The novel coronavirus can cause gastrointestinal symptoms such as nausea, vomiting and diarrhea.
Patient: “Doc, I get heartburn every time I eat birthday cake.”
Gastroenterologist: “Next time, remove the candles.”
In a medical specialty about the gut, bloating and pooping, jokes pretty much write themselves. But for many people struggling with gastrointestinal (GI) symptoms and Covid-19 infection, life is far less funny. And right now, the coronavirus pandemic shows no signs of slowing down. Amid nationwide protests following the murder of Mr. George Floyd, Covid-19 cases and deaths in the U.S. are rising steadily, now at 1.98 million and 112,000, respectively.
As coronavirus unnervingly looms, we continue to learn more about this novel SARS-CoV-2 pathogen. For instance, stomach ache and diarrhea may be the first signs of the infection, as Robert Glattner, MD discussed in March. Since that time, we’ve gained additional information about the ‘COVID Gut’ both in adults and in children, as well as its mechanism of action and treatment options.
GI Symptoms in Kids and Adults
Diarrhea is a common symptom in children who test positive for Covid-19.
A recent case report from China reported that digestive issues were the first symptoms observed in five Covid-19-positive children. Another study from the U.K. described eight children presenting with atypical appendicitis. Abdominal pain, diarrhea and vomiting were observed in children presenting with the Kawasaki-like illness now referred to as multisystem inflammatory syndrome in children.
We also know that adults infected with Covid-19 are also presenting with GI issues. In fact, the CDC tacked on GI complaints to their symptom watch list.
“The main GI symptom in adults is diarrhea, occurring in up to 30% of patients,” states Mark Pochapin, MD, Director of the Division of Gastroenterology and Hepatology at NYU Langone Health. “However, patients also can have lack of appetite (anorexia), nausea and vomiting.” Dr. Pochapin also cited a Stanford study demonstrating that Covid-19-infected patients with GI symptoms were five times more likely to be hospitalized than those without GI symptoms (8 times more likely if experiencing diarrhea).
Tests and Procedures
Endoscopic procedures such as EGDs and colonoscopies are routinely used screen for benign and ... [+]
In addition to digestive symptoms, clinicians need to be mindful of abnormal tests.
“The common GI manifestations of Covid are diarrhea, nausea and vomiting,” observes Shifali Arora, MD, Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, UNC Chapel Hill. “But the other issue to watch out for are elevated liver enzymes which we see typically as well.” Namely, AST and ALT are enzymes that are usually elevated during liver injury. In addition, a recent meta-analysis revealed that 48% of patients with Covid-19 and GI symptoms had viral RNA detected in their stool.
The pandemic put a halt on all elective procedures including esophagogastroduodenoscopies (EGDs) and colonoscopies. How these endoscopy procedure units open and ramp up will differ nationwide, according to Dr. Arora who is assisting with reopening efforts at her institution. She adds: “Clinicians and staff have been working hard to create new workflows and work spaces that allow for socially distanced waiting rooms, providing masks for patients and staff, and extensively cleaning between cases.”
Mechanism
SARS-CoV-2 coronavirus binds to the ACE2 receptor which is found in many organs including the lungs, ... [+]
So, what’s the connection between this presumed respiratory virus and the gut? Well, it involves the ACE2 receptor which is found in multiple organs, including the lungs and the GI system (e.g. esophagus, gallbladder, pancreas, liver and colon).
“In terms of the mechanism, it's thought that the ACE2 receptor plays a role in the pathogenesis of Covid-19,” explains Supriya Rao, MD, gastroenterologist and managing partner at Integrated Gastroenterology Consultants in Chelmsford, MA. “This receptor is present in very high amounts in the GI tract. The virus adheres to the receptor via its spike protein and can then cause symptoms.”
Moreover, according to Dr. Wenbin Li, author of the Wuhan study, the presence of the ACE2 receptor in two different organ systems suggests that Covid-19 can infect patients through the respiratory tract in the form of air droplets as well as through the digestive tract by fecal-oral transmission.
Speaking of transmission, we still don’t know how much a toilet plume can transmit Covid-19, reminds Dr. Pochapin: “People should pay particular attention to hand washing after using the toilet, close the toilet lid and wear a mask in public bathrooms.”
Treatment Options
Current treatment for Covid-19 patients with GI symptoms includes medications such as Imodium and ... [+]
We still do not have a treatment, cure or vaccine for Covid-19, so doctors are managing symptoms.
“Treatment relies on supportive care – antiemetics, PPI (proton-pump inhibitors), antidiarrheals and adequate hydration,” advises Dr. Rao.
Loperamide (“Imodium”) and bismuth (“Pepto-Bismol”) are common over-the-counter medications used to treat diarrhea. Omeprazole (“Prilosec”) is a PPI that can reduce heartburn and gastritis. Promethazine (“Phenergan”), odansetron (“Zofran”) and metoclopramide (“Reglan”) minimize nausea and vomiting.
What About Advanced Liver Disease?
A recent study reports that the coronavirus pandemic has caused “seismic shifts” in the management of patients with liver transplants, cirrhosis and hepatocellular carcinoma, a.k.a. liver cancer, and other forms of advanced liver disease. Decreased access to routine care including procedures such as EGDs to screen for esophageal varices has prompted hepatologists and other GI professionals to adjust quickly.
What’s the Best Way to Maintain a Healthy Gut?
Gut health. Follow a meal plan that's high in fiber, whole grains, fruits and vegetables; and low in ... [+]
The gut microbiome is key to maintaining overall health and immunity, according to Dr. Rao, who recommends following a “plant-based diet that’s high in diverse fruits and vegetables, fiber, whole grains, and minimal animal products and processed foods.” She adds that adequate water intake and sleep, smoking cessation and daily exercise are also critical.
Stress and anxiety can also manifest as GI symptoms, points out Dr. Arora. In the midst of a pandemic, record unemployment and nationwide racial tensions, who isn’t tense as an overstretched elastic band?! “Someone with irritable bowel syndrome may experience a flare-up of symptoms during this stressful period,” indicates Dr. Arora.
Other key GI health tips:
- Talk to your doctor before stopping or changing any meds for chronic conditions (IBS, IBD, etc.)
- Know your family history so you can be screened appropriately
- Mindful practice (meditation, yoga), regular exercise and social connections with friends and loved ones can reduce stress and improve gut health
Digestive health sometimes takes a back seat to cardiac or neurologic issues. Until something goes wrong. Sharp abdominal pain, unrelenting vomiting and severe diarrhea are some of the most debilitating and concerning symptoms experienced by humans. As coronavirus continues to spread, we need to be mindful of GI issues, report them to our doctors and treat them accordingly. We’re still learning about this novel virus, and like a trainee gastroenterologist, we have to work our way up from the bottom. [I clearly have too many GI doc friends…]
