Are gastrointestinal symptoms associated with higher risk of Mortality in COVID-19 patients? A systematic review and meta-analysis

Gastrointestinal symptoms in COVID-19 and disease severity: a Japanese registry-based retrospective cohort study

BACKGROUND

Research on whether gastrointestinal symptoms correlate with the severity of Coronavirus Disease 2019 (COVID-19) has been inconclusive. This study aimed to clarify any associations between gastrointestinal symptoms and the prognosis of COVID-19.

METHODS

We collected data from the Japanese nationwide registry for COVID-19 to conduct a retrospective cohort study. Data from 3498 Japanese COVID-19 patients, diagnosed at 74 facilities between February 2020 and August 2022, were analyzed in this study. Hospitalized patients were followed up until discharge or transfer to another hospital. Outpatients were observed until the end of treatment. Associations between gastrointestinal symptoms and clinical outcomes were investigated using multivariable-adjusted logistic regression models.

RESULTS

The prevalence of diarrhea, nausea/vomiting, abdominal pain, and melena were 16.6% (581/3498), 8.9% (311/3498), 3.5% (121/3498), and 0.7% (23/3498), respectively. In the univariable analysis, admission to intensive care unit (ICU) and requirement for mechanical ventilation were less common in patients with diarrhea than those without (ICU, 15.7% vs. 20.6% (p = 0.006); mechanical ventilation, 7.9% vs. 11.4% (p = 0.013)). In the multivariable-adjusted analysis, diarrhea was associated with lower likelihood of ICU admission (adjusted odds ratio (aOR), 0.70; 95% confidence interval (CI), 0.53-0.92) and mechanical ventilation (aOR, 0.61; 95% CI, 0.42-0.89). Similar results were obtained in a sensitivity analysis with another logistic regression model that adjusted for 14 possible covariates with diarrhea (ICU; aOR, 0.70; 95% CI, 0.53-0.93; mechanical ventilation; aOR 0.62; 95% CI, 0.42-0.92).

CONCLUSIONS

Diarrhea was associated with better clinical outcomes in COVID-19 patients.

Efficacy and safety of aniseed powder for treating gastrointestinal symptoms of COVID-19: a randomized, placebo-controlled trial

Background: Gastrointestinal symptoms are prevalent amongst patients with a confirmed diagnosis of COVID-19 and may be associated with an increased risk of disease severity. This trial aimed to evaluate the efficacy and safety of aniseed (Pimpinella anisum L.) powder as an add-on therapy to standard care for treating gastrointestinal symptoms experienced by adults with an acute SARS-CoV-2 infection. Methods: The study was a randomized parallel-group double-blinded placebo-controlled add-on therapy trial. Adults with an acute SARS-CoV-2 infection who did not require hospitalization and reported at least one gastrointestinal symptom in the preceding 48 h were assigned to either the aniseed or placebo group in a 1:4 ratio. All 225 participants (45 in the aniseed group and 180 in the placebo group) were instructed to use 25 g of powdered aniseed or placebo twice daily for 2 weeks. The primary outcomes were the proportion of patients who experienced an improvement of at least one point in the symptom score after adjusting for age group, gender, and time. Backwards stepwise logistic regression was applied to calculate the risk ratios. The clinical symptoms and adverse events were assessed at the beginning, 1 week later, and at the end of the trial (week two). Results: Participants in the aniseed group were significantly more likely to report symptom improvement for abdominal pain [adjusted risk ratio (RR):0.55; 95% confidence interval (CI): 0.46-0.72], anorexia (RR:0.62; 95% CI: 0.47-0.82), and diarrhea (RR:0.19; 95% CI: 0.12-0.30), but not nausea/vomiting (RR:0.87; 95% CI: 0.71-1.08) or bloating (RR:0.87; 95% CI: 0.72-1.05). Two participants in the aniseed group and three participants in the placebo group reported mild to moderate adverse events. Conclusion: This study showed that 2 weeks of aniseed powder containing trans-anethole (87%-94%) may help improve abdominal pain, anorexia, and diarrhea in COVID-19 patients. The findings align with the known biological, multitargeted activity of P. anisum and trans-anethole, which includes inhibiting SARS-CoV-2 along with other anti-infective, anti-inflammatory, antioxidant, hepatoprotective, and anti-dysbiosis properties. Multicenter trials with larger sample sizes and longer follow-up are warranted to confirm these findings. Clinical Trial Registration: Iranian Registry of Clinical Trials (IRCT20120506009651N3).

