What is Gastrointestinal and Hepatic Manifestations of Coronavirus (COVID-19)?
COVID-19 is the illness caused by a virus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It spreads very quickly and was named a worldwide pandemic after it started in China in December 2019 and spread to over 200 countries. It can pass on from one person to another through tiny droplets from the mouth or nose, contact with mucous membranes like the eyes or mouth, or touching infected surfaces.
SARS-CoV-2 primarily targets the respiratory system. Still, it can also impact many other major organs like the digestive system, liver, heart, brain, and kidneys. Recent information has shown that people with COVID-19 might only have symptoms related to the digestive system, like upset stomach, and no symptoms of respiratory problems. People who experience these digestive symptoms are more likely to end up in the hospital compared to people without these symptoms.
The virus’s genetic material, SARS-CoV-2 RNA, can be found in the feces of people who don’t show any symptoms and whose nose or throat swabs test negative for COVID-19. Some people with symptoms who have recovered continue to shed the virus in their stools for a longer period. This raises concerns that the virus can be passed on via the fecal-oral route, meaning by touching something contaminated with feces and then touching the mouth. Some labs have found live virus in feces, suggesting that the GI tract may not just be shedding the virus but could be a primary site of infection.
Frequently, COVID-19 patients, irrespective of whether they have symptoms or not, show abnormal results in liver tests. Moreover, patients with COVID-19 are increasingly at risk of developing blood clot related complications, like blocked blood supply to the intestines and clots in the portal vein, which carries blood to the liver. This information focuses on how SARS-CoV-2 affects the digestive tract and liver in adult patients.
What Causes Gastrointestinal and Hepatic Manifestations of Coronavirus (COVID-19)?
Coronaviruses are viruses that contain a single strand of RNA within a protective envelope. They are organized into four different categories which include Alphacoronavirus, Betacoronavirus, Gammacoronavirus, and Deltacoronavirus.
SARS-CoV-2, the virus that causes COVID-19, is a type of Betacoronavirus. It is similar to the viruses that caused past outbreaks of severe respiratory illnesses, such as SARS and MERS. These outbreaks had death rates of around 10% and 35% respectively.
Analysis of the genetic makeup of SARS-CoV-2 showed that it shared 89% of its genetic material with a type of coronavirus found in bats, and 82% with the human SARS virus. SARS-CoV-2 has also been changing over time, resulting in different variants of the virus appearing.
During the outbreaks of SARS and MERS, and now in COVID-19, these viruses often affected the gastrointestinal system and the liver, causing similar symptoms across the three diseases.
Risk Factors and Frequency for Gastrointestinal and Hepatic Manifestations of Coronavirus (COVID-19)
COVID-19 first surfaced in Wuhan, China, in December 2019. Since then, it has spread to over 200 countries, infecting more than 701 million people and resulting in over 6.9 million deaths. The World Health Organization (WHO) declared it a global pandemic due to its highly infectious nature. It’s crucial to note that people over 65 years old and those with certain health conditions are more likely to develop serious COVID-19 symptoms. These conditions include severe obesity, high blood pressure, chronic kidney disease, diabetes, ongoing lung issues, smoking, and immune system suppression with medication.
Research done on 50 studies from the US and UK reveals that people from Black and Asian ethnic backgrounds may have a higher chance of contracting COVID-19 than white individuals. Additionally, Asian people might have a higher risk of needing intensive care or dying from the virus. This finding has significant implications for global public health.
Signs and Symptoms of Gastrointestinal and Hepatic Manifestations of Coronavirus (COVID-19)
Doctors must collect detailed information from patients suspected of having COVID-19. They need to know when symptoms began, how long they have lasted, any recent travels, exposure to other people with COVID-19, existing health conditions, and current medications.
Testing should be done for patients who show typical symptoms of COVID-19, including:
- Fever
- Cough
- Sore throat
- Loss of taste or smell
- Feeling unwell
- Muscle aches
Patients with only digestive symptoms such as diarrhea, nausea, vomiting, stomach pain, or unusual blood test results showing possible liver issues should also be tested, especially in areas where COVID-19 cases are numerous. Some patients with a SARS-CoV-2 infection may have no symptoms, some mild symptoms, and others may become very ill with breathing difficulty, severe infection throughout the body, or multiple organ failure.
Most people with COVID-19 will experience symptoms like fever, cough, sore throat, difficulty breathing, loss of smell, taste changes, feeling unwell, and muscle aches. Some may only experience digestive symptoms, either alone or along with other symptoms. According to a review of 1992 patients, 53% reported having digestive symptoms, most commonly:
- Diarrhea (34%)
- Nausea (27%)
- Vomiting (16%)
- Abdominal pain (11%)
Loss of appetite is also a common symptom in patients with COVID-19. In rare cases, patients have been reported to experience bleeding in the colon, which was linked to the SARS-CoV-2 virus after ruling out other possible causes.
