Abstract
Gastrointestinal manifestations of SARS-CoV-2 are reported in 10–50% of patients, being diarrhea, nausea, vomiting, and abdominal pain the most frequent ones. Gastrointestinal manifestations could be present without respiratory symptoms, leading to delayed diagnosis. In addition, COVID-19 is commonly associated with hepatic dysfunction manifesting with elevation of hepatic enzymes and total bilirubin levels, observed in up to 50% of the COVID-19 patients. Other less common gastrointestinal manifestations include acute cholecystitis, pancreatitis, and oral lesions. Clinicians should be also aware that the gastrointestinal tract is also frequently involved in COVID-19-related complications. As a matter of fact, several studies reported ileus, intestinal ischemia, perforation, and gastrointestinal bleeding during the course of COVID-19 disease. Lastly, the inappropriate and excessive use of antibiotics has led to an increase in Clostridioides difficile infection with consequent prolonged hospitalization and higher mortality. Although, the exact pathogenesis of gastrointestinal involvement is not completed understood, four main mechanisms have been advocated: the direct angiotensin converting enzyme 2 mediated viral cytotoxicity, cytokine-induced inflammation, gut dysbiosis, and vascular abnormalities.
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References
Gupta A, Madhavan MV, Sehgal K, et al. Extrapulmonary manifestations of COVID-19. Nat Med. 2020;26(7):1017–32.
Han Cha M, Regueiro M, Sandhu DS, et al. Gastrointestinal and hepatic manifestations of COVID-19: a comprehensive review. World J Gastroenterol. 2020;26(19):2323–32.
Cheung KS, Hung IFN, Chan PPY, et al. Gastrointestinal manifestations of SARS-CoV-2 infection and virus load in fecal samples from a Hong Kong cohort: systematic review and meta-analysis. Gastroenterology. 2020;159(1):81–95.
Leal T, Costa E, Arroja B, et al. Gastrointestinal manifestations of COVID-19: results from a European Centre. Eur J Gastroenterol Hepatol. 2021;33(5):691–4.
Vena A, Giacobbe DR, Di Biagio A, et al. Clinical characteristics, management and in-hospital mortality of patients with coronavirus disease 2019 in Genoa, Italy. Clin Microbiol Infect. 2020;26(11):1537–154.
Nobel YR, Phipps M, Zucker J, et al. Gastrointestinal symptoms and COVID-19: case–control study from the United States. Gastroenterology. 2020;159:373–5.
Redd WD, Zhou JC, Hathorn KE, et al. Prevalence and characteristics of gastrointestinal symptoms in patients with severe acute respiratory syndrome coronavirus 2 infection in the United States: a multicenter cohort study. Gastroenterology. 2020;159:765–7.
Mao R, Qiu Y, He J-S, et al. Manifestations and prognosis of gastrointestinal and liver involvement in patients with COVID-19: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol. 2020;5(7):667–78.
Sultan S, Altayar O, Siddique SM, et al. AGA institute rapid review of the gastrointestinal and liver manifestations of COVID-19, meta-analysis of international data, and recommendations for the consultative management of patients with COVID-19. Gastroenterology. 2020;159(1):320–34.
Buscarini E, Manfredi G, Brambilla G, et al. GI symptoms as early signs of COVID-19 in hospitalised Italian patients. Gut. 2020;69(8):1547–8.
Cao W, Li T. COVID-19: towards understanding of pathogenesis. Cell Res. 2020;30:367–9.
Devaux CA, Lagier J, Raoult D. New insights into the physiopathology of COVID-19: SARS-CoV-2 associated gastrointestinal illness. Front Med (Lausanne). 2021;8:640073.
Xiao F, Tang M, Zheung X, et al. Evidence for gastrointestinal infection of SARS-CoV-2. Gastroenterology. 2020;158(6):1831–3.
Parasa S, Desai M, Chandrasekar VT, et al. Prevalence of gastrointestinal symptoms and fecal viral shedding in patients with coronavirus disease 2019: a systematic review and meta-analysis. JAMA Netw Open. 2020;3(6):e2011335.
D'Amico F, Baumgart DC, Danese S, et al. Diarrhea during COVID-19 infection: pathogenesis, epidemiology, prevention, and management. Clin Gastroenterol Hepatol. 2020;18(8):1663–72.
Zuo T, Zhang F, Lui GC, et al. Alterations in gut microbiota of patients with COVID-19 during time of hospitalization. Gastroenterology. 2020;159(3):944–55.
Ackermann M, Verleden SE, Kuehnel M, et al. Pulmonary vascular endothelialitis, thrombosis and angiogenesis in COVID-19. N Engl J Med. 2020;383:120–8.
Varga Z, Flammer AJ, Steiger P, et al. Endothelial cell infection and endotheliitis in COVID-19. Lancet. 2020;395:1417–8.
Kim KD, Zhao J, Auh S, et al. Adaptive immune cells temper initial innate responses. Nat Med. 2007;13(10):1248–52.
Huang KJ, Su IJ, Theron M, et al. An interferon-gamma-related cytokine storm in SARS patients. J Med Virol. 2005;75(2):185–94.
Cummings MJ, Baldwin MR, Abrams D, et al. Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study. Lancet. 2020;395:1763–70.
Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA. 2020;323(11):1061–9.
Fang D, Ma J, Guan J, et al. Manifestations of digestive system in hospitalized patients with novel coronavirus pneumonia in Wuhan, China: a single-center, descriptive study. Chin J Dig. 2020;12:E005.
