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Prevalence of Gastrointestinal Symptoms and Fecal Viral Shedding in Patients With Coronavirus Disease 2019A Systematic Review and Meta-analysis

Educational Objective
To understand the prevalence of gastrointestinal symptoms and fecal viral shedding in patients with COVID-19
1 Credit CME
Key Points

Question  What are the incidence rates of gastrointestinal symptoms among patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection?

Findings  This systematic review and meta-analysis of 23 published and 6 preprint studies found that approximately 12% of patients with SARS-CoV-2 infection reported gastrointestinal symptoms, including diarrhea, nausea, and vomiting. Liver enzyme levels outside reference ranges were observed in 15% to 20% of patients, and SARS-CoV-2 RNA shedding in stool was detected in up to 41% of patients.

Meaning  These findings suggest that patients with SARS-CoV-2 infection can present with gastrointestinal symptoms with possible fecal-oral route of transmission due to the presence of viral RNA in stool.


Importance  Coronavirus disease 2019 (COVID-19) is a global pandemic and can involve the gastrointestinal (GI) tract, including symptoms like diarrhea and shedding of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in feces.

Objective  To provide a pooled estimate of GI symptoms, liver enzyme levels outside reference ranges, and fecal tests positive for SARS-CoV-2 among patients with COVID-19.

Data Sources  An electronic literature search was performed for published (using MEDLINE/PubMed and Embase) and preprint (using bioRxiv and medRxiv) studies of interest conducted from November 1, 2019, to March 30, 2020. Search terms included “COVID-19,” “SARS-Cov-2,” and/or “novel coronavirus.”

Study Selection  Eligible studies were those including patients with SARS-CoV-2 infection who reported GI symptoms.

Data Extraction and Synthesis  Data on patients with GI symptoms (ie, diarrhea, nausea, or vomiting), liver enzyme level changes, and fecal shedding of virus were extracted. Quality of studies was examined using methodological index for nonrandomized studies. Pooled estimates (%) were reported with 95% CIs with level of heterogeneity (I2).

Main Outcomes and Measures  Study and patient characteristics with pooled detection rates for diarrhea, nausea or vomiting, liver enzyme levels outside reference ranges, and SARS-CoV-2 positivity in feces tests were analyzed.

Results  Of 1484 records reviewed, 23 published and 6 preprint studies were included in the analysis, with a total of 4805 patients (mean [SD] age, 52.2 [14.8] years; 1598 [33.2%] women) with COVID-19. The pooled rates were 7.4% (95% CI, 4.3%-12.2%) of patients reporting diarrhea and 4.6% (95% CI, 2.6%-8.0%) of patients reporting nausea or vomiting. The pooled rate for aspartate aminotransferase levels outside reference ranges was 20% (95% CI, 15.3%-25.6%) of patients, and the pooled rate for alanine aminotransferase levels outside reference ranges was 14.6% (95% CI, 12.8%-16.6%) of patients. Fecal tests that were positive for SARS-CoV-2 were reported in 8 studies, and viral RNA shedding was detected in feces in 40.5% (95% CI, 27.4%-55.1%) of patients. There was high level of heterogeneity (I2 = 94%), but no statistically significant publication bias noted.

Conclusions and Relevance  These findings suggest that that 12% of patients with COVID-19 will manifest GI symptoms; however, SAR-CoV-2 shedding was observed in 40.5% of patients with confirmed SARS-CoV-2 infection. This highlights the need to better understand what measures are needed to prevent further spread of this highly contagious pathogen.

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Article Information

Accepted for Publication: May 2, 2020.

Published: June 11, 2020. doi:10.1001/jamanetworkopen.2020.11335

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Parasa S et al. JAMA Network Open.

Corresponding Author: Sravanthi Parasa, MD, Swedish Medical Center, 1221 Madison St, Ste 1220, Seattle, WA 98104 (sravanthi.parasa@swedish.org).

Author Contributions: Dr Parasa had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Parasa, Desai, Thoguluva Chandrasekar, Colombo, Repici, Sharma.

Acquisition, analysis, or interpretation of data: Parasa, Desai, Thoguluva Chandrasekar, Patel, Kennedy, Roesch, Spadaccini, Gabbiadini, Artifon.

Drafting of the manuscript: Parasa, Desai, Patel, Colombo, Repici.

Critical revision of the manuscript for important intellectual content: Parasa, Desai, Thoguluva Chandrasekar, Patel, Kennedy, Roesch, Spadaccini, Colombo, Gabbiadini, Artifon, Sharma.

Statistical analysis: Kennedy, Repici.

Administrative, technical, or material support: Parasa, Desai, Thoguluva Chandrasekar, Patel.

Supervision: Parasa, Roesch, Artifon, Sharma.

Conflict of Interest Disclosures: Dr Sharma reported receiving personal fees from Boston Scientific and Olympus and grants from US Endoscopy, Medtronics, Fujifilm, Ironwood, Cosmo Pharmaceuticals, and Erbe outside the submitted work. No other disclosures were reported.

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Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

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