Testing for Gastrointestinal and Hepatic Manifestations of Coronavirus (COVID-19)
When a patient first arrives for COVID-19 testing, doctors typically order a variety of blood tests. These can include a complete blood count (CBC) and a comprehensive metabolic panel (CMP) which checks kidney and liver health. Additionally, tests for blood clotting and the enzyme lipase, which helps break down dietary fats, are often included.
Also, studies have found that the genetic material (RNA) of the COVID-19 virus can be found in the stool of patients. In fact, 41% of patients in one study were found to have the virus in their digestive system. This suggests that the virus might spread through fecal matter (poop) as well as respiratory droplets (exhaled breath).
A significant number of COVID-19 patients, 14% to 53%, have shown evidence of liver damage. This is usually indicated by elevated levels of liver enzymes (AST and ALT) along with a mild increase in bilirubin, a substance produced by the liver. Patients with severely elevated liver enzymes are at higher risk for serious illness, including possible ICU admission and death.
Additionally, it’s not unusual to see minor elevation of some other liver enzymes (alkaline phosphatase and GGT) in COVID-19 patients. This is because these enzymes are linked to a protein (ACE2) that the virus uses to enter cells. You should ensure to rule out other bacterial and viral infections, especially Clostridium difficile, if you’re experiencing symptoms like severe diarrhea and abdominal pain.
If liver abnormalities are present, doctors may also perform a troponin test and an electrocardiogram (EKG), which are used to detect heart damage. They may also test for inflammation markers such as C-reactive protein (CRP), D-dimer, and ferritin.
If your liver tests are abnormal, doctors may do additional tests to exclude other possible causes, such as hepatitis A, B, or C. If you have a history of autoimmune hepatitis or liver transplant and are actively infected with COVID-19, be aware that worsened symptoms may not necessarily indicate a flare-up or rejection, and a biopsy may be needed to confirm this.
Finally, COVID-19 patients seem to have a higher risk for blood clotting complications. Therefore, if indicated, you might be assessed for these risks. The tests could include an X-ray, ultrasound, CT scan, or MRI. If severe digestive symptoms are present, a special examination called endoscopy might be performed. However, due to the high risk of virus transmission, appropriate personal protective equipment (PPE) must be used during such procedures.
Treatment Options for Gastrointestinal and Hepatic Manifestations of Coronavirus (COVID-19)
The management of COVID-19, the disease caused by the coronavirus, depends on how sick the patient is when first seen by a medical professional. Those who have no symptoms or only mild symptoms can be cared for at home, where they should rest, drink plenty of fluids, and stay away from others as much as possible.
However, people who have moderate to severe symptoms, or those who may be more likely to get very sick, should be closely watched in a hospital. This care is guided by updates from the National Institute of Health.
As with other stomach bugs, unpleasant symptoms like nausea and vomiting should be treated cautiously with intravenous (IV) hydration, medications to help prevent vomiting, and continued checks of the body’s mineral balance, also known as serum electrolytes.
The first drug to be approved by the FDA for treating adults and children hospitalized with COVID-19 is remdesivir. Patients given this drug need to have their liver functions tested at the beginning and at regular intervals during treatment. Other drugs that could potentially damage the liver need to be identified early and, if possible, should be avoided in patients who already have high liver test results.
Another drug, Nirmatrelvir/ritonavir (Paxlovid), was approved in December 2021 for use in patients with mild-to-moderate COVID-19 symptoms who are at high risk of complications from the disease. Nirmatrelvir stops the virus from replicating within cells, and ritonavir increases the concentration of nirmatrelvir in the body. This medication is most effective when given within the first 5 days the symptoms appear.
Patients with COVID-19 can have a higher risk of developing blood clots. Healthcare providers should be on high alert for these complications and consider starting appropriate blood-thinning medication, as long as there are no other reasons to not begin this medication.
Because the coronavirus is airborne, procedures that aerosolize the virus, including procedures done with an endoscope, can put gastroenterologists, medical staff, and endoscopy staff at a higher risk of catching or spreading the virus. Specific precautions can help prevent or decrease the spread of the virus.
Precautions at the Endoscopy Suite:
In the area where endoscopies are performed:
* Since procedures like endoscopy can spread the virus through the air, all healthcare providers in the room should wear full protective equipment. This includes a gown, an N95 mask approved by the National Institute for Occupational Safety and Health (NIOSH), and a face shield for all procedures. For positive COVID-19 cases, a powered-air purifying respirator (PAPR) should be worn.
* All procedures should be done in negative pressure rooms if they are available.
* All staff members need training in how to correctly put on and take off protective equipment and how to store it correctly.
* Consider placing NIOSH-approved air filters in the room where endoscopies are done, if possible.
* Handwashing for at least 20 seconds with soap and water should be done before and after each exam.
What else can Gastrointestinal and Hepatic Manifestations of Coronavirus (COVID-19) be?
