Shahnaz Sultan ¹, Osama Altayar ², Shazia M Siddique ³, Perica Davitkov ⁴, Joseph D Feuerstein ⁵, Joseph K Lim ⁶, Yngve Falck-Ytter ⁴, Hashem B El-Serag ⁷, American Gastroenterological Association. Electronic address: ewilson@gastro.org

Gastroenterology. 2020 May 11;S0016-5085(20)30593-X. doi: 10.1053/j.gastro.2020.05.001.Online ahead of print.

Author information

¹Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis Veterans Affairs Healthcare System, Minneapolis, Minnesota.

²Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri.

³Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.

⁴Division of Gastroenterology, Northeast Ohio Veterans Affairs Healthcare System, Case Western Reserve University School of Medicine, Cleveland, Ohio.

⁵Division of Gastroenterology and Center for Inflammatory Bowel Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

⁶Yale Liver Center and Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut; and.

⁷Department of Medicine, Baylor College of Medicine, Houston, Texas.

Free PMC article

Abstract

Background & aims: Multiple gastrointestinal (GI) symptoms, including diarrhea, nausea/vomiting, and abdominal pain, as well as liver enzyme abnormalities, have been variably reported in patients with coronavirus disease 2019 (COVID-19). The American Gastroenterological Association Institute Clinical Guideline Committee and Clinical Practice Updates Committee performed a systematic review and meta-analysis of international data on GI and liver manifestations of COVID-19.

Methods: We performed a systematic literature search to identify published and unpublished studies using OVID Medline and preprint servers (medRxiv, LitCovid, and SSRN [Social Science Research] up until April 5, 2020; major journal sites were monitored for US publications until April 19, 2020. We analyzed the prevalence of diarrhea, nausea, vomiting, and abdominal pain, as well as liver function tests abnormalities, using a fixed-effect model and assessed the certainty of evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework.

Results: We identified 118 studies and used a hierarchal study selection process to identify unique cohorts. We performed a meta-analysis of 47 studies including 10,890 unique patients. Pooled prevalence estimates of GI symptoms were as follows: diarrhea 7.7% (95% confidence interval [CI], 7.2%-8.2%), nausea/vomiting 7.8% (95% CI, 7.1%-8.5%), and abdominal pain 2.7% (95% CI, 2.0%-3.4%). Most studies reported on hospitalized patients. The pooled prevalence estimates of elevated liver abnormalities were as follows: aspartate transaminase 15.0% (95% CI, 13.6%-16.5%) and alanine transaminase 15.0% (95% CI, 13.6%-16.4%). When analyzed comparing data from China to studies from countries other than China, diarrhea, nausea/vomiting, and liver abnormalities were more prevalent outside of China, with diarrhea reported in 18.3% (95% CI, 16.6%-20.1%). Isolated GI symptoms were reported rarely. We also summarized the Gl and liver adverse effects of the most commonly utilized medications for COVID-19.

Conclusions: GI symptoms are associated with COVID-19 in <10% of patients. In studies outside of China, estimates are higher. Further studies are needed with standardized GI symptoms questionnaires and liver function test checks on admission to better quantify and qualify the association of these symptoms with COVID-19. Based on findings from our meta-analysis, we provide several Best Practice Statements for the consultative management of COVID-19.