Gastrointestinal and hepatic abnormalities in patients with confirmed COVID-19: A systematic review and meta-analysis

COVID-19 Diarrhea is Inflammatory, Caused by Direct Viral Effects Plus Major Role of Virus-induced Cytokines

BACKGROUND & AIMS

Diarrhea occurs in up to 50% of cases of COVID-19. Nonetheless, the pathophysiologic mechanism(s) have not been determined.

METHODS

This was examined using normal human enteroid monolayers exposed apically to live SARS-CoV-2 or non-replicating virus-like particles (VLPs) bearing the 4 SARS-CoV-2 structural proteins or irradiated virus, all of which bound and entered enterocytes.

RESULTS

Live virus and VLPs increased secretion of multiple cytokines and reduced mRNAs of ACE2, NHE3, and DRA. Interleukin (IL)-6 plus IL-8 alone reduced NHE3 mRNA and protein and DRA mRNA. Neither VLPs nor IL-6 plus IL-8 alone altered Cl- secretion, but together they caused Cl- secretion, which was Ca2+-dependent, CFTR-independent, blocked partially by a specific TMEM16 A inhibitor, and entirely by a general TMEM16 family inhibitor. VLPs and irradiated virus, but not IL-6 plus IL-8, produced Ca2+ waves that began within minutes of VLP exposure, lasted for at least 60 minutes, and were prevented by pretreatment with apyrase, a P2Y1 receptor antagonist, and general TMEM16 family inhibitor but not by the specific TMEM16A inhibitor.

CONCLUSIONS

The pathophysiology of COVID-19 diarrhea appears to be a unique example of a calcium-dependent inflammatory diarrhea that is caused by direct viral effects plus the virus-induced intestinal epithelial cytokine secretion.

COVID-19 presenting as severe acute hepatitis in a pediatric patient with thalassemia minor: A case report

Key Clinical Message

This case emphasizes the significance of COVID-19 in pediatric patients presenting with unusual hepatic manifestations, urging clinicians to broaden their diagnostic lens. The unexpected elevation of SARS-CoV-2 antibodies and the effective use of N-acetyl cysteine highlight the importance of adaptability in treatment strategies.

Abstract

This case report presents a unique manifestation of severe hepatic involvement in a 4-year-old girl with thalassemia minor and COVID-19. Despite the absence of prominent respiratory symptoms, the patient exhibited jaundice, elevated liver enzymes, and coagulopathy. Initial suspicion of viral hepatitis was replaced by the discovery of significantly elevated SARS-CoV-2 antibodies. A multidisciplinary approach, including gastroenterology consultation and an extensive workup, was pivotal in ruling out alternative etiologies. Unconventional use of N-acetyl cysteine contributed to clinical improvement, highlighting the need for adaptable treatment strategies. This case underscores the importance of heightened awareness in recognizing atypical presentations of COVID-19 in pediatric patients, especially those with underlying health conditions. Further exploration into nuanced manifestations and treatment approaches is warranted for comprehensive clinical management.

Gastrointestinal Endoscopy in Patients with Coronavirus Disease 2019: Indications, Findings, and Safety

The coronavirus disease 2019 (COVID-19) pandemic has changed the practice of gastroenterology and how we perform endoscopy. As with any new or emerging pathogen, early in the pandemic, there was limited evidence and understanding of disease transmission, limited testing capability, and resource constraints, especially availability of personal protective equipment (PPE). As the COVID-19 pandemic progressed, enhanced protocols with particular emphasis on assessing the risk status of patients and proper use of PPE have been incorporated into routine patient care. The COVID-19 pandemic has taught us important lessons for the future of gastroenterology and endoscopy.

Liver involvement in patients with COVID-19 infection: A comprehensive overview of diagnostic imaging features

During the first wave of the pandemic, coronavirus disease 2019 (COVID-19) infection has been considered mainly as a pulmonary infection. However, different clinical and radiological manifestations were observed over time, including involvement of abdominal organs. Nowadays, the liver is considered one of the main affected abdominal organs. Hepatic involvement may be caused by either a direct damage by the virus or an indirect damage related to COVID-19 induced thrombosis or to the use of different drugs. After clinical assessment, radiology plays a key role in the evaluation of liver involvement. Ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI) may be used to evaluate liver involvement. US is widely available and it is considered the first-line technique to assess liver involvement in COVID-19 infection, in particular liver steatosis and portal-vein thrombosis. CT and MRI are used as second- and third-line techniques, respectively, considering their higher sensitivity and specificity compared to US for assessment of both parenchyma and vascularization. This review aims to the spectrum of COVID-19 liver involvement and the most common imaging features of COVID-19 liver damage.

Risk Factors of Severe COVID-19: A Review of Host, Viral and Environmental Factors

The clinical course and outcome of COVID-19 are highly variable, ranging from asymptomatic infections to severe disease and death. Understanding the risk factors of severe COVID-19 is relevant both in the clinical setting and at the epidemiological level. Here, we provide an overview of host, viral and environmental factors that have been shown or (in some cases) hypothesized to be associated with severe clinical outcomes. The factors considered in detail include the age and frailty, genetic polymorphisms, biological sex (and pregnancy), co- and superinfections, non-communicable comorbidities, immunological history, microbiota, and lifestyle of the patient; viral genetic variation and infecting dose; socioeconomic factors; and air pollution. For each category, we compile (sometimes conflicting) evidence for the association of the factor with COVID-19 outcomes (including the strength of the effect) and outline possible action mechanisms. We also discuss the complex interactions between the various risk factors.

