key: cord-267509-w7nfbnbb authors: Tian, Yuan; Rong, Long; Nian, Weidong; He, Yan title: Review article: gastrointestinal features in COVID‐19 and the possibility of faecal transmission date: 2020-03-31 journal: Aliment Pharmacol Ther DOI: 10.1111/apt.15731 sha: doc_id: 267509 cord_uid: w7nfbnbb BACKGROUND: There is little published evidence on the gastrointestinal features of COVID‐19. AIMS: To report on the gastrointestinal manifestations and pathological findings of patients with COVID‐19, and to discuss the possibility of faecal transmission. METHODS: We have reviewed gastrointestinal features of, and faecal test results in, COVID‐19 from case reports and retrospective clinical studies relating to the digestive system published since the outbreak. RESULTS: With an incidence of 3% (1/41)‐79% (159/201), gastrointestinal symptoms of COVID‐19 included anorexia 39.9% (55/138)‐50.2% (101/201), diarrhoea 2% (2/99)‐49.5% (146/295), vomiting 3.6% (5/138)‐66.7% (4/6), nausea 1% (1/99)‐29.4% (59/201), abdominal pain 2.2% (3/138)‐6.0% (12/201) and gastrointestinal bleeding 4% (2/52)‐13.7% (10/73). Diarrhoea was the most common gastrointestinal symptom in children and adults, with a mean duration of 4.1 ± 2.5 days, and was observed before and after diagnosis. Vomiting was more prominent in children. About 3.6% (5/138)‐15.9% (32/201) of adult and 6.5% (2/31)‐66.7% (4/6) of children patients presented vomiting. Adult and children patients can present with digestive symptoms in the absence of respiratory symptoms. The incidence of digestive manifestations was higher in the later than in the early stage of the epidemic, but no differences in digestive symptoms among different regions were found. Among the group of patients with a higher proportion of severe cases, the proportion of gastrointestinal symptoms in severe patients was higher than that in nonsevere patients (anorexia 66.7% vs 30.4%; abdominal pain 8.3% vs 0%); while in the group of patients with a lower severe rate, the proportion with gastrointestinal symptoms was similar in severe and nonsevere cases (nausea and vomiting 6.9% vs 4.6%; diarrhoea 5.8% vs 3.5%). Angiotensin converting enzyme 2 and virus nucleocapsid protein were detected in gastrointestinal epithelial cells, and infectious virus particles were isolated from faeces. Faecal PCR testing was as accurate as respiratory specimen PCR detection. In 36% (5/14)‐53% (39/73) faecal PCR became positive, 2‐5 days later than sputum PCR positive. Faecal excretion persisted after sputum excretion in 23% (17/73)‐82% (54/66) patients for 1‐11 days. CONCLUSIONS: Gastrointestinal symptoms are common in patients with COVID‐19, and had an increased prevalence in the later stage of the recent epidemic in China. SARS‐CoV‐2 enters gastrointestinal epithelial cells, and the faeces of COVID‐19 patients are potentially infectious. Up to the submission date, a novel coronavirus (severe acute respira- published in China were reviewed in this paper with a view to providing reference for prevention and control, as well as diagnosis and treatment of the disease. We included data on COVID-19 patients who have confirmed in case reports and retrospective clinical studies relating to the digestive system that were published in English or Chinese from the end of December 2019 to the end of February 2020. Studies that did not mention digestive symptoms were excluded. Most of the patients were from China, including Wuhan city and areas outside Wuhan. We reviewed eligible studies and extracted data on province or city, study time period, patient age group range, study size, severity of illness, symptom categories and the incidence of symptoms. We also extracted sensitivity of faecal PCR test and time window between faecal and respiratory PCR test, if mentioned. When extracting information from the studies, pairs of researchers conferred to compare findings and reach consensus. Where consensus was not reached, an independent researcher was consulted. We The first autopsy report was of an 85-year-old man with COVID-19. This showed segmental dilatation and stenosis of the small intestine. 21 Substantial evidence from previous studies of SARS supported the gastrointestinal tract tropism of SARS-CoV, which was verified by viral detection in biopsy specimens and stool. 22 Similarly, SARS-CoV-2 was first reported in stool samples of the first case in the United States. 23 drugs. However, the assessment of loss of appetite was difficult because of its subjective nature; diarrhoea was a more objective find- Interestingly, they pointed out that patients with digestive symptoms were inclined to have a worse prognosis than those without digestive symptoms (34.3% discharged vs 60% discharged). We noticed that there were 74 (36%) critically ill patients in this paper and the severe and critical rate was much higher than the large-scale statistics rate in CDC report, which was 18.5%. 20 The results supported our finding that critical patients with high severe rate were more likely to manifest digestive symptoms. We may speculate that the high rate of severe cases indicated a high density and virulence of virus, which damaged the digestive system. The reason for the phenomenon is unclear, and should be verified by a larger clinical data in future research. The proportion of children with vomiting was higher than that of adults. The vast majority of children with gastrointestinal symptoms were noncritically ill, only one of 57 children in the literature we reviewed was critically ill. 7, 11, 17 Gastrointestinal symptoms were also present in critically ill children, 28 Early studies indicated that individuals infected with SARS-CoV-2 might shed and spread the virus while they were pre-symptomatic or asymptomatic. [31] [32] [33] Considering that viral shedding might last for more than a month, 34 we should pay attention to minimise the risk of faecal transmission. The latest treatment protocol in China stipulates that two RT-PCR tests of respiratory specimens carried out more than 24 h apart should be negative before a patient is discharged from the hospital, and that the patient should be isolated for 14 days after discharge. 19 In view of the possibility that stool samples of the discharged patient could still be positive, we suggest that the patient should implement a more thorough protocol for hand hygiene during isolation, thoroughly disinfect toilets and sinks, and try to avoid sharing toilets with family members. Meanwhile, we recommend a test for faecal nucleic acid before a patient is released from isolation. Medical staff who perform gastrointestinal endoscopy for isolated convalescent patients should consider all patients to be confirmed cases and take strict protective measures. Proper disinfection of toilets is crucial in endemic regions; otherwise, sanitation facilities can turn into 'virus traps'. We are grateful to the authors of literature involved in this article for their contribution to the fight against COVID-19. We also want to thank our family for supporting and understanding in this particular period. And best wishes to the health workers around the world who fight in the front lines of this pandemic. Declaration of personal and funding interests: None. Guarantor of the article: Long Rong and Yuan Tian. Long Rong https://orcid.org/0000-0001-5450-0535 A new coronavirus associated with human respiratory disease in China The digestive system is a potential route of 2019-nCov infection: a bioinformatics analysis based on single-cell transcriptomes. BioRxiv 927806. 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