COVID-19 and Gastrointestinal Tract: From Pathophysiology to Clinical Manifestations

Background: Since its first report in Wuhan, China, in December 2019, COVID-19 has become a pandemic, affecting millions of people worldwide. Although the virus primarily affects the respiratory tract, gastrointestinal symptoms are also common. The aim of this narrative review is to provide an overview of the pathophysiology and clinical manifestations of gastrointestinal COVID-19. Methods: We conducted a systematic electronic search of English literature up to January 2023 using Medline, Scopus, and the Cochrane Library, focusing on papers that analyzed the role of SARS-CoV-2 in the gastrointestinal tract. Results: Our review highlights that SARS-CoV-2 directly infects the gastrointestinal tract and can cause symptoms such as diarrhea, nausea/vomiting, abdominal pain, anorexia, loss of taste, and increased liver enzymes. These symptoms result from mucosal barrier damage, inflammation, and changes in the microbiota composition. The exact mechanism of how the virus overcomes the acid gastric environment and leads to the intestinal damage is still being studied. Conclusions: Although vaccination has increased the prevalence of less severe symptoms, the long-term interaction with SARS-CoV-2 remains a concern. Understanding the interplay between SARS-CoV-2 and the gastrointestinal tract is essential for future management of the virus.

Gastrointestinal manifestations in symptomatic Coronavirus disease - 19 patients and its relevance in predicting severity and outcome

INTRODUCTION

Recent developments characterizing the pathophysiological basis of infection in the Coronavirus disease - 19 (COVID-19) have stirred great interest in studying this disease outside the purview of respiratory involvement and especially focusing on the gastrointestinal (GI) system. The present study involving a large cohort of COVID-19-infected patients reports on the characteristics of GI manifestations in patients infected with COVID-19 as well as the predictive role in their association with disease severity and adverse outcomes.

METHODS

A retrospective cohort study was carried out in a tertiary care hospital in northern India. Descriptive analysis of GI symptoms was carried out followed by predictive analysis assessing COVID-19 severity and with the primary endpoint of 28-day in-hospital all-cause mortality.

RESULTS

Of 3842 hospitalized COVID-19 patients, 2113 (55%) were symptomatic. GI symptoms were present in 163 (7.1%) patients. Common GI symptoms were diarrhea 65 (3.1%), anorexia 61 (2.9%) and vomiting 37 (1.8%). Mild and moderate-to-severe disease was seen in 1725 (81.6%) and 388 (18.4%) patients, respectively. Logistic regression showed greater odds of moderate-to-severe disease in patients with any GI symptoms (odds ratio [OR] 1.849, 95% CI 1.289-2.651 [p = 0.001]) and anorexia in particular (OR 2.797, 95% CI 1.647-4.753 [p = 0.001]); however, on multivariable-analysis, this association lost its significance. A total of 172 patients succumbed to illness. In the Cox proportional hazards model for mortality, patients with any GI symptom (HR 2.184, 95 CI 1.439-3.317 [p < 0.001]) and anorexia (HR 3.556, 95% CI 2.155-5.870 [p < 0.001]) had higher risk. In multi-variable analysis after adjustment to age, sex, oxygen saturation and comorbidities, the presence of any GI symptom was a significant predictor of mortality (hazard ratio adjusted [HRadj] 1.758, 95% CI 1.147-2.694 [p = 0.010]).

CONCLUSION

GI symptoms were common among patients infected with COVID-19. The presence of any GI symptom was a significant predictor of the risk of mortality after adjustment to respiratory failure, age, sex and pre-existing comorbidities. The clinical and pathophysiological basis of these associations has been explored.