COVID-19 and diarrhea: putative mechanisms and management

BACKGROUND

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the causative agent of the coronavirus disease 2019 (COVID-19), has recently posed a threat to global health by spreading at a high rate and taking millions of lives worldwide. Along with the respiratory symptoms, there are gastrointestinal manifestations and one of the most common gastrointestinal symptoms is diarrhea which is seen in a significant percentage of COVID-19 patients.

LITERATURE REVIEW

Several studies have shown the plausible correlation between overexpressed angiotensin converting enzyme 2 (ACE2) in enterocytes and SARS-CoV-2, as ACE2 is the only known receptor for the virus entry. Along with the dysregulated ACE2, there are other contributing factors such as gut microbiome dysbiosis, adverse effects of antiviral and antibiotics for treating infections and inflammatory response to SARS-CoV-2 which bring about increased permeability of gut cells and subsequent occurrence of diarrhea. Few studies found that the SARS-CoV-2 is capable of damaging liver cells too. No single effective treatment option is available.

LIMITATIONS

Confirmed pathophysiology is still unavailable. Studies regarding global population are also insufficient.

CONCLUSION

In this review, based on the previous works and literature, we summarized the putative molecular pathophysiology of COVID-19 associated diarrhea, concomitant complications and the standard practices of management of diarrhea and hepatic manifestations in international setups.

Association between nutritional therapy and complications in patients diagnosed with COVID-19 followed in the state of Pernambuco

Objective: To analyze the association between nutritional therapy and complications in patients diagnosed with COVID-19 followed in Pernambuco. Methods: A prospective cohort study was conducted to investigate secondary data from multicenter research from June 2020 to June 2021. Patients of both sexes over 18 years old were hospitalized for COVID-19 in wards or intensive care units of eight hospitals. Sociodemographic and economic data, nutritional status, nutritional therapy, gastrointestinal complications, and clinical outcome were collected during admission and at the end of hospitalization. Results: The sample consisted of 272 patients, with a median age of 67 years (IQR 54 - 76), equally distributed between men and women (50.4% vs. 49.6%). A higher frequency of overweight/obesity (40.31%) was observed. The most frequent alterations were inappetence (12.88%) and dysgeusia (8.28%). It was observed that 84.6% received an early diet, the caloric adequacy varied between 72.1% and 60.7%, the oral route between 82.4% and 70.7%, the majority (58%) received up to 1.3 g of protein per day, and 46.7% died. Caloric adequacy was associated with dysgeusia (p = 0.040) and clinical outcome (p = 0.044) and tended to be associated with vomiting (p = 0.077). No association was found with proteins. Conclusion: Nutritional therapy is associated with gastrointestinal symptoms such as vomiting and dysgeusia and the clinical outcome of patients with COVID-19.

The des-Arg9-bradykinin/B1R axis: Hepatic damage in COVID-19

Patients infected by the SARS-CoV-2 virus are commonly diagnosed with threatening liver conditions associated with drug-induced therapies and systemic viral action. RNA-Seq data from cells in bronchoalveolar lavage fluid from COVID-19 patients have pointed out dysregulation of kallikrein-kinin and renin-angiotensin systems as a possible mechanism that triggers multi-organ damage away from the leading site of virus infection. Therefore, we measured the plasma concentration of biologically active peptides from the kallikrein-kinin system, bradykinin and des-Arg⁹-bradykinin, and liver expression of its proinflammatory axis, bradykinin 1 receptor (B1R). We measured the plasma concentration of bradykinin and des-Arg⁹-bradykinin of 20 virologically confirmed COVID-19 patients using a liquid chromatography-tandem mass spectrometry-based methodology. The expression of B1R was evaluated by immunohistochemistry from post-mortem liver specimens of 27 COVID-19 individuals. We found a significantly higher blood level of des-Arg⁹-bradykinin and a lower bradykinin concentration in patients with COVID-19 compared to a healthy, uninfected control group. We also observed increased B1R expression levels in hepatic tissues of patients with COVID-19 under all hepatic injuries analyzed (liver congestion, portal vein dilation, steatosis, and ischemic necrosis). Our data indicate that des-Arg⁹-bradykinin/B1R is associated with the acute hepatic dysfunction induced by the SARS-CoV-2 virus infection in the pathogenesis of COVID-19.

COVID19 biomarkers: What did we learn from systematic reviews?

