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    Original Investigation
    Gastroenterology and Hepatology
    June 11, 2020

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

    Author Affiliations
    • 1Swedish Medical Center, Seattle, Washington
    • 2Kansas City Veterans Affairs Medical Center, Kansas City, Missouri
    • 3University of Kansas Medical Center, Kansas City
    • 4Ochsner Clinic Foundation, New Orleans, Louisiana
    • 5St Luke’s Medical Center, Kansas City, Missouri
    • 6Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
    • 7Instituto Clinico Humanitas, Department of Endoscopy, Humanitas University School of Medicine, Milano, Italy
    • 8Division of Gastrointestinal Endoscopy, University of São Paulo School of Medicine, São Paulo, Brazil
    JAMA Netw Open. 2020;3(6):e2011335. doi:10.1001/jamanetworkopen.2020.11335
    Key Points español 中文 (chinese)

    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.

    Abstract

    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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