Impact of COVID-19 in individuals with and without pre-existent digestive disorders with a particular focus on elderly patients

Coronavirus disease 2019 (COVID-19) has several extrapulmonary symptoms. Gastrointestinal (GI) symptoms are among the most frequent clinical manifestations of COVID-19, with severe consequences reported in elderly patients. Furthermore, the impact of COVID-19 on patients with pre-existing digestive diseases still needs to be fully elucidated, particularly in the older population. This review aimed to investigate the impact of COVID-19 on the GI tract, liver, and pancreas in individuals with and without previous digestive diseases, with a particular focus on the elderly, highlighting the distinctive characteristics observed in this population. Finally, the effectiveness and adverse events of the anti-COVID-19 vaccination in patients with digestive disorders and the peculiarities found in the elderly are discussed.

Understanding clinical characteristics influencing adverse outcomes of Omicron infection: a retrospective study with propensity score matching from a Fangcang hospital

Objectives

The epidemic of coronavirus disease 2019 (COVID-19) is causing global health concerns. The aim of this study was to evaluate influence of clinical characteristics on outcomes during the Omicron outbreak.

Methods

A total of 25182 hospitalized patients were enrolled, including 39 severe patients and 25143 non-severe patients. Propensity score matching (PSM) was applied to balance the baseline characteristics. Logistic regression analysis was used to assess the risk of severe disease, as well as the risk of prolonged viral shedding time (VST) and increased length of hospital stay (LOS).

Results

Before PSM, patients in the severe group were older, had higher symptom scores, and had a higher proportion of comorbidities (p<0.001). After PSM, there were no significant differences in age, gender, symptom score and comorbidities between severe (n=39) and non-severe (n=156) patients. Symptoms of fever (OR=6.358, 95%CI 1.748-23.119, p=0.005) and diarrhea (OR=6.523, 95%CI 1.061-40.110, p=0.043) were independent risk factors for development of severe disease. In non-severe patients, higher symptom score was associated with prolonged VST (OR=1.056, 95% CI 1.000-1.115, p=0.049) and LOS (OR=1.128, 95% CI 1.039-1.225, p=0.004); older age was associated with longer LOS (OR=1.045, 95% CI 1.007-1.084, p=0.020).

Conclusion

The overall condition of the Shanghai Omicron epidemic was relatively mild. Potential risk factors for fever, diarrhea, and higher symptom score can help clinicians to predict clinical outcomes in COVID-19 patients.

Intestinal Damage, Inflammation and Microbiota Alteration during COVID-19 Infection

Background: The virus SARS-CoV-2 is responsible for respiratory disorders due to the fact that it mainly infects the respiratory tract using the Angiotensin-converting enzyme 2 (ACE2) receptors. ACE2 receptors are also highly expressed on intestinal cells, representing an important site of entry for the virus in the gut. Literature studies underlined that the virus infects and replicates in the gut epithelial cells, causing gastrointestinal symptoms such as diarrhea, abdominal pain, nausea/vomiting and anorexia. Moreover, the SARS-CoV-2 virus settles into the bloodstream, hyperactivating the platelets and cytokine storms and causing gut–blood barrier damage with an alteration of the gut microbiota, intestinal cell injury, intestinal vessel thrombosis leading to malabsorption, malnutrition, an increasing disease severity and mortality with short and long-period sequelae. Conclusion: This review summarizes the data on how SARS-CoV-2 effects on the gastrointestinal systems, including the mechanisms of inflammation, relationship with the gut microbiota, endoscopic patterns, and the role of fecal calprotectin, confirming the importance of the digestive system in clinical practice for the diagnosis and follow-up of SARS-CoV-2 infection.