The coronavirus disease 2019 (COVID19) pandemic continues to represent a substantial public health concern. It can rapidly progress to severe disease, with poor prognosis and a high mortality risk. An early diagnosis and specific prognostic tools can help healthcare providers to start interventions promptly, understand the likely prognosis and to identify and treat timely individuals likely to develop severe disease with enhanced mortality risk. Here we focused on an impressive set of systematic reviews and meta-analyses that were performed since the start of the COVID19 pandemic and summarized their results related to the levels of hematologic, inflammatory, immunologic biomarkers as well as markers of cardiac, respiratory, hepatic, gastrointestinal and renal systems and their association with the disease progression, severity and mortality. The evidence outlines the significance of specific biomarkers, including inflammatory and immunological parameters (C-reactive protein, procalcitonin, interleukin-6), hematological (lymphocytes count, neutrophil-to-lymphocyte ratio, D-dimer, ferritin, red blood cell distribution width), cardiac (troponin, CK-MB, myoglobin), liver (AST, ALT, total bilirubin, albumin) and lung injury (Krebs von den Lungen-6) that can be used as prognostic biomarkers to aid the identification of high-risk patients and the prediction of serious outcomes, including mortality, in COVID19. Thus, these parameters should be used as essential tools for an early risk stratification and adequate intervention in improving disease outcomes in COVID19 patients.

Hepatic manifestations of coronavirus disease 2019 infection: Clinical and laboratory perspective

The novel coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2, has become a global challenge of unprecedented nature since December 2019. Although most patients with COVID-19 exhibit mild clinical manifestations and upper respiratory tract involvement, in approximately 5%-10% of patients, the disease is severe and involves multiple organs, leading to multi-organ dysfunction and failure. The liver and gastrointestinal tract are also frequently involved in COVID-19. In the context of liver involvement in patients with COVID-19, many key aspects need to be addressed in both native and transplanted organs. This review focuses on the clinical presentations and laboratory abnormalities of liver function tests in patients with COVID-19 with no prior liver disease, patients with pre-existing liver diseases and liver transplant recipients. A brief overview of the history of COVID-19 and etiopathogenesis of the liver injury will also be described as a prelude to better understanding the above aspects.

Multi-organ system involvement in coronavirus disease 2019 (COVID-19): A mega review

Since the pandemic of the coronavirus disease 2019 (COVID-19) infection, many people have been affected in different ways. The majority of infected people experience mild to moderate symptoms and recover without the need for hospitalization. However, in some affected people, it may lead to catastrophic disease. The severity of COVID-19 infection is widely influenced by co-morbidities, immune system functions, and extra-pulmonary organ injuries. Since the emergence of COVID-19, multi-organ involvement has been documented. In order to implement preventative and protective measures, full attention to potential organ injuries is required. Most existing articles and review papers are focused on a specific organ system, and their numbers are growing. In this review paper, attempts were made to collect review papers and articles published on seven organ system involvements in COVID-19 infection published till 15 July and highlight conclusions and managements of all affected organs. We tried to add to the medical knowledge on COVID-19, pointing out its multi-organ system impact. Finally, we tried to facilitate access to organized information and optimum conclusion by representing review tables for each organ system. Besides, this review article can clarify and magnify the empty research space easily for future investigations.

Liver Function Tests in COVID-19: Assessment of the Actual Prognostic Value

Deviations in laboratory tests assessing liver function in patients with COVID-19 are frequently observed. Their importance and pathogenesis are still debated. In our retrospective study, we analyzed liver-related parameters: aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), gamma-glutamyltransferase (GGT), total bilirubin (TBIL), albumin, comorbidities and other selected potential risk factors in patients admitted with SARS-CoV-2 infection to assess their prognostic value for intensive care unit admission, mechanical ventilation necessity and mortality. We compared the prognostic effectiveness of these parameters separately and in pairs to the neutrophil-to-lymphocyte ratio (NLR) as an independent risk factor of in-hospital mortality, using the Akaike Information Criterion (AIC). Data were collected from 2109 included patients. We created models using a sample with complete laboratory tests n = 401 and then applied them to the whole studied group excluding patients with missing singular variables. We estimated that albumin may be a better predictor of the COVID-19-severity course compared to NLR, irrespective of comorbidities (p < 0.001). Additionally, we determined that hypoalbuminemia in combination with AST (OR 1.003, p = 0.008) or TBIL (OR 1.657, p = 0.001) creates excellent prediction models for in-hospital mortality. In conclusion, the early evaluation of albumin levels and liver-related parameters may be indispensable tools for the early assessment of the clinical course of patients with COVID-19.

Gastrointestinal Involvement in SARS-CoV-2 Infection

SARS-CoV-2 has evolved into a virus that primarily results in mild or asymptomatic disease, making its transmission more challenging to control. In addition to the respiratory tract, SARS-CoV-2 also infects the digestive tract. Some gastrointestinal symptoms occur with or before respiratory symptoms in patients with COVID-19. Respiratory infections are known to cause intestinal immune impairment and gastrointestinal symptoms. When the intestine is inflamed, cytokines affect the lung immune response and inflammation through blood circulation. The gastrointestinal microbiome may be a modifiable factor in determining the risk of SARS-CoV-2 infection and disease severity. The development of oral SARS-CoV-2 vaccine candidates and the maintenance of gut microbiota profiles may contribute to the early control of COVID-19 outbreaks. To this end, this review summarizes information on the gastrointestinal complications caused by SARS-CoV-2, SARS-CoV-2 infection, the gastrointestinal–lung axis immune response, potential control strategies for oral vaccine candidates and maintaining intestinal microbiota homeostasis.

