How Common are Gastrointestinal Symptoms in COVID-19?

By Miguel Regueiro, MD

Every day, we learn more about the symptoms of coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). While the primary symptoms are fever, cough and respiratory difficulty, gastrointestinal symptoms may be present as well and fecal-oral transmission appears possible.

This phenomenon could be due to a combination of the presence in the gastrointestinal tract of angiotensin converting enzyme-2 (ACE2) receptors, which are the SARS-CoV-2 binding site, as well as direct damage from an inflammatory response to viral shedding in the gastrointestinal tract.

Reports from China and Singapore suggest that about half of stool samples tested were positive for SARS-CoV-2. Among 74 patients with COVID-19 in China, 55% tested positive for SARS-CoV-2 RNA in both fecal and respiratory samples. Moreover, the fecal samples remained positive on average 11.2 days longer than did the respiratory samples. In one individual, stool samples were positive 47 days after symptom onset.

Among more than 72,000 cases reported from China, about 10% of patients presented with gastrointestinal symptoms, including diarrhea in 2 to 10% and nausea/vomiting in 1 to 10%. These typically lasted one to two days prior to fever and respiratory symptoms.

Interestingly, another paper from China reported that 3% had gastrointestinal symptoms without respiratory symptoms, although most had fever. Of course, we’re not testing people who don’t have respiratory symptoms, so we really don’t know the extent of this phenomenon.

Loss of appetite is also common and may be secondary to the reported phenomenon of loss of taste/smell just prior to respiratory symptom onset. With loss of appetite included, the overall prevalence of gastrointestinal symptoms in COVID-19 is roughly 20 to 25%.

At Cleveland Clinic, we are doing absolutely everything we can to prepare for if and when the surge hits here. We’re doing it in a unified way, and everyone is on the same page. We have a COVID-19 research registry involving a team of immunologists, virologist, microbiologists, clinical scientists and others who are actively studying all aspects of this illness including how it impacts the GI system. We should know more soon about the prevalence and severity of gastrointestinal symptoms in COVID-19.

Dr. Regueiro is Chairman of Gastroenterology and Hepatology at Cleveland Clinic.