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Objective

To investigate the prevalence of gastrointestinal and hepatic manifestations of COVID-19 patients, and explore their effect on the clinical outcomes in these patients.

Methods

This retrospective review of consecutive adult patients (age ≥18) with a positive real-time reverse-transcription polymerase chain reaction for SARS-CoV-2 was recorded from March 4 to April 9, 2020 at one of two hospitals in Manhattan (an academic tertiary referral center and a smaller community hospital). The history, laboratory data, and outcome measures were extracted from patients' medical records, using a structured abstraction tool. All vital signs and lab data were collected at presentation. "GI manifestation" was defined as presence of nausea, vomiting, diarrhea, or abdominal pain. Patients were considered to have indication of liver injury at presentation if they had elevated ALT, AST, total bilirubin, or alkaline phosphatase. The primary clinical outcome for admitted patients was defined as a composite of ICU admission or death.

Results

Of 1,059 patients diagnosed with COVID-19 (mean age 61 years, 58% male), 22% had diarrhea, 7% had abdominal pain, and 16% and 9% had nausea and vomiting, respectively. 33% of patients had at least one GI manifestation. At presentation, patients had a mean ALT of 50 (65), mean AST 60 (79) U/L, mean total bilirubin 0.7 (0.6) mg/dL, and mean alkaline phosphatase of 88 (74) U/L. 62% of the patients had biochemical evidence of liver injury with at least one of their liver enzymes elevated. In multivariable analysis of the effect of gender, age, pre-existing immunosuppression, IBD or chronic liver disease on presence of GI manifestation or liver injury, female patients (OR 1.30, 95% CI 1.01-1.69, P=0.048), and patients with chronic liver disease (OR 2.18, 95% CI 1.08-4.44, P=0.031) were more likely to present with GI symptoms; however age, immunosuppression, and IBD were not associated with GI symptoms at presentation. Only older age was significantly associated with higher rate of liver test abnormalities at presentation (OR 1.01, 95% CI 1.00-1.02, P=0.031). Both GI manifestations (78% vs 70% for patients without GI symptoms, P=0.007) and liver injury (87% vs 76% for patients without liver injury, P<0.001) on presentation were associated with higher admission rate. Those with GI symptoms had lower rates of death (8.5% vs 16.5% in patients without GI symptoms, P=0.003), and lower risk of the composite of death and ICU admission (28% vs 38% in patients without GI symptoms, P=0.006) in univariable analysis.

Conclusion

COVID-19 patients commonly exhibit GI manifestations. Liver injury was also commonly seen on initial presentation, and was independently associated with poor clinical outcomes. These results provide clarification of the diagnosis of patients with COVID-19, and can be considered in risk stratification.

You can read an interview with study author Reem Z. Sharaiha, MD, MSc, here, and about the clinical implications of the study here.