Global research production pertaining to gastrointestinal involvement in COVID-19: A bibliometric and visualised study

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a global pandemic that can cause diarrhoea, nausea/vomiting, and abdominal pain, among other gastrointestinal (GI) symptoms.

AIM

To perform a bibliometric analysis of the global research production pertaining to GI involvement in COVID-19.

METHODS

The Scopus database was used to search the global literature on GI involvement in COVID-19 during 2020. A bibliometric review of these publications was also performed using VOSviewer.

RESULTS

Scopus had published 95615 documents on COVID-19 in all areas of research at the time of data collection. In total, 1267 publications on the topic of GI and COVID-19 were identified. Research articles (n = 606; 47.83%), letters (293; 23.13%), and reviews (186; 14.68%) were the most popular types of documents. The most productive countries and institutions in this field were the United States and Huazhong University of Science and Technology. The most cited paper was Xiao et al, which was published in Gastroenterology as a brief communication, with 798 citations. This paper provides evidence for GI infection of COVID-19 and its possible faecal–oral transmission route. In the term cluster analysis, there were two frontiers in this field: GI manifestations among COVID-19 patients and the implications of COVID-19 for the gastroenterologist.

CONCLUSION

GI manifestations among COVID-19 patients and implications of COVID-19 for gastroenterologists were of interest, especially in the early stages of the pandemic.

Liver Dysfunction in COVID-19: From Onset to Recovery

With the spread of coronavirus disease 2019 (COVID-19) worldwide, extrapulmonary lesions, including liver dysfunction, have attracted growing attention. The mechanisms underlying liver dysfunction in COVID-19 remain unclear. The reported prevalence of liver dysfunction varies widely across studies. In addition, its impact on clinical outcomes and its recovery after discharge are still controversial. In this review, pathological and laboratory findings were analyzed to reveal the potential mechanisms of COVID-19-induced liver injury from onset to recovery. Four patterns of liver damage were summarized according to the pathological findings, including hypoxemia and shock changes, vascular thrombosis and vascular damage, bile duct damage, and other histological changes. With a strict definition, the prevalence of liver dysfunction was not as high as reported. Meanwhile, liver dysfunction improved during the process of recovery. Nevertheless, the definite liver dysfunction was significantly associated with severe clinical course, which should not be ignored.

Gastrointestinal symptoms and the severity of COVID-19: Disorders of gut-brain interaction are an outcome

BACKGROUND

Many of the studies on COVID-19 severity and its associated symptoms focus on hospitalized patients. The aim of this study was to investigate the relationship between acute GI symptoms and COVID-19 severity in a clustering-based approach and to determine the risks and epidemiological features of post-COVID-19 Disorders of Gut-Brain Interaction (DGBI) by including both hospitalized and ambulatory patients.

METHODS

The study utilized a two-phase Internet-based survey on: (1) COVID-19 patients' demographics, comorbidities, symptoms, complications, and hospitalizations and (2) post-COVID-19 DGBI diagnosed according to Rome IV criteria in association with anxiety (GAD-7) and depression (PHQ-9). Statistical analyses included univariate and multivariate tests.

RESULTS

Five distinct clusters of symptomatic subjects were identified based on the presence of GI symptoms, loss of smell, and chest pain, among 1114 participants who tested positive for SARS-CoV-2. GI symptoms were found to be independent risk factors for severe COVID-19; however, they did not always coincide with other severity-related factors such as age >65 years, diabetes mellitus, and Vitamin D deficiency. Of the 164 subjects with a positive test who participated in Phase-2, 108 (66%) fulfilled the criteria for at least one DGBI. The majority (n = 81; 75%) were new-onset DGBI post-COVID-19. Overall, 86% of subjects with one or more post-COVID-19 DGBI had at least one GI symptom during the acute phase of COVID-19, while 14% did not. Depression (65%), but not anxiety (48%), was significantly more common in those with post-COVID-19 DGBI.

CONCLUSION

GI symptoms are associated with a severe COVID-19 among survivors. Long-haulers may develop post-COVID-19 DGBI. Psychiatric disorders are common in post-COVID-19 DGBI.

COVID-19 pathophysiology and ultrasound imaging: A multiorgan review

COVID-19 is a dynamic disease and may affect different tissues and organs as it progresses. Therefore, the impact generated by the disease in all its stages and organs requires a functional and versatile imaging technique able to detect particularities or artifacts dynamically. Ultrasonography fulfills all these requirements and exhibit several advantages relative to other imaging modalities, including portability, lower cost and biosafety. Throughout the COVID-19 pandemic, ultrasonography displayed a crucial role in the triage, monitoring, indicating organ damages and enabling individualized therapeutical decisions in COVID-19 patients. This review is dedicated to highlight the main pathological effects correlated with ultrasound changes caused by COVID-19 in the lungs, heart and liver.

