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

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          Abstract

          Although not common, gastrointestinal and liver symptoms have reportedly been the initial presentation of coronavirus disease‐2019 (COVID‐19) in a large group of patients. Therefore, knowing the frequency and characteristics of these manifestations of COVID‐19 is important for both clinicians and health policy makers. A systematic review and meta‐analysis of the available data on the gastrointestinal and liver manifestations of patients with COVID‐19 was performed. PubMed and Scopus databases and Google Scholar search engine were searched for published and unpublished preprint articles up to 10 April 2020. Original studies providing information on clinical digestive symptoms or biomarkers of liver function in patients with polymerase chain reaction confirmed diagnosis of COVID‐19 were included. After quality appraisal, data were extracted. Prevalence data from individual studies were pooled using a random‐effects model. Overall, 67 studies were included in this systematic review and meta‐analysis, comprising a pooled population of 13 251 patients with confirmed COVID‐19. The most common gastrointestinal symptoms were anorexia (10.2%, 95% confidence interval [CI] = 6.2%‐16.4%), diarrhea (8.4%, 95% CI = 6.2%‐11.2%), and nausea (5.7%, 95% CI = 3.7%‐8.6%), respectively. Decreased albumin levels (39.8%, 95% CI = 15.3%‐70.8%), increased aspartate aminotransferase (22.8%, 95% CI = 18.1%‐28.4%), and alanine aminotransferase (20.6%, 95% CI = 16.7%‐25.1%) were common hepatic findings. After adjusting for preexisting gastrointestinal (5.9%) and liver diseases (4.2%), the most common gastrointestinal findings were diarrhea (8.7%, 95% CI = 5.4%‐13.9%), anorexia (8.0%, 95% CI = 3.0%‐19.8%), and nausea (5.1%, 95% CI = 2.2%‐14.3%). Gastrointestinal and liver manifestations are not rare in patients with COVID‐19, but their prevalence might be affected by preexisting diseases. Diarrhea and mild liver abnormalities seem to be relatively common in COVID‐19, regardless of comorbidities

          Highlights

          • Anorexia (10.2%), diarrhea (8.4%), and nausea (5.7%) were the most common gastrointestinal manifestations in confirmed COVID‐19 patients.

          • Serum albumin reduction (39.8%), AST elevation (22.8%), and ALT elevation (20.6%) were the most common hepatic abnormalities in confirmed COVID‐19 patients.

          • Preexisting gastrointestinal and liver diseases were present in 5.9% and 4.2% of COVID‐19 patients. After adjusting for these illnesses, diarrhea (8.7%) became the most prevalent gastrointestinal finding.

          • The prevalence of gastrointestinal and hepatic abnormalities were markedly higher in patients with severe COVID‐19 infection, compared to non‐severe cases.

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          Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China

          Chaolin Huang, Yeming Wang, Xingwang Li … (2020)
          Summary Background A recent cluster of pneumonia cases in Wuhan, China, was caused by a novel betacoronavirus, the 2019 novel coronavirus (2019-nCoV). We report the epidemiological, clinical, laboratory, and radiological characteristics and treatment and clinical outcomes of these patients. Methods All patients with suspected 2019-nCoV were admitted to a designated hospital in Wuhan. We prospectively collected and analysed data on patients with laboratory-confirmed 2019-nCoV infection by real-time RT-PCR and next-generation sequencing. Data were obtained with standardised data collection forms shared by WHO and the International Severe Acute Respiratory and Emerging Infection Consortium from electronic medical records. Researchers also directly communicated with patients or their families to ascertain epidemiological and symptom data. Outcomes were also compared between patients who had been admitted to the intensive care unit (ICU) and those who had not. Findings By Jan 2, 2020, 41 admitted hospital patients had been identified as having laboratory-confirmed 2019-nCoV infection. Most of the infected patients were men (30 [73%] of 41); less than half had underlying diseases (13 [32%]), including diabetes (eight [20%]), hypertension (six [15%]), and cardiovascular disease (six [15%]). Median age was 49·0 years (IQR 41·0–58·0). 27 (66%) of 41 patients had been exposed to Huanan seafood market. One family cluster was found. Common symptoms at onset of illness were fever (40 [98%] of 41 patients), cough (31 [76%]), and myalgia or fatigue (18 [44%]); less common symptoms were sputum production (11 [28%] of 39), headache (three [8%] of 38), haemoptysis (two [5%] of 39), and diarrhoea (one [3%] of 38). Dyspnoea developed in 22 (55%) of 40 patients (median time from illness onset to dyspnoea 8·0 days [IQR 5·0–13·0]). 26 (63%) of 41 patients had lymphopenia. All 41 patients had pneumonia with abnormal findings on chest CT. Complications included acute respiratory distress syndrome (12 [29%]), RNAaemia (six [15%]), acute cardiac injury (five [12%]) and secondary infection (four [10%]). 13 (32%) patients were admitted to an ICU and six (15%) died. Compared with non-ICU patients, ICU patients had higher plasma levels of IL2, IL7, IL10, GSCF, IP10, MCP1, MIP1A, and TNFα. Interpretation The 2019-nCoV infection caused clusters of severe respiratory illness similar to severe acute respiratory syndrome coronavirus and was associated with ICU admission and high mortality. Major gaps in our knowledge of the origin, epidemiology, duration of human transmission, and clinical spectrum of disease need fulfilment by future studies. Funding Ministry of Science and Technology, Chinese Academy of Medical Sciences, National Natural Science Foundation of China, and Beijing Municipal Science and Technology Commission.
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            Clinical Characteristics of Coronavirus Disease 2019 in China