Intestinal barrier dysfunction as a key driver of severe COVID-19

The intestinal lumen harbors a diverse consortium of microorganisms that participate in reciprocal crosstalk with intestinal immune cells and with epithelial and endothelial cells, forming a multi-layered barrier that enables the efficient absorption of nutrients without an excessive influx of pathogens. Despite being a lung-centered disease, severe coronavirus disease 2019 (COVID-19) affects multiple systems, including the gastrointestinal tract and the pertinent gut barrier function. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can inflict either direct cytopathic injury to intestinal epithelial and endothelial cells or indirect immune-mediated damage. Alternatively, SARS-CoV-2 undermines the structural integrity of the barrier by modifying the expression of tight junction proteins. In addition, SARS-CoV-2 induces profound alterations to the intestinal microflora at phylogenetic and metabolomic levels (dysbiosis) that are accompanied by disruption of local immune responses. The ensuing dysregulation of the gut-lung axis impairs the ability of the respiratory immune system to elicit robust and timely responses to restrict viral infection. The intestinal vasculature is vulnerable to SARS-CoV-2-induced endothelial injury, which simultaneously triggers the activation of the innate immune and coagulation systems, a condition referred to as “immunothrombosis” that drives severe thrombotic complications. Finally, increased intestinal permeability allows an aberrant dissemination of bacteria, fungi, and endotoxin into the systemic circulation and contributes, to a certain degree, to the over-exuberant immune responses and hyper-inflammation that dictate the severe form of COVID-19. In this review, we aim to elucidate SARS-CoV-2-mediated effects on gut barrier homeostasis and their implications on the progression of the disease.

Prevalence and prognosis of acute pancreatitis in critically ill patients with COVID-19

Background

Coronavirus disease 2019 (COVID-19) is a global pandemic issue. In addition to the well-known respiratory and fever symptoms, gastrointestinal symptoms have also been reported. This study aimed to evaluate the prevalence and prognosis of patients with COVID-19 infection complicated with acute pancreatitis in intensive care unit (ICU).

Methods

This is a retrospective observational cohort study, patients aged 18 years or older, admitted into the ICU in a single tertiary center from January 1, 2020, to April 30, 2022 were enrolled. Patients were identified by electronic medical records and reviewed manually. The primary outcome was the prevalence of acute pancreatitis among ICU patients with COVID-19. The secondary outcomes were the length of hospital stay, need for mechanical ventilation (MV), need for continuous renal replacement therapy (CRRT), and in-hospital mortality.

Results

A total of 4133 patients, admitted into the ICU, were screened. Among these patients, 389 were infected by COVID-19, and 86 were diagnosed with acute pancreatitis. COVID-19 positive patients were more likely to present with acute pancreatitis than COVID-19 negative patients (odds ratio = 5.42, 95% confidence interval: 2.35-6.58, P < 0.01). However, the length of hospital stay, need for MV, need for CRRT, and in-hospital mortality was not significantly different between acute pancreatitis patients with and without COVID-19 infection.

Conclusion

Severe COVID-19 infections may cause acute pancreas damage in critically ill patients. However, the prognosis may not differ between acute pancreatitis patients with and without COVID-19 infection.

COVID-19, the Gut, and Nutritional Implications

PURPOSE OF REVIEW

Our goal is to provide the most recent and accurate scientific evidence available regarding COVID-19's interaction with the human gut and the role of nutrition/nutritional supplementation in the prevention and treatment of the disease.

RECENT FINDINGS

Gastrointestinal symptoms of COVID-19 are common and often persist even after classically defined illness resolution. Nutritional status and content have been shown to impact infection risk and severity. Well-balanced diets are associated with decreased infection risk/severity, and early nutrition is associated with better outcomes in the critically ill. No specific vitamin supplementation regimen has shown consistent benefit for infection treatment or prevention. The impact of COVID-19 extends far past the pulmonary system, and its impact on the gut should not be ignored. For those interested in adopting lifestyle modifications to prevent severe COVID-19 infection/side effects, consideration should be made for adoption of a well-balanced diet (e.g., Mediterranean style), utilization of probiotics, and addressing nutritional/vitamin deficiencies. Future, high-quality research is needed in this arena.

Non-Typical Clinical Presentation of COVID-19 Patients in Association with Disease Severity and Length of Hospital Stay

BACKGROUND

This study aimed to investigate the incidence of non-typical symptoms in ambulatory patients with mild-to-moderate COVID-19 infection and their potential association with disease progression.