A Physiological Study to Evaluate Liver Function in Male and Female Patients Infected with COVID-19 Virus in Najaf City

COVID-19 infection usually causes respiratory distress syndrome. Liver impairment has been reported, there is no clear mechanism for liver damage. Liver damage may be due to other factors, such as a viral infection or inflammations in the liver. Lack of information among the residents of the city of Najaf about the differences between males and females infected with the “Corona Virus” disease (“Covid-19”). In this study, we focus on the effects of (“COVID-19”) on liver physiology in 60 (“COVID-19”) patients (20-70 years old). Examinations, taking into account demographic information as well as clinical findings, show that the patient has liver abnormalities. The result indicated increasing of  liver enzymes ALT,AST,ALP and TBiL levels on patients with covid-19 Corona Virus.Males patients had a higher risk of liver enzymes level elevation than females. ("TBiL") concentrations were highly increased when compared with control.  In critical patients, severe liver cells abnormalities result from ("COVID-19"), which requires follow-up and immediate therapeutic intervention. Because of its strong relationship with the severity of  the injury in ("COVID-19"), ALT,AST,ALP, and TBiL it is expected to be of great importance in the future prediction and diagnosis of infection.

COVID-19 and liver dysfunction: Epidemiology, association and potential mechanisms

Currently, there have been more than one hundred million confirmed cases of coronavirus disease 2019 (COVID-19), with two million deaths worldwide. This has caused a huge medical burden. Severe COVID-19 patients can experience multi-organ damage, including cardiac injury, kidney injury, and liver injury. About 2.0%-4.9% of COVID-19 cases involve patients with preexisting liver diseases. Additionally, preexisting liver diseases were reported and associated with severity (odds ratio (OR) or risk ratio (RR) = 1.48-1.70) and mortality (OR or RR = 1.08-2.65) among COVID-19 patients. Furthermore, the prevalence of liver injury was 16%-29% in COVID-19 patients. Higher prevalence of liver injury may worsen prognosis in patients (severity: OR or RR = 1.9-2.6; mortality: OR or RR = 1.1-4.0). The mechanisms of this association between liver injury and severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) infection are complex, including direct cholangiocyte damage induced by SARS-COV-2, cytokine storm, and drug-induced liver injury. In particular, drug-induced liver injury may be the most important reason. This review discusses the epidemiology of COVID-19 and liver dysfunction as well as potential mechanisms underlying the association between COVID-19 and liver dysfunction or other preexisting liver diseases. However, the association between preexisting liver diseases and COVID-19 prognosis and potential mechanisms underlying these associations require further prospective studies.

Amoebic liver abscess in a COVID-19 patient: a case report

BACKGROUND

Amoebiasis is a parasitic disease caused by Entamoeba histolytica, which affects people living in low- and middle-income countries and has intestinal and extraintestinal manifestations. To date, knowledge on coronavirus disease 2019 (COVID-19) coinfection with enteric parasites is limited, and E. histolytica coinfection has not been previously described. Here we present the case of a patient with COVID-19 who, during hospitalisation, presented a clinical picture consistent with an amoebic liver abscess (ALA).

CASE PRESENTATION

A 54-year-old man, admitted as a suspected case of COVID-19, presented to our hospital with dyspnoea, malaise, fever and hypoxaemia. A nasopharyngeal swab was positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by reverse-transcription polymerase chain reaction. After 7 days, he developed diarrhoea, choluria and dysentery. An abdominal ultrasound showed a lesion compatible with a liver abscess; stool examination revealed E. histolytica trophozoites, and additional serology for E. histolytica was positive. After 12 days of treatment with metronidazole, ceftazidime and nitazoxanide, the patient reported acute abdominal pain, and an ultrasound examination revealed free liquid in the abdominal cavity. An emergency exploratory laparotomy was performed, finding 3000 mL of a thick fluid described as "anchovy paste". Computed tomography scan revealed a second abscess. He ended up receiving 21 days of antibiotic treatment and was discharged with satisfactory improvement.

CONCLUSION

Here we present, to the best of our knowledge, the first report of ALA and COVID-19 co-presenting. Based on their pathophysiological similarities, coinfection with SARS-CoV-2 and E. histolytica could change the patient's clinical course; however, larger studies are needed to fully understand the interaction between these pathogens.

Gastrointestinal manifestations of coronavirus disease 2019

PURPOSE OF REVIEW

The ubiquitous expression of angiotensin-converting enzyme-2 receptors and its significance as the origin of viral entry have assisted in comprehending the pathophysiology of extrapulmonary manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In this review, we focus on the clinical significance of gastrointestinal manifestations.

RECENT FINDINGS

The global pandemic, a result of the widespread implications of SARS-CoV-2, remains a significant burden to current healthcare systems. Fever, dyspnea, and tussive symptoms have primarily been recognized as the most common presenting signs/symptoms. During the past one year our scope of practice has transcended beyond the management of the respiratory system to incorporate other varying systemic manifestations such as anorexia, nausea, vomiting, diarrhea, and abdominal pain. The outcomes reported by recent studies suggest an association between the presence of gastrointestinal symptoms and important clinical factors such as delay in presentation, disease severity, and mortality.

SUMMARY

We provide a summarization of the most recent in-depth investigations of coronavirus disease 2019 with gastrointestinal manifestations and their conclusions. Although the pathophysiology remains an area of evolving interest, a better understanding of this disease process may allow for early recognition, efficient triage, and improved prognostication for those presenting with gastrointestinal manifestations of SARS-CoV-2.