            Wei-jie Guan, Zheng-yi Ni, Yu Hu … (2020)
            Abstract Background Since December 2019, when coronavirus disease 2019 (Covid-19) emerged in Wuhan city and rapidly spread throughout China, data have been needed on the clinical characteristics of the affected patients. Methods We extracted data regarding 1099 patients with laboratory-confirmed Covid-19 from 552 hospitals in 30 provinces, autonomous regions, and municipalities in mainland China through January 29, 2020. The primary composite end point was admission to an intensive care unit (ICU), the use of mechanical ventilation, or death. Results The median age of the patients was 47 years; 41.9% of the patients were female. The primary composite end point occurred in 67 patients (6.1%), including 5.0% who were admitted to the ICU, 2.3% who underwent invasive mechanical ventilation, and 1.4% who died. Only 1.9% of the patients had a history of direct contact with wildlife. Among nonresidents of Wuhan, 72.3% had contact with residents of Wuhan, including 31.3% who had visited the city. The most common symptoms were fever (43.8% on admission and 88.7% during hospitalization) and cough (67.8%). Diarrhea was uncommon (3.8%). The median incubation period was 4 days (interquartile range, 2 to 7). On admission, ground-glass opacity was the most common radiologic finding on chest computed tomography (CT) (56.4%). No radiographic or CT abnormality was found in 157 of 877 patients (17.9%) with nonsevere disease and in 5 of 173 patients (2.9%) with severe disease. Lymphocytopenia was present in 83.2% of the patients on admission. Conclusions During the first 2 months of the current outbreak, Covid-19 spread rapidly throughout China and caused varying degrees of illness. Patients often presented without fever, and many did not have abnormal radiologic findings. (Funded by the National Health Commission of China and others.)
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              A Novel Coronavirus from Patients with Pneumonia in China, 2019

              Na Zhu, Dingyu Zhang, Wenling Wang … (2020)
              Summary In December 2019, a cluster of patients with pneumonia of unknown cause was linked to a seafood wholesale market in Wuhan, China. A previously unknown betacoronavirus was discovered through the use of unbiased sequencing in samples from patients with pneumonia. Human airway epithelial cells were used to isolate a novel coronavirus, named 2019-nCoV, which formed a clade within the subgenus sarbecovirus, Orthocoronavirinae subfamily. Different from both MERS-CoV and SARS-CoV, 2019-nCoV is the seventh member of the family of coronaviruses that infect humans. Enhanced surveillance and further investigation are ongoing. (Funded by the National Key Research and Development Program of China and the National Major Project for Control and Prevention of Infectious Disease in China.)
              Article 0 comments Cited 12704 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Azita Ganji: ganjia@mums.ac.ir
                Journal
                Journal ID (nlm-ta): J Med Virol
                Journal ID (iso-abbrev): J. Med. Virol
                Journal ID (doi): 10.1002/(ISSN)1096-9071
                Journal ID (publisher-id): JMV
                Title: Journal of Medical Virology
                Publisher: John Wiley and Sons Inc. (Hoboken )
                ISSN (Print): 0146-6615
                ISSN (Electronic): 1096-9071
                Publication date (Electronic): 27 July 2020
                Electronic Location Identifier: 10.1002/jmv.26314
                Affiliations
                [ 1 ] Clinical Research Unit Mashhad University of Medical Sciences Mashhad Iran
                [ 2 ] Student Research Committee, Faculty of Medicine Mashhad University of Medical Sciences Mashhad Iran
                [ 3 ] Student Research Committee, School of Nursing and Midwifery Mashhad University of Medical Sciences Mashhad Iran
                [ 4 ] Clinical Research Development Unit, Faculty of Medicine Mashhad University of Medical Sciences Mashhad Iran
                [ 5 ] Lung Diseases Research Center Mashhad University of Medical Sciences Mashhad Iran
                [ 6 ] Department of Gastroenterology and Hepatology, Faculty of Medicine Mashhad University of Medical Sciences Mashhad Iran
                Author notes
                [*] [* ] Correspondence Azita Ganji, Department of Gastroenterology and Hepatology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad 9137913316, Iran.

                Email: ganjia@ 123456mums.ac.ir

                Article
                Publisher ID: JMV26314
                DOI: 10.1002/jmv.26314
                PMC ID: 7405277
                PubMed ID: 32681674
                SO-VID: aee06327-0fbd-4cbe-b3ca-b764846cd75d
                Copyright © © 2020 Wiley Periodicals LLC
                License:

                This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

                History
                Date received : 13 May 2020
                Date accepted : 13 July 2020
                Page count
                Figures: 5, Tables: 4, Pages: 15, Words: 8805
                Categories
                Subject: Review
                Subject: Reviews
                Custom metadata
                source-schema-version-number 2.0
                edited-state corrected-proof
                details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_JATSPMC version:5.8.6 mode:remove_FC converted:05.08.2020

                ScienceOpen disciplines: Microbiology & Virology
                Keywords: covid‐19,digestive symptoms,gastrointestinal symptoms,hepatic abnormalities,hepatic injury
                Data availability:
                ScienceOpen disciplines: Microbiology & Virology
                Keywords: covid‐19, digestive symptoms, gastrointestinal symptoms, hepatic abnormalities, hepatic injury

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