Gastrointestinal symptoms post COVID-19: New MoHFW updates

M3 India Newsdesk Mar 01, 2022

In COVID-19, most symptoms pertaining to the gastrointestinal (GI) tract are mild and self-limiting. In some patients, GI symptoms may appear before the onset of fever and other respiratory symptoms. This article focuses on the guidelines on post-COVID gastrointestinal sequelae and its management.

Key takeaways

COVID-19 patients may have the possibility of faecal-oral transmission.
Besides the common respiratory symptoms, some COVID-19 patients experience gastrointestinal symptoms such as ageusia, lack of appetite, nausea, vomiting, dyspepsia, diarrhoea, abdominal pain and hepatitis.
Most symptoms pertaining to the GI tract are mild and self-limiting.
Management of post-COVID gastrointestinal syndrome depends on the severity, relation with COVID illness, intake of drugs and presence of any alarming feature.

GI symptoms post-COVID-19

Although it is spread by air, SARS-CoV-2 has been identified from faeces samples of COVID-19 patients, indicating the potential of faecal-oral transmission. Apart from the more frequent respiratory symptoms, some COVID-19 patients have GI symptoms such as:

Ageusia
Loss of appetite
Nausea
Vomiting
Dyspepsia
Diarrhoea
Stomach pain
Hepatitis

The majority of gastrointestinal symptoms are minor and self-limiting. The presence of angiotensin-converting enzyme 2 (ACE 2) receptors in the GI tract epithelium enhances viral entrance and multiplication in the GI system, resulting in GI symptoms.

The symptoms may manifest before the development of fever and respiratory symptoms in some people. Numerous investigations on the incidence of GI and liver symptoms during active COVID-19 have been reported. However, the frequency of post-COVID GI and liver manifestations is unknown.

Factors that increase the likelihood of having post-COVID GI and liver symptoms

Severe illness
Advanced age
Intensive care admission
Respiratory tract infection
Gut dysbiosis as a result of antiviral and antibiotic usage while hospitalised
Liver damage as a result of COVID-19, medicines, or alternative treatment use
Polypharmacy

Prevalence of GI and liver manifestations during COVID-19

Diarrhoea is observed in 8% of the patients. It can be a presenting symptom, commonly in hospitalised patients. It is essential to rule out drugs or infectious causes. Nausea/vomiting is seen in 8% and abdominal pain in 4% of the patients. Polypharmacy should be avoided in such cases.

Patients with severe liver disease may have raised SGOT/SGPT levels noticed in 15% of the affected. Exclude drug-induced liver injury and compare the baseline values if available.

Classification of GI symptoms

COVID-19 induced new onset GI symptoms
Persistence or aggravation of preexisting GI Symptoms
Drugs induced GI symptoms

Difference between COVID-19 induced and drug-induced liver injury

COVID-19 induced liver injury will be having less than 5 times elevation in enzymes upper normal level with AST>ALT. Abnormal LFT may be present at the initial presentation.

The commonly used drugs in COVID can have GI side effects such as:

Azithromycin
Hydroxychloroquine
Lopinavir
Remdesivir
Favipiravir
Tocilizumab

Management of post-COVID GI symptoms

Dyspepsia

Assess severity, relationship to COVID illness, drug intake and alarm features.
If Alarm features +nt, then consider UGIE.
If H. pylori ag or breath test positive or negative, then start Anti H. pylori treatment.
If Drug-related symptoms are suspected, then stop the drug and consider antacids, PPI.

Diarrhoea

Assess severity, hydration, haemodynamic status, relationship to COVID-19 illness, drug intake and pre-existing diarrhoea.
If drug-induced symptoms are suspected, then stop the agent, start ORS to prevent dehydration.
If there are COVID related symptoms, consider reassurance and diet modification.
In cases of pre-existing IBD or IBS, start the treatment as per guidelines.
If antibiotic-related symptoms are suspected, then rule out Cl. Difficile infection, consider probiotics.

Abdominal pain

Assess severity, hemodynamic status, relationship to COVID-19 illness, drug intake and pre-existing pain.
If drug-induced symptoms are suspected, then stop the agent, and start antacid.
In case of COVID related pancreatitis/cholecystitis, evaluate