Mortality is not increased in SARS-CoV-2 infected persons with hepatitis C virus infection

BACKGROUND

Impact of SARS-CoV-2 infection upon hospitalization, intensive care unit (ICU) admissions and mortality in persons with hepatitis C virus (HCV) infection is unknown.

METHODS

We used the Electronically Retrieved Cohort of HCV infected Veterans (ERCHIVES) database to determine the impact of HCV infection upon the rates of acute care hospitalization, ICU admission and all-cause mortality. We identified Veterans with chronic HCV infection and propensity score matched controls without HCV in ERCHIVES. We excluded those with HIV or hepatitis B virus coinfection.

RESULTS

We identified 975 HCV+ and 975 propensity score matched HCV- persons with SARS-CoV-2 infection. Mean FIB-4 score (±SD) was higher in those with HCV (1.9 ± 2.1 vs 1.2 ± 0.9; P < .0001) and a larger proportion of those with HCV had cirrhosis (8.1% vs 1.4%; P < .0001). A larger proportion of HCV+ were hospitalized compared to HCV- (24.0% vs 18.3%; P = .002); however, those requiring ICU care and mortality were also similar in both groups (6.6% vs 6.5%; P = .9). Among those with FIB-4 score of 1.45-3.25, hospitalization rate/1000-person-years was 41.4 among HCV+ and 20.2 among HCV-, while among those with a FIB-4 > 3.25, the rate- was 9.4 and 0.6 (P < .0001). There was no difference in all-cause mortality by age, gender, FIB-4 score, number of comorbidities or treatment with remdesivir and/or systemic corticosteroids.

CONCLUSIONS

HCV+ persons with SARS-CoV-2 infection are more likely to be admitted to a hospital. The hospitalization rate also increased with higher FIB-4 score. However, admission to an ICU and mortality are not different between those with and without HCV infection.

Prevalence and prognosis of otorhinolaryngological symptoms in patients with COVID-19: a systematic review and meta-analysis

Objective

A systematic review and meta-analysis were performed to evaluate the prevalence and prognosis of otorhinolaryngological symptoms in patients with the diagnosed coronavirus disease 2019 (COVID-19).

Methods

A systematic search of PubMed, Embase, Web of Science, and Google Scholar databases was performed up to August 19, 2020.We included studies that reported infections with COVID-19 and symptoms of otolaryngology. The retrieved data from the respective studies were evaluated and summarized. The study's immediate result was to assess the combined prevalence of otorhinolaryngological symptoms in patients with COVID-19. However, the secondary result was to determine the exacerbation of COVID-19 infection in patients with otorhinolaryngological symptoms.

Results

Fifty-four studies with 16,478 patients were included. Olfactory dysfunction, sneezing and sputum production were the 3 most prevalent otorhinolaryngological symptoms in patients with COVID-19. The pooled prevalence amongst the prevalent symptoms was 47% (95% CI 29–65; range 0–98; I² = 99.58%), 27% (95% CI 11–48; range 12–40; I² = 93.34%), and 22% (95% CI 16–30; range 2–56; I² = 97.60%), respectively. The proportion of severely ill patients with sputum production and shortness of breath was significantly higher among patients with COVID-19 infections (OR 1.66 [95% CI 1.08–2.54]; P = 0.02, I² = 51% and 3.29 [95% CI 1.57–6.90]; P = 0.002, I² = 49%, respectively). Subgroup analysis showed no statistically significant differences between the incidence of otolaryngology symptoms in severely ill patients and non-severely ill patients (OR 1.43 [95% CI 1.12–1.82]; P = 0.07 I² = 53.1%). In contrast, the incidence of shortness of breath in severely ill patients was significantly increased (3.29 [1.57–6.90]; P = 0.002, I² = 49%).

Conclusion

Our research shows that otorhinolaryngology symptoms in patients with COVID-19 are not uncommon, which should attract otorhinolaryngologists' attention.

Diarrhoea in adults with coronavirus disease-beyond incidence and mortality: a systematic review and meta-analysis

AIM

Diarrhoea is a relatively common manifestation of coronavirus disease (COVID-19), but there is no systematic review which comprehensively describes it beyond its incidence and impact on prognosis. This study aims to provide a detailed systematic review of diarrhoea in adults with COVID-19.

METHODS

A PUBMED and Scopus search (until 7 September 2020) was performed. Studies that were limited to describing incidence of diarrhoea and its effect on prognosis were excluded.

RESULTS

Twenty-six papers including 7860 patients with COVID-19 were subjected to synthesis. Mean duration of diarrhoea was 4.2 (3.6-4.9) days (range 1-16 days), whereas mean bowel movement count was 4.6 (3.8-5.3) and maximum was 20 per day. Diarrhoea started on an average 5.1 (3.8-6.5) days after disease onset but was the first manifestation in 4.3% patients. Stool occult blood was detected in 6.8% of patients with diarrhoea, while 53.3% cases had watery diarrhoea. Patients with diarrhoea also had elevated faecal calprotectin. Viral genome in faeces was detected more often in patients with diarrhoea and most often in patients without respiratory symptoms. Fever, myalgia and respiratory symptoms were observed with the same incidence in patients with and without diarrhoea. Similarly, there were no differences noted in complete blood count and most inflammation biomarkers between patients with and without diarrhoea. However, nausea, vomiting abdominal pain, sneezing and headache were more common in patients with diarrhoea. Diarrhoea was the main manifestation of COVID-19 in 6.1% of cases and this form of the disease had specific features.