Rowley AH. Understanding SARS-CoV-2-related multisystem inflammatory syndrome in children. Nat Rev Immunol. 2020;20(8):453–4.
Mutiawati E, Fahriani M, Mamada SS, et al. Anosmia and dysgeusia in SARS-CoV-2 infection: incidence and effects on COVID-19 severity and mortality, and the possible pathobiology mechanisms—a systematic review and meta-analysis. F1000Res. 2021;10:40.
Xu L, Liu J, Lu M, et al. Liver injury during highly pathogenic human coronavirus infections. Liver Int. 2020;40(5):998–1004.
Zhang C, Shi L, Wang FS. Liver injury in COVID-19: management and challenges. Lancet Gastroenterol Hepatol. 2020;5(5):428–30.
Hajifathalian K, Krisko T, Mehta A, et al. Gastrointestinal and hepatic manifestations of 2019 novel coronavirus disease in a large cohort of infected patients from New York: clinical implications. Gastroenterology. 2020;159(3):1137–40.
Taramasso L, Vena A, Bovis F, et al. Higher mortality and intensive care unit admissions in COVID-19 patients with liver enzyme elevations. Microorganisms. 2020;8(12):2010.
Bangash MN. COVID-19 and the liver: little cause concern. Lancet Gastroenterol Hepatol. 2020;5:529–30.
Li J, Fan JG. Characteristics and mechanism of liver injury in 2019 coronavirus disease. J Clin Transl Hepatol. 2020;8(1):13–7.
Sun JK, Liu Y, Zou L, et al. Acute gastrointestinal injury in critically ill patients with COVID-19 in Wuhan, China. World J Gastroenterol. 2020;26(39):6087–97.
Scutari R, Piermatteo L, Ciancio Manuelli M, et al. Long-term SARS-CoV-2 infection associated with viral dissemination in different body fluids including bile in two patients with acute cholecystitis. Life (Basel). 2020;10(11):302.
Mattone E, Sofia M, Schembari E, et al. Acute acalculous cholecystitis on a COVID-19 patient: a case report. Ann Med Surg (Lond). 2020;58:73–5.
McNabb-Baltar J, Jin DX, Grover AS, et al. Lipase elevation in patients with COVID-19. Am J Gastroenterol. 2020;115(8):1286–8.
Farid H, Khan M, Jamal S, et al. Oral manifestations of Covid-19—a literature review. Rev Med Virol. 2021;32:e2248.
Brandão TB, Gueiros LA, Melo TS, et al. Oral lesions in patients with SARS-CoV-2 infection: could the oral cavity be a target organ? Oral Surg Oral Med Oral Pathol Oral Radiol. 2021;131(2):e45–51.
El Moheb M, Naar L, Christensen MA, et al. Gastrointestinal complications in critically ill patients with and without COVID-19. JAMA. 2020;324(18):1899–901.
Parry AH, Wani AH, Yaseen M. Acute mesenteric ischemia in severe Coronavirus-19 (COVID-19): possible mechanisms and diagnostic pathway. Acad Radiol. 2020;27(8):1190.
Kaafarani HMA, El Moheb M, Hwabejire JO, et al. Gastrointestinal complications in critically ill patients with COVID-19. Ann Surg. 2020;272(2):e61–2.
Gartland RM, Velmahos GC. Bowel necrosis in the setting of COVID-19. J Gastrointest Surg. 2020;24(12):2888–9.
Kerawala AA, Das B, Solangi A. Mesenteric ischemia in COVID-19 patients: a review of current literature. World J Clin Cases. 2021;9(18):4700–8.
Vikse J, Henry BM. Tocilizumab in COVID-19: beware the risk of intestinal perforation. Int J Antimicrob Agents. 2020;56(1):106009.
Martin TA, Wan DW, Hajifathalian K, et al. Gastrointestinal bleeding in patients with coronavirus disease 2019: a matched case-control study. Am J Gastroenterol. 2020;115(10):1609–16.
Rawson TM, Moore LS, Castro-Sánchez E, et al. COVID-19 and the potential long-term impact on antimicrobial resistance. J Antimicrob Chemother. 2020;75:1681–4.
Magnasco L, Mikulska M, Giacobbe DR, et al. Spread of carbapenem-resistant Gram-Negatives and Candida auris during the COVID-19 pandemic in critically ill patients: one step back in antimicrobial stewardship? Microorganisms. 2021;9(1):95.
Khanna S, Kraft CS. The interplay of SARS-CoV-2 and Clostridioides difficile infection. Future Microbiol. 2021;16:439–43. https://doi.org/10.2217/fmb-2020-0275.
Puoti MG, Rybak A, Kiparissi F, et al. SARS-CoV-2 and the gastrointestinal tract in children. Front Pediatr. 2021;9:617980.
Sahn B, Eze OP, Edelman MC, et al. Features of intestinal disease associated with COVID-related multisystem inflammatory syndrome in children. J Pediatr Gastroenterol Nutr. 2021;72(3):384–7.
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Bassetti, M., Vena, A., Giacobbe, D.R., Briano, F., Portunato, F. (2022). Gastrointestinal Manifestations of COVID-19. In: Battaglini, D., Pelosi, P. (eds) COVID-19 Critical and Intensive Care Medicine Essentials. Springer, Cham. https://doi.org/10.1007/978-3-030-94992-1_21
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DOI: https://doi.org/10.1007/978-3-030-94992-1_21
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