MATERIALS AND METHODS

Data on the symptomatology of COVID-19 patients presenting to the fast-track emergency department were collected between March 2020 and March 2021. Fever, cough, shortness of breath, and fatigue-weakness were defined as "typical" symptoms, whereas all other symptoms such as nasal congestion, rhinorrhea, gastrointestinal symptoms, etc., were defined as "non-typical".

RESULTS

A total of 570 COVID-19 patients with a mean age of 42.25 years were included, the majority of whom were male (61.3%; N = 349), and were divided according to their symptoms into two groups. The mean length of hospital stay was found to be 9.5 days. A higher proportion of patients without non-typical symptoms were admitted to the hospital (p = 0.001) and the ICU (p = 0.048) as well. No significant differences were observed between non-typical symptoms and outcome (p = 0.685). Patients who did not demonstrate at least one non-typical symptom had an extended length of stay (p = 0.041). No statistically significant differences in length of hospital stay were associated with individual symptoms.

CONCLUSION

With the possible exception of gastrointestinal symptoms, non-typical symptoms of COVID-19 at baseline appear to predispose to a milder disease.

Robust cross-cohort gut microbiome associations with COVID-19 severity

Although many recent studies have examined associations between the gut microbiome and COVID-19 disease severity in individual patient cohorts, questions remain on the robustness across international cohorts of the biomarkers they reported. Here, we performed a meta-analysis of eight shotgun metagenomic studies of COVID-19 patients (comprising 1,023 stool samples) and 23 > 16S rRNA gene amplicon sequencing (16S) cohorts (2,415 total stool samples). We found that disease severity (as defined by the WHO clinical progression scale) was associated with taxonomic and functional microbiome differences. This alteration in gut microbiome configuration peaks at days 7-30 post diagnosis, after which the gut microbiome returns to a configuration that becomes more similar to that of healthy controls over time. Furthermore, we identified a core set of species that were consistently associated with disease severity across shotgun metagenomic and 16S cohorts, and whose abundance can accurately predict disease severity category of SARS-CoV-2 infected subjects, with Actinomyces oris abundance predicting population-level mortality rate of COVID-19. Additionally, we used relational diet-microbiome databases constructed from cohort studies to predict microbiota-targeted diet patterns that would modulate gut microbiota composition toward that of healthy controls. Finally, we demonstrated the association of disease severity with the composition of intestinal archaeal, fungal, viral, and parasitic communities. Collectively, this study has identified robust COVID-19 microbiome biomarkers, established accurate predictive models as a basis for clinical prognostic tests for disease severity, and proposed biomarker-targeted diets for managing COVID-19 infection.

Meta-analysis of the demographic and prognostic significance of gastrointestinal symptoms in COVID-19 patients

Background and Aim

To evaluate the demographic and prognostic significance of gastrointestinal (GI) symptoms in patients with coronavirus disease 2019 (COVID-19).

Methods

A systematic search of electronic information sources was conducted. Combined overall effect sizes were calculated using random-effects models for baseline demographic factors and outcomes including mortality, intensive care unit (ICU) admission, and length of hospital stay.

Results

Twenty-four comparative observational studies reporting a total of 51 522 COVID-19 patients with (n = 6544) or without (n = 44 978) GI symptoms were identified. The patients with GI symptoms were of comparable age (mean difference [MD]: 0.25, 95% confidence interval [CI] -2.42 to 2.92, P = 0.86), rate of pre-existing hypertension (odds ratio [OR]: 1.11, 95% CI 0.86-1.42, P = 0.42), diabetes mellitus (OR: 1.14, 95% CI 0.91-1.44, P = 0.26), and coronary artery disease (OR: 1.00, 95% CI 0.86-1.16, P = 0.98) compared with those without GI symptoms. However, there were significantly more male patients in the GI symptoms group (OR: 0.85, 95% CI 0.75-0.95, P = 0.005). The presence of GI symptoms was associated with similar risk of mortality (OR: 0.73; 95% CI 0.47-1.13, P = 0.16), ICU admission (OR: 1.15; 95% CI 0.67-1.96, P = 0.62), and length of hospital stay (MD: 0.43; 95% CI -0.73 to 1.60, P = 0.47) when compared with their absence.