CONCLUSIONS

Diarrhoea in COVID-19 needs further investigation.

Coronavirus Disease-2019 (COVID-19) and the Liver

Within a year of its emergence, coronavirus disease-2019 (COVID-19) has evolved into a pandemic. What has emerged during the past 1 year is that, apart from its potentially fatal respiratory presentation from which the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) derives its name, it presents with a myriad of gastrointestinal (GI) and liver manifestations. Expression of the angiotensin-converting enzyme-2 (ACE-2) receptor throughout the GI tract and liver, which is the receptor for the SARS-CoV-2, may be responsible for the GI and liver manifestations. Besides acting directly via the ACE-2 receptor, the virus triggers a potent immune response, which might have a role in pathogenesis. The virus leads to derangement in liver function tests in close to 50% of the patients. The impact of these derangements in patients with a normal underlying liver seems to be innocuous. Severe clinical presentations include acute decompensation and acute-on-chronic liver failure in a patient with chronic liver disease, leading to high mortality. Evolving data suggests that, contrary to intuition, liver transplant recipients and patients with autoimmune liver disease on immunosuppression do not have increased mortality. The exact mechanism underlying why immunosuppressed patients fare well as compared to other patients remains to be deciphered. With newer variants of COVID-19, which can spread faster than the original strain, the data on hepatic manifestations needs to be updated to keep a step ahead of the virus.

Gastroenterological and hepatic manifestations of patients with COVID-19, prevalence, mortality by country, and intensive care admission rate: systematic review and meta-analysis

BACKGROUND AND AIMS

Patients infected with the SARS-CoV-2 usually report fever and respiratory symptoms. However, multiple gastrointestinal (GI) manifestations such as diarrhoea and abdominal pain have been described. The aim of this study was to evaluate the prevalence of GI symptoms, elevated liver enzymes and mortality of patients with COVID-19.

METHODS

A systematic review and meta-analysis of published studies that included a cohort of patients infected with SARS-CoV-2 were performed from 1 December 2019 to 15 December 2020. Data were collected by conducting a literature search using PubMed, Embase, Scopus, and Cochrane according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We analysed pooled data on the prevalence of individual GI symptoms and elevated liver enzymes and performed subanalyses to investigate the relationship between GI symptoms/elevated liver enzymes, geographical location, mortality, and intensive care unit (ICU) admission.

RESULTS

The available data of 78 798 patients positive for SARS-CoV-2 from 158 studies were included in our analysis. The most frequent manifestations were diarrhoea (16.5%, 95% CI 14.2% to 18.4%), nausea (9.7%, 95% CI 9.0% to 13.2%) and elevated liver enzymes (5.6%, 95% CI 4.2% to 9.1%). The overall mortality and GI mortality were 23.5% (95% CI 21.2% to 26.1%) and 3.5% (95% CI 3.1% to 6.2%), respectively. Subgroup analysis showed non-statistically significant associations between GI symptoms/elevated liver enzymes and ICU admissions (OR=1.01, 95% CI 0.55 to 1.83). The GI mortality was 0.9% (95% CI 0.5% to 2.2%) in China and 10.8% (95% CI 7.8% to 11.3%) in the USA.

CONCLUSION

GI symptoms/elevated liver enzymes are common in patients with COVID-19. Our subanalyses showed that the presence of GI symptoms/elevated liver enzymes does not appear to affect mortality or ICU admission rate. Furthermore, the proportion of GI mortality among patients infected with SARS-CoV-2 varied based on geographical location.

Implications of SARS-CoV-2 infection for neurogastroenterology

BACKGROUND

Coronavirus disease 2019 (COVID-19) is associated with gastrointestinal and hepatic manifestation in up to one fifth of patients. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the etiologic agent of COVID-19, infects gastrointestinal epithelial cells expressing angiotensin-converting enzyme 2 (ACE2) receptors triggering a cascade of events leading to mucosal and systemic inflammation. Symptomatic patients display changes in gut microbiota composition and function which may contribute to intestinal barrier dysfunction and immune activation. Evidence suggests that SARS-CoV-2 infection and related mucosal inflammation impact on the function of the enteric nervous system and the activation of sensory fibers conveying information to the central nervous system, which, may at least in part, contribute symptom generation such as vomiting and diarrhea described in COVID-19. Liver and pancreas dysfunctions have also been described as non-respiratory complications of COVID-19 and add further emphasis to the common view of SARS-CoV-2 infection as a systemic disease with multiorgan involvement.

PURPOSE

The aim of this review was to highlight the current knowledge on the pathophysiology of gastrointestinal SARS-CoV-2 infection, including the crosstalk with the gut microbiota, the fecal-oral route of virus transmission, and the potential interaction of the virus with the enteric nervous system. We also review the current available data on gastrointestinal and liver manifestations, management, and outcomes of patients with COVID-19.

