Gastrointestinal manifestations among hospitalized coronavirus disease 2019 patients in Vadodara, Gujarat, India

Jugal Hiren Bhatt; Rikin Raj; Kedar Gautambhai Mehta; Meenakshi Shah; Bhoomi Bavadiya

doi:10.4103/ajim.ajim_86_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 10 | Issue : 3 | Page : 190-194

Gastrointestinal manifestations among hospitalized coronavirus disease 2019 patients in Vadodara, Gujarat, India

Jugal Hiren Bhatt¹, Rikin Raj¹, Kedar Gautambhai Mehta², Meenakshi Shah¹, Bhoomi Bavadiya¹
¹ Department of Medicine, GMERS Medical College and Hospital, Gotri, Vadodara, Gujarat, India
² Department of Community Medicine, GMERS Medical College and Hospital, Gotri, Vadodara, Gujarat, India

Date of Submission	06-Aug-2021
Date of Decision	23-Aug-2021
Date of Acceptance	18-Dec-2021
Date of Web Publication	12-Jul-2022

Correspondence Address:
Dr. Jugal Hiren Bhatt
GMERS General Hospital, GMERS Medical College, Gotri, Vadodara, Gujarat
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajim.ajim_86_21

Abstract

Background: SARS-CoV-2 is an RNA virus that causes coronavirus disease 2019 (COVID-19) which was initially detected in the province of Wuhan, China, and World Health Organization ultimately determined the outbreak to be labeled as a “pandemic” in March 2020. It lead to various clinical manifestations among COVID-19 patients and so, this study was conducted with the objective to study gastrointestinal (GI) symptoms among hospitalized COVID-19 patients. Materials and Methods: This retrospective study was conducted at a tertiary-level hospital in Vadodara. Hospital records of hospitalized COVID-19 patients from September to November 2020 were reviewed and included in the study. Clinical profiles including GI symptoms, respiratory symptoms, comorbidities, and length of hospital stay were extracted from the records. Results: A total record of 439 COVID-19 positive patients admitted during the study duration were reviewed. Out of 439 patients, 264 were males and 175 were females. Almost one-fifth (21.2%) of total patients had GI manifestations. The most common GI symptom was anorexia, followed by diarrhea, vomiting, and abdominal pain. Other less frequent GI symptoms include nausea and blood in stools. Around 30% of patients showing GI symptoms had comorbidities of diabetes mellitus or hypertension or both. The length of hospital stay was higher among patients with one or more comorbidities as compared to patients without any comorbidities. Conclusions: The proportion of having GI manifestations in hospitalized COVID-19 patients was 21.2%. The common GI symptoms were diarrhea, vomiting, anorexia, nausea, abdominal pain, and blood in stools. Patients with comorbidities had an elongated length of hospital stay.

Keywords: Diabetes mellitus, gastrointestinal symptoms, heart disease, hypertension, India, SARS CoV-2

How to cite this article:
Bhatt JH, Raj R, Mehta KG, Shah M, Bavadiya B. Gastrointestinal manifestations among hospitalized coronavirus disease 2019 patients in Vadodara, Gujarat, India. APIK J Int Med 2022;10:190-4

How to cite this URL:
Bhatt JH, Raj R, Mehta KG, Shah M, Bavadiya B. Gastrointestinal manifestations among hospitalized coronavirus disease 2019 patients in Vadodara, Gujarat, India. APIK J Int Med [serial online] 2022 [cited 2022 Aug 11];10:190-4. Available from: https://www.ajim.in/text.asp?2022/10/3/190/350752

Introduction

SARS–CoV-2, also called 2019 nCoV, is an RNA virus that arose in the region of Wuhan (China), in December 2019.^[1] As of August 2020, there were 20 million confirmed cases worldwide and around 740,000 global deaths.^[2]

Even asymptomatic coronavirus disease 2019 (COVID-19) positive individuals can transmit the disease. This way of transmission is most dangerous and is the main reason with regards to why this virus continues to transmit and infect the global population in an accelerated and uncontrolled manner.^[3]

There were cases of asymptomatic COVID-19-positive patients who managed to eliminate the virus without developing any kind of COVID-19 disease symptoms. This infers that immunity plays a major role in developing COVID-19. Therefore, patients may show the different level (high or low grade) of symptoms of COVID-19 disease, and the duration of treatment (long or short) may vary based on the patient's immunity. COVID-19 not only influences respiratory and cardiovascular systems but also the central nervous system and gastrointestinal (GI) system.^[4] This Coronavirus binds to a specific receptor (ACE2) that is mainly present in the alveoli of lungs but is also expressed in the GI mucosa. Hence, it can be the reason behind the COVID-19 positive patients manifesting GI symptoms.