Conclusion

Meta-analysis of the best possible available evidence demonstrated that GI symptoms in COVID-19 patients do not seem to affect patients with any specific demographic patterns and may not have any important prognostic significance. Although no randomized studies can be conducted on this topic, future high-quality studies can provide stronger evidence to further understand the impact of GI symptoms on outcomes of COVID-19 patients.

Clues from the Pandora's Box: Frequency of Acute Abdominal Symptoms in COVID-19 and Its Association with Inflammatory Markers-a Cross-Sectional Study

Coronavirus disease 2019 (COVID-19) is primarily considered to be a respiratory ailment. Hitherto, abdominal symptoms have been reported with variable frequency in acute COVID-19. The purpose of this study was to estimate the frequency of abdominal symptoms at presentation among patients hospitalised with COVID-19 infection, and to determine their association with disease severity. This was a single-centre cross-sectional observational study conducted at a COVID-19 tertiary care hospital (CTRI/2021/10/037195, registered on 08/10/2021). Consecutive patients hospitalised with acute COVID-19 illness during the study period were included in the study. Their demographic information, abdominal symptoms, comorbidities and category of COVID-19 illness were elicited. All patients had serum inflammatory markers tested on the day of hospitalisation. Among the 685 participants, 214 patients had mild-to-moderate category illness whereas the rest 471 had severe COVID-19 illness. Abdominal complaints were present among 132/685 (18.3%) patients with distension of abdomen (8.03%) being the most common symptom, followed by vomiting (6.72%) and abdominal pain (3.94%). At admission to the hospital, abdominal complaints were commoner among patients with severe disease than in those with mild-to-moderate disease (101/471 vs. 31/214; p=0.029). Abdominal symptoms were associated with a higher neutrophil to lymphocyte ratio (p=0.029). The mortality among COVID-19 patients with abdominal symptoms was higher (9.09 vs. 3.25%; p = 0.007). This study demonstrates the spectrum of abdominal symptoms that can be a part of acute COVID-19 at hospitalisation and also highlights their prognostic potential in acute COVID-19 infection.

Cluster analysis unveils a severe persistent respiratory impairment phenotype 3-months after severe COVID-19

BACKGROUND

The mid-term respiratory sequelae in survivors of severe COVID-19 appear highly heterogeneous. In addition, factors associated with respiratory sequelae are not known. In this monocentric prospective study, we performed a multidisciplinary assessment for respiratory and muscular impairment and psychological distress 3 months after severe COVID-19. We analysed factors associated with severe persistent respiratory impairment, amongst demographic, COVID-19 severity, and 3-month assessment.

METHODS

Patients with severe SARS-CoV-2 pneumonia requiring ≥ 4L/min were included for a systematic 3-month visit, including respiratory assessment (symptoms, lung function, CT scan), muscular evaluation (body composition, physical function and activity, disability), psychopathological evaluation (anxiety, depression, post-traumatic stress disorder-PTSD) and quality of life. A cluster analysis was performed to identify subgroups of patients based on objective functional measurements: D_LCO, total lung capacity and 6-min walking distance (6MWD).

RESULTS

Sixty-two patients were analysed, 39% had dyspnea on exercise (mMRC ≥ 2), 72% had D_LCO < 80%, 90% had CT-scan abnormalities; 40% had sarcopenia/pre-sarcopenia and 31% had symptoms of PTSD. Cluster analysis identified a group of patients (n = 18, 30.5%) with a severe persistent (SP) respiratory impairment (D_LCO 48 ± 12%, 6MWD 299 ± 141 m). This SP cluster was characterized by older age, severe respiratory symptoms, but also sarcopenia/pre-sarcopenia, symptoms of PTSD and markedly impaired quality of life. It was not associated with initial COVID-19 severity or management.

CONCLUSIONS AND CLINICAL IMPLICATION

We identified a phenotype of patients with severe persistent respiratory and muscular impairment and psychological distress 3 months after severe COVID-19. Our results highlight the need for multidisciplinary assessment and management after severe SARS-CoV-2 pneumonia. Trial registration The study was registered on ClinicalTrials.gov (May 6, 2020): NCT04376840.