Digestive symptoms are common in COVID-19, occurring as the chief complaint in nearly half of patients presenting to hospital according to a new descriptive, cross-sectional multicenter study from China by investigators from the Wuhan Medical Treatment Expert Group for COVID-19 published today in The American Journal of Gastroenterology, the official publication of the American College of Gastroenterology.

Most patients with COVID-19 present with typical respiratory symptoms and signs. However, early experience with the outbreak in Wuhan, China revealed that many patients experienced digestive symptoms as their chief complaint. "Clinicians must bear in mind that digestive symptoms, such as diarrhea, may be a presenting feature of COVID-19, and that the index of suspicion may need to be raised earlier in these cases rather than waiting for respiratory symptoms to emerge," write the authors.

"In this study, COVID-19 patients with digestive symptoms have a worse clinical outcome and higher risk of mortality compared to those without digestive symptoms, emphasizing the importance of including symptoms like diarrhea to suspect COVID-19 early in the disease course before respiratory symptoms develop," said Brennan M.R. Spiegel, MD, MSHS, FACG, Co-Editor-in-Chief of The American Journal of Gastroenterology. "This may lead to earlier diagnosis of COVID-19, which can lead to earlier treatment and more expeditious quarantine to minimize transmission from people who otherwise remain undiagnosed."

The authors underscore the importance of their finding that COVID-19 patients present with GI symptoms as their chief complaint and warn, "If clinicians solely monitor for respiratory symptoms to establish case definitions for COVID-19, they may miss cases initially presenting with extra-pulmonary symptoms, or the disease may not be diagnosed later until respiratory symptoms emerge."

Key Findings

Compared to COVID-19 patients without digestive symptoms, those with digestive symptoms have a longer time from onset to admission and a worse clinical outcome according to this analysis by investigators from several hospitals and research centers in China who gathered data on 204 patients with COVID-19 presenting to three hospitals in Hubei province from January 18, 2020 to February 28, 2020. Diagnosis was confirmed by real-time RT-PCR. Clinical characteristics, laboratory data and treatment information for the patients were included in the final analysis.

Of the 204 patients, the average age of the patients was 54.9 years (SD +15.4), including 107 men and 97 women. The average time from symptom onset to hospital admission was 8.1 days (SD +4.9)
Patients with digestive symptoms had a significantly longer time from onset to admission than patients without digestive symptoms (9.0 days versus 7.3 days). This may indicate that patients presenting with digestive symptoms sought care later because they did not yet suspect COVID-19 in the absence of respiratory symptoms, like cough or shortness of breath
Patients with digestive symptoms had a variety of manifestations, such as anorexia (83 [83.8%] cases), diarrhea (29 [29.3%] cases), vomiting (8 [0.8%] cases), and abdominal pain (4 [0.4%] cases).
Seven patients with COVID-19 presented with digestive symptoms but no respiratory symptoms.
As the severity of the disease increased, digestive symptoms became more pronounced.
Patients without digestive symptoms were more likely to be cured and discharged than patients with digestive symptoms (60% versus 34.3%).
Laboratory data revealed no significant liver injury, although other studies have shown signs of liver involvement; more research is required to understand the impact of COVID-19 on liver function.