GI symptoms are not uncommon in patients with COVID-19 infection and with the progression of time as the number of cases increased rapidly, and with more number of cases GI symptoms were also reported quite frequently. Hence, it can be deciphered that many COVID-19 positive patients may showcase GI manifestations clinically. Fecal discharge of virus and its spotting not only proves the GI tract (GIT) involvement by the virus but also draws attention to a capable source of spread through fecal-oral transmission.^[5] It is still unclear whether stool PCR positivity can be equated to the presence of an infectious virus. Till date, there have been no reports of fecal-oral transmission of the SARS-CoV-2 virus.^[6]

The characteristics of GI symptoms in COVID-19 are more insidious than the respiratory symptoms, making them easy to overlook. Hence, the present study was carried out to know the proportion of GI symptoms in COVID-19-infected patients admitted at GMERS General Hospital, Gotri, Vadodara, Gujarat, India.

Materials and Methods

This retrospective study was conducted using records of COVID-19 patients admitted at GMERS General Hospital, Gotri, Vadodara, a COVID-19 dedicated tertiary level hospital. We have included the records of all COVID-19 patients hospitalized from September to November 2020.

Demographic variables such as age, sex, education, religion, and area of residence were extracted from records. Clinical variables such as respiratory symptoms, GI symptoms, existing comorbidities (diabetes mellitus [DM], hypertension [HTN], heart disease [HD], and lung disease), and duration of hospital stay were also noted. Records of patients below 18 years of age were excluded from the study.

Statistical analysis

Data were entered into a Microsoft Excel worksheet. Descriptive statistics have been presented as frequencies (percentages). Association between “comorbidities and GI symptoms” and “length of hospital stay” was assessed.

Ethical consideration

Ethics Committee approval was obtained before conducting this study. Data confidentiality was maintained during the process of data collection and data entry.

Results

A total of 439 records were reviewed during the whole study duration. The gender-wise distribution shows 264 (60%) were males and 175 (40%) were female. A majority (98.7%) followed Hindu religion, 72.4% were literate and 89% of patients were from urban areas [Table 1].

Table 1: Sociodemographic profile of admitted coronavirus disease-2019 positive patients (n=439)

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Out of 439 COVID-19 patients, 93 (21.2%) patients showed GI manifestation as the first symptom, 312 patients had respiratory symptoms and 34 patients were asymptomatic positive[Table 2].

Table 2: Type of symptom wise distribution of coronavirus disease-2019 positive patients (n=439)

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The common GI symptoms among patients were anorexia (9.3%), diarrhea (4.5%), vomiting (5.0%), nausea (1.6%), abdominal pain (2.5%) and blood in stools (1.1%) [Table 3].

Table 3: Distribution of all gastrointestinal symptoms in hospitalized coronavirus disease-2019 patients (n=439)*

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As shown in [Table 4], 30% of COVID-19 patients presented anorexia as the first symptom had comorbidities of DM and HTN while, 30% and 25% of the patients presenting diarrhea as first symptoms had comorbidities of DM and HTN, respectively. Other GI symptoms did not show any significant co-relation with comorbidities.

Table 4: Distribution of gastrointestinal symptoms among patients with comorbidities*

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[Table 5] depicts that 13% and 20% of COVID-19 patients with 0–5 days length of hospital stay, had DM and HTN as comorbidities respectively, while around 30% and 33% of COVID-19 patients with 6–15 days length of hospital stay had DM and HTN, respectively. There were a total of five COVID-19 patients with >15 days length of hospital stay. Among them 60% had DM and chronic obstructive pulmonary disease as comorbidity, 40% had HTN and 20% had HD as comorbidities.

Table 5: Distribution of comorbidities with the length of hospital stay among coronavirus disease-2019 patients*

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Discussion

COVID-19 is an infectious disease that causes infection in nose, sinuses, or upper throat. The virus enters the body through the nose, eyes, or mouth. The spike protein present on the virus binds specifically to ACE2 receptors present on the type 2 pneumocytes in the alveoli of the lungs. These ACE2 receptors permit entry of the virus into it (type 2 pneumocyte) due to host cell protease that cleaves the spike protein and the virus enters the cell either by direct membrane fusion or by endocytosis. The transcribed mRNA is translated to produce viral proteins that induce cytokine release which results in the activation of the innate immune response.^[4] These ACE2 receptors are also expressed by GI mucosa and the virus may bind to them, which may have manifested GI symptoms. A total of 439 patient records were analyzed, exhibiting a ratio of 60:40 in the cases of males and females respectively. This manifests the fact that more males were affected by SARS CoV-2 than females in the 1^st wave of COVID-19 in Vadodara City. The increased ratio towards males may be due to their lifestyles which may pertain to habits such as more abundant drinking and smoking as compared to females or increased expression of ACE2 receptors in males and also may be due to sex hormones.^[7] Our study found that a majority of COVID-19 positive patients were Hindu (98.7%), probably this may be related to demographics of patients visiting our hospital. Majority of patients (72.4%) were literate and majority (80%) were living in urban areas. This may be because our hospital is present in an urban area and usually urban areas are more densely populated in contrast to rural areas.