The Clinical Characteristics and Risk Factors of Severe COVID-19

Objective

We aim to investigate the clinical characteristics and risk factors for the severe cases of coronavirus disease 2019 (COVID-19) in comparison with the non-severe patients.

Methods

We searched PubMed, EMBASE, Web of Science, and CNKI to collect all relevant studies published before July 26, 2020, and a total of 30 papers were included in this meta-analysis.

Results

In the severe COVID-19 patients, 60% (95% CI = 56–64%) were male, 25% (95% CI = 21–29%) were over 65 years old, 34% (95% CI = 24–44%) were obese, and 55% (95% CI = 41–70%) had comorbidities. The most prevalent comorbidities were hypertension (34%, 95% CI = 25–44%), diabetes (20%, 95% CI = 15–25%), and cardiovascular disease (CVD; 12%, 95% CI = 9–16%). The most common blood test abnormalities were elevated C-reactive protein (CRP; 87%, 82–92%), decreased lymphocyte count (68%, 58–77%), and increased lactate dehydrogenase (69%, 95% CI = 57–81%). In addition, abnormal laboratory findings revealing organ dysfunctions were frequently observed in the severe cases, including decrease in albumin (43%, 95% CI = 24–63%) and increase in aspartate aminotransferase (47%, 95% CI = 38–56%), alanine aminotransferase (28%, 95% CI = 16–39%), troponin I/troponin T (TnI/TnT; 29%, 95% CI = 13–45%), and serum Cr (SCr; 10%, 95% CI = 5–15%).

Conclusion

The male, elderly and obese patients and those with any comorbidities, especially with hypertension, diabetes, and CVD, were more likely to develop into severe cases. But the association between hypertension, diabetes, CVD, and severity of COVID-19 was declined by the increase of age. A significant elevation in cardiac TnI/TnT, the hepatic enzymes, and SCr and the reduction in lymphocytes with elevated CRPs are important markers for the severity. Specific attention should be given to the elderly male and obese patients and those with indications of severe immune injury in combination with bacterial infection and indication of multi-organ dysfunction or damages.

Rates and characteristics of SARS-CoV-2 infection in persons with hepatitis C virus infection

BACKGROUND

Rate of SARS-CoV-2 infection and impact of liver fibrosis stage upon infection rates in persons with hepatitis C virus (HCV) infection are unknown.

METHODS

We retrospectively analysed the Electronically Retrieved Cohort of HCV Infected Veterans (ERCHIVES), a well-established database of HCV-infected Veterans in care. We excluded those with missing FIB-4 score and those with HIV or hepatitis B virus co-infection. We determined the number of persons tested, proportion who tested positive for SARS-CoV-2 and the infection rate by age and liver fibrosis stage.

RESULTS

Among 172,235 persons with HCV, 14,305 (8.3%) were tested for SARS-CoV-2 infection and 892 (6.2%) tested positive. Those with SARS-CoV-2 infection were older, more likely to be Black (55.2% vs 37.8%), obese (body mass index >30 kg/m² 36.2% vs 29.7%) and have diabetes or stroke (P < .0001 for all comparisons). Mean FIB-4 scores and proportion of persons with cirrhosis (based on a FIB-4 > 3.25) were similar in both groups. Incidence rate/1,000 tested persons was much higher among Blacks (88.4; 95% CI 81.1, 96.2) vs Whites (37.5; 95% CI 33.1, 42.4) but similar among those with cirrhosis (FIB-4 > 3.25). The rates were also similar among those who were untreated for HCV vs those treated with or without attaining a sustained virologic response.

CONCLUSIONS

Testing rates among persons with HCV are very low. Persons with infection are more likely to be Black, have a higher body mass index and diabetes or stroke. The degree of liver fibrosis does not appear to have an impact on infection rate.

Risk factors associated with prolonged viral clearance in patients with a refractory course of COVID-19: a retrospective study

BACKGROUND

This study aimed to characterize a cohort of patients with a refractory course of COVID-19, and to investigate factors associated with the duration of viral clearance (DoVC).

MATERIALS & METHODS

A total of 65 patients with refractory COVID-19 were retrospectively enrolled from Huoshenshan Hospital. Univariate analysis and multivariate analysis were performed to examine the potential association between clinicopathologic characteristics and the DoVC.

RESULTS

The median DoVC in the overall study cohort was 48 days (ranged from 21 to 104 days). Multivariate analysis indicated that fever at illness onset (Hazard ratio (HR) = 4.897, 95% CI [1.809-13.260], p = 0.002), serum level of aspartate aminotransferase (AST) > 21.8 IU/L (HR = 3.010, 95% CI [1.195-7.578], p = 0.019), and titer of SARS-CoV-2 IgG > 142.09 AU/ml (HR = 3.061, 95% CI [1.263-7.415], p = 0.013) were the three independent risk factors associated with delayed viral clearance.

CONCLUSION

The current study suggested that clinical characteristics such as fever at illness onset, a high serum level of AST or SARS-CoV-2 IgG were associated with delayed viral clearance. Patients with these characteristics might need a more individualized treatment strategy to accelerate their recovery from the refractory COVID-19.