When dealing with patients who have active COVID-19 and are experiencing gastrointestinal (GI) symptoms, doctors must also consider other common causes of GI and liver problems. The symptoms could be due to:
- Other types of infectious diarrhea
- Ischemic colitis (damage to the colon due to reduced blood flow)
- Inflammatory bowel disease (chronic inflammation of the digestive tract)
- Irritable Bowel Syndrome (a common disorder affecting the large intestine)
- Small bowel intestinal overgrowth (an excess of bacteria in the small intestine)
- Acute or chronic pancreatitis (inflammation of the pancreas)
- Acute cholecystitis (inflammation of the gallbladder)
- Choledocholithiasis (stones in the bile ducts)
- Peptic ulcer disease (sores in the lining of the stomach or first part of the small intestine)
Moreover, they need to consider that elevated liver enzymes could be due to:
- Overuse of Acetaminophen (a common pain reliever)
- Viral hepatitis (A, B, or C)
- Drug-induced liver injury
- Ischemic hepatitis (damage to the liver cells from lack of oxygen)
- Primary biliary cholangitis (a disease where the bile ducts in the liver are slowly destroyed)
- Budd-Chiari syndrome (a rare liver condition)
- Low blood pressure caused by sepsis (body’s extreme response to an infection)
- Autoimmune hepatitis (the body’s immune system attacks liver cells)
- Infections, such as CMV, EBV, or HSV
- Muscle-related disorders, like polymyositis or rhabdomyolysis (breakdown of muscle tissue)
What to expect with Gastrointestinal and Hepatic Manifestations of Coronavirus (COVID-19)
The recovery outcome of COVID-19 varies widely and depends on several factors. These include how severe the illness is when first diagnosed, any pre-existing health conditions, and how the body responds to treatment. A large study from China involving 44,415 patients found that the vast majority (81%) had a mild case of the illness and experienced good recovery. The remaining 19% had a severe to very severe case and needed to be hospitalized. About 5% of these developed serious symptoms which included breathing difficulties and multiple organs not functioning properly.
Research has shown that COVID-19 patients who had primary symptoms related to the gastrointestinal system or had these symptoms along with others, were at a higher risk of being hospitalized compared to those without gastrointestinal symptoms. However, it’s worth noting that this aspect needs more comprehensive research. Sudden liver failure is not very common in COVID-19 patients. But COVID-19 patients who show signs of a damaged liver when first diagnosed are at a very high risk of being admitted to the intensive care unit (ICU) and even death.
Possible Complications When Diagnosed with Gastrointestinal and Hepatic Manifestations of Coronavirus (COVID-19)
COVID-19 is a virus that can affect many major organs in the body, making it a widespread illness. The disease might lead to serious health problems because it can cause a sudden or gradual worsening of the person’s condition, leading to severe respiratory problems and failure of multiple organs in the body.
People with COVID-19 are also showing an increased likelihood of developing complications related to blood clotting. Sudden blockage of blood flow in the intestines, which is called acute mesenteric ischemia, is one of these complications. It’s a dangerous condition that requires immediate medical attention and often has poor outcomes. A study showed that 31% of the abdomen CT scans (mainly of ICU patients) displayed abnormalities in the wall of the intestines, including the presence of gas inside and along the veins of the intestines. In some of these patients, surgery confirmed the presence of death tissue in the intestine due to clotting in small blood vessels.
There is a thought that these clotting-related complications occur because of the body’s increased tendency to clot during this viral illness. Other complications like severe liver inflammation, bleeding in the colon, and death of pancreatic tissue could be caused by various factors including low oxygen levels, inflammation caused by immune response, and reduced blood flow.
Common Complications of COVID-19:
- Acute respiratory failure
- Acute respiratory distress syndrome
- Multiorgan failure
- Complications link to blood clotting
- Acute mesenteric ischemia
- Severe liver inflammation
- Bleeding in the colon
- Death of pancreatic tissue
Preventing Gastrointestinal and Hepatic Manifestations of Coronavirus (COVID-19)
Using strategies to prevent and control the spread of COVID-19 is crucial, particularly in reducing stomach and liver complications arising from the disease. Patients should keep up-to-date on COVID-19 vaccinations and receive their necessary boosters when required. It’s essential to focus on raising public awareness about the various ways the virus may show up, including symptoms related to the digestive system alone. It’s essential to understand the significance of reporting these symptoms early and seeking immediate medical help, which can lead to quicker diagnosis and medical intervention. Given that the effectiveness of a drug known as nirmatrelvir/ritonavir decreases as more time passes since the initial symptoms, people who may be more vulnerable to the disease should seek medical care at the earliest.
Putting into place thorough screening protocols, especially for populations more at risk, can help in recognizing cases early on. Maintaining hygiene and infection control measures is also very important to prevent the virus from spreading, considering the possibility that it can be passed on from fecal matter to mouth (fecal-oral transmission). Those providing medical care need to educate patients and those close to them about the potential shedding of the virus from fecal matter, and advise them to be cautious about coming into contact with others, in order to limit the virus’s spread. It’s necessary for patients to understand the importance of regular handwashing with soap and water for at least 20 seconds, especially after being in contact with surfaces that might be infected.
Teaming up healthcare professionals, public health agencies, and communities is key to creating a comprehensive plan that ensures effectiveness in deterring and preventing stomach and liver complications that can be caused by COVID-19.