In our study, the proportion of GI symptoms among hospitalized COVID-19 patients was almost one in five patients (21.2%). A similar finding was observed in a study conducted by Ramachandran et al. with the proportion of GI symptoms being 20.6% among COVID-19 patients.^[8] Contrary to our study, a study done by Yang and Tu in China, reported a high proportion of GI symptoms as 50% in COVID-19 patients.^[9] Anorexia is a nonspecific GI symptom that may be presented in any infection or inflammatory process having a febrile response. The main reason for such high proportions of GI symptoms could be because of very high frequency of anorexia (40%) presented by China's Population. This may be due to their different food habits and geographical variation which needs to be further investigated. A study conducted by Trottein and Sokol hypothesized that SARS-CoV-2 associated GI symptoms are likely due to dysregulation of ACE-2 (SARS-CoV-2 host target) expression and activity in the GIT. ACE-2 is an essential regulator of intestinal homeostasis and is involved in the absorption of nutrients, especially aminoacids. Some researchers have mentioned that individuals with SARS-CoV-2 associated GI symptoms, also have enrichment of opportunist pathogenic bacteria in the GIT.^[10]

Amongst GI manifestations, anorexia was the most common symptom observed in COVID-19 positive patients, followed by vomiting, diarrhea, abdominal pain, nausea, and blood in stools. A similar discovery was observed in a study done by Yang and Tu while diarrhea was the most common GI symptom in a study done by Ramachandran et al.^[8],[9] Similar study in Thailand at Association of South East Asian Nations reported that 30% of COVID-19 patients had GI symptoms and anorexia was the most common symptom observed followed by diarrhea.^[11] Another study by Meredith Goodwin also found anorexia (39.9–50.2%) being the most common GI manifestation followed by diarrhea (19.4%) and vomiting (3.6%–15.9%).^[12] This reveals that clinical GI symptoms such as anorexia, vomiting, and diarrhea are the most common among all kinds of manifestations, whereas other GI symptoms like abdominal pain, blood in stool and nausea may appear but their incidence is relatively rare.

In our study, some rare GI symptoms presented by the COVID-19 infected patients involved abdominal pain and blood in stools. Since GI mucosa also expresses ACE2 receptors, the entry of virus into GI mucosal cells is mediated by the binding of viral spike protein with these ACE2 receptors. Once the virus enters into the cell, it synthesizes more viral RNA molecules and these RNA molecules are translated to produce more viral proteins. The newly assembled viruses travel in a special compartment to leave the cell. When, they leave the infected cells, it triggers the release of cytokines, that play a major role in inflammatory response resulting in GI symptoms including abdominal pain.^[13] In our study, five patients presented with blood in stools of whom, two patients had a prior history of hemorrhoids with constipation. Hence, one of the common causes for blood in stools may be due to bleeding hemorrhoids which may have aggravated due to constipation.^[14] The cause of blood in stool in the remaining three patients remains to be unclear since it was a retrospective study so we could not enquire detailed history. However, it may be possible due to prior history of some GIT-related pathology like peptic ulcer, inflammatory bowel disease or oesophageal varices which leads to recurrence of blood in stools aggravated by COVID-19 infection. Another study conducted by Martin et al. had also reported that the most common causes for upper and lower GI bleeding among COVID-19 patients were gastric or duodenal ulcerations and rectal ulcerations respectively.^[15]

Around 30% of the COVID-19 patients showing diarrhea as GI symptoms were diabetic or hypertensive. Similarly, about 30% of the COVID-19 patients showing anorexia as a GI symptom were diabetic or hypertensive. According to American Diabetes Association, Diabetic patients with COVID-19 infection may present GI symptoms such as anorexia, vomiting, and diarrhea.^[16] This indicates that GI symptoms were more frequent among patients with DM or HTN. Other comorbidities do not show any notable correlation with the GI symptoms and are consequently not mentioned in this discussion.

In our study, it was found that COVID-19 patients with one or more comorbidities had a longer duration of hospital stay for treatment as compared to those without comorbidities. In Table 5, we can see that 74.09% (226/305) of patients in the category of 0–5 days had no comorbidities however as the days of hospital stay increased the patients being without any comorbidities simultaneously decreased. 52.71% of patients were without any comorbidities in the category of 6–15 days of hospital stay. Whereas, only 20% of patients in the category of >16 days of hospital stay were free from any comorbidities. A study conducted in Dubai revealed that COVID-19 infected patients with DM as the comorbidities and others like HTN, ischemic HD had to be admitted to intensive care and had a longer hospital stay.^[17] Another study completed in New York divulged that the most common comorbidity in their study that was associated with COVID-19 patients was HTN, followed by, DM. It revealed that patients with these comorbidities had to stay longer in the hospitals for treatment.^[18]

Conclusions

Every one in five COVID-19 positive hospitalized patients showed GI symptoms according to our study. The GI symptoms observed among COVID-19 patients were anorexia, vomiting, diarrhea, nausea, abdominal pain, and blood in stools. Among these GI symptoms, the most common was anorexia (9.3%) followed by vomiting (5.0%), diarrhea (4.5%), and abdominal pain (2.5%). Nausea and blood in stools were less frequent. Around 30% of patients who manifested symptoms of diarrhea and anorexia were having comorbidities DM and HTN. COVID-19-infected patients with one or more comorbidities had a longer duration of hospital stay as compared to those without comorbidities.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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