms could be the initial
presentation of COVID-19, prompt and timely diagnostic testing is necessary for early
detection
The use of fecal nucleic acid tests to diagnose COVID-19 have recently increased
A study by Zhang et al. demonstrated that fecal specimens were as accurate as
pharyngeal specimens
Journal of Clinical Virology 128 (2020) 10438

24. Diagnostic testing & Laboratory
Abnormalities
• Apart from diagnostic tests, certain laboratory abnormalities have been noted in
patients with COVID-19.
• In a study of 1099 confirmed COVID-19 cases from main land China, patients exhibited
lymphocytopenia (83.2%), thrombocytopenia (36.2%), and leukopenia (33.7%) on
admission
• Based on a study involving 140 COVID-19 patients, those with severe disease were
noted to have an elevated D-dimer (2.0 fold), C-reactive protein (1.7-fold),
procalcitonin (2.0-fold), lactate dehydrogenase (2.1-fold), decreased lymphocyte
count, and leukopenia as compared to individuals with milder disease
Journal of Clinical Virology 128 (2020) 10438

25. Treatment
• To date, there is no specific antiviral treatment recommended for the
treatment of COVID-19 nor is there a vaccine currently available
• However, clinical trials are in effect with medications such as
• Lopinavir/ ritonavir
• Chloroquine
• Hydroxychloroquine
• Aerosolized alpha-interferon
• Tocilizumab
• Remdesivir (an RNA polymerase inhibitor)
• Current treatment options remain primarily supportive including oxygen
therapy, antipyretics, etc.
• critically-ill individuals may require mechanical ventilation or hemodynamic
support in cases of septic shock.
Journal of Clinical Virology 128 (2020) 10438

26. ManagementofGastrointestinalSymptoms
• Gastrointestinal symptoms such as nausea and vomiting are conservatively
managed with antiemetic medications.
• Prior to initiating supportive care, it is recommended to perform an
additional work-up to rule out other infectious etiologies such as
Clostridium difficile toxin assay and a gastrointestinal pathogen panel
• The use of antibiotics remains controversial but recommended only if
coinfection is noted.
Journal of Clinical Virology 128 (2020) 10438

27. ManagementofGastrointestinalSymptoms
Given that patients can have positive stool results after having tested negative by
nasopharyngeal samples, management should include effective infection control
Patients and their families should be notified that viral shedding may take
place in the active phase of COVID-19 infection
As such, close contacts are at a heightened risk of becoming infected
Patients should be advised to practice proper hand hygiene and maintain social
distancing
Journal of Clinical Virology 128 (2020) 10438

28. Conclusion
• While SARS-CoV-2 has been established as a respiratory tract pathogen, its
pathogenesis may also be responsible for the gastrointestinal manifestations that
accompany COVID-19
• Some patients have experienced symptoms such as diarrhea, nausea, vomiting, and
abdominal pain
• Additionally, laboratory abnormalities, hepatic injury, and pancreatic injury have been
evident in a subset of patients, ranging on a spectrum with the severity of disease.
• As the viral receptor ACE2 is present in the gastrointestinal tract, it may play a role in
the virus’s ability to dysregulate the digestive system, hepatobiliary function, and
pancreatic function, thereby resulting in gastrointestinal symptoms
Journal of Clinical Virology 128 (2020) 10438

29. Thank you!