1.1. Background: The first case of novel coronavirus 2019 (COVID-19) was reported in Wuhan, China in December 2019, and the disease has rapidly spread globally. This study aimed to determine the characteristics and functioning of the Gastrointestinal (GI) system in patients admitted to our center with COVID-19 and to provide guidance on the prevention and treatment of this disease.
1.2. Methods and Material: This observational study included 64 patients hospitalized with coronavirus disease 2019 within the age range of 18-85 years. We analyzed data on patient characteristics, disease severity, incubation period, initial symptoms and GI manifestations, timing of positive testing, duration of symptoms, and duration of antiviral therapy. Analysis involved continuity-adjusted chi-square test for independent samples.
1.3. Results: The mean incubation period was 7.7±6.5 days, and the mean duration of hospitalization was 18.84±9.75 days. Key symptoms were fever (84.37%), cough (57.8%), fatigue (20.3%), diarrhea (18.75%), muscle aches (17.18%), dyspnea (14%), sore throat (12.5%), decreased appetite, and headache (10.9%). Sixty percent of patients developed GI symptoms 1–30 days after disease onset, including diarrhea (69.2%), nausea (23.07%), abdominal distension (7.69%), and hematochezia (2.56%). Among patients with GI symptoms, 33.33% had symptoms before receiving therapy, of whom 92.3% had diarrhea; 66.67% of patients developed GI symptoms, primarily diarrhea (57.69%), after receiving therapy.
1.4. Conclusions: Most NCIP patients had diarrhea and abnormal transaminase levels. Severe complications such as GI bleeding should be anticipated in this patient group. Data presented herein can serve as a reference for COVID-19 prevention and treatment.
Keywords:Coronavirus-infected pneumonia; Diarrhea; Gastrointestinal symptoms; Novel coronavirus 2019
2. IntroductionSince the first reported case of novel coronavirus 2019 (COVID-19) in Wuhan in December 2019, the disease has spread rapidly throughout China and other countries worldwide, including Singapore, Japan, and the United States. The COVID-19 outbreak has triggered global concern [1, 2]. COVID-19, which was caused by the infection of 2019 novel coronaviruses (2019-nCoV), has now been included as a Class B infectious disease in the Law of the People’s Republic of China on Prevention and Treatment of Infectious Diseases [2], while preventive and control measures designated for Class A infectious diseases have been adopted to deal with the outbreak.
3. Methods3.1. Study Population Data of patients with COVID-19 admitted to the Fifth Medical Center of Chinese PLA General Hospital in China were collected from Jan 25 to Feb 29, 2020. The inclusion criteria were based on the Guidelines for Diagnosis and Treatment of Novel Coronavirus Pneumonia (provisional version 7), issued by the National Health Commission of China [10], and included: 1) patients with fever and cough-related symptoms; 2) patients with positive results of 2019-nCoV nucleic acid testing, whose chest Computed Tomography (CT) scans indicated changes associated with viral pneumonia, and who had a clinical diagnosis of COVID-19.
3.2. Study Methods We analyzed data on patients’ general condition, severity of disease, and incubation period, as well as the initial symptoms, manifestations, timing, and duration of GI symptoms. We estimated the time of disease onset from the time of contact with an individual with suspected COVID-19 or visit to a venue that might have been exposed to COVID-19.
3.3. Statistical Analysis Data were analyzed using the SPSS 23.0 statistical software (IBM SPSS statistics). Quantitative data were expressed as x̄±SD, and qualitative data were expressed as count (percentage). P-values < 0.05 were considered statistically significant.
4. Results4.1. Patient Characteristics and Disease Conditions The study included 36 males (56.25%) and 28 females (43.75%), within the age range of 18-85 (49±18) years. Thirty-two patients (50%) had history of contact with someone infected with COVID-19. The mean incubation period was 7.7±6.5 days, and the mean length of stay (LOS) in the hospital was 18.84±9.75 days. Key disease manifestations were fever (84.37%), cough (57.8%), fatigue (20.3%), diarrhea (18.75%), myalgia (17.18%), dyspnea (14%), sore throat (12.5%), and others, including decreased appetite, headache, nausea, and hematochezia (10.9%) (Table 1). All the patients were treated with antiviral therapy by lopinavir/ ritonavir.
4.2. Key GI Manifestations A total of 60.9% (39/64) of patients developed GI symptoms at the time of disease onset and during the treatment course. These symptoms appeared 1-30 days after disease onset and lasted for 1-15 days, with a mean of 3.9±3.1 days. The GI symptoms reported were diarrhea (69.2%; 27/39), nausea (23.07%; 9/39), abdominal distension (7.69%; 3/39), and hematochezia (2.56%; 1/39) (Table 2). Among patients who had GI symptoms, 33.33% (13/39) had GI symptoms before receiving treatment; among these patients, 92.3% (12/13) had diarrhea. GI symptoms developed after therapy in 66.67% (26/39) of patients, primarily diarrhea (57.69%; 15/26). Among patients who developed GI symptoms after therapy, 7 (26.9%; 7/26) developed symptoms after discontinuation of antiviral drugs. The GI symptoms reported among these patients were nausea (26.9%; 7/26), abdominal distension (11.54%; 3/26), and hematochezia (3.85%; 3.85) (Table 3). Moreover, 28.1% (18/64) of patients had abnormal liver function on the day of admission, with mean levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) at 96.7±22.6 and 107.2±35.2 U/L, respectively. Approximately 10.8±8.6 days after receiving therapy, 31.25% (20/64) of patients had mean AST and ALT levels at 102.5±66.3 and 119.6±60.2 U/L, respectively. However, the increase in bilirubin level was not significant, with a mean value of 12.06±6.29 umol/L. Concurrently, the mean albumin level was 38.23±5.26 g/L, prothrombin time (PT) was 12.28±1.29 seconds, and International Normalized Ratio (INR) was 1.23±0.59 (Table 4).
4.3. Adjunct Testing Patients with GI bleeding underwent emergency gastroscopy and colonoscopy. Gastroscopy revealed no discernable bleeding mucosal lesions. Colonoscopy revealed old blood and local diverticula that were visible in the intestinal lumen (Figure 1). The base of the mucous membrane appeared smooth after washing. We observed no erosion, ulcers, or bleeding lesions in the washed mucosa. Lung CT scans showed multiple bilateral ground-glass opacities (Figure 2).
5. DiscussionCurrent epidemiological investigations show that the incubation period of the 2019-nCoV is 1–14 days, with the majority being 3-7 days [10]. The key manifestations are fever, dry cough, and fatigue, while some patients also have symptoms such as nasal congestion, rhinorrhea, sore throat, and diarrhea [10, 11]. The present study has found that 60.9% of infected patients displayed GI symptoms at disease onset and during diagnosis and treatment, among which 33.33% had GI symptoms at the time of disease onset. Among these patients, the most common GI symptom was diarrhea (92.3%). GI symptoms developed in 66.67% of the patients after receiving therapy, which primarily manifested as diarrhea (57.69%). As such, it is possible that disease-related factors and GI symptoms might be therapy-related. Lopinavir/ritonavir is a compound formulation. Lopinavir is a protease inhibitor for the treatment of acquired immunodeficiency syndrome (AIDS) caused by human immunodeficiency virus (HIV) infection. It blocks the cleavage of Gag-Pol polyprotein, leading to the production of immature, non-infectious viral particles. Ritonavir is an active peptidomimetic inhibitor against the aspartyl proteases HIV-1 and HIV-2. The inhibition of HIV proteases by ritonavir in turn inhibits the processing of the Gag-Pol polyprotein precursor. This results in production of immature HIV particles that fail to initiate a new infection cycle. The most common treatment-related adverse reactions during the use of lopinavir/ritonavir are diarrhea, nausea, vomiting, hypertriglyceridemia, and hypercholesterolemia. The risk of diarrhea may be higher in patients who receive their drugs once daily [12, 13].
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Yanling Wang. Gastrointestinal Symptoms in Patients with Coronavirus Disease 2019: A Single-Center Observational Study. Annals of Clinical and Medical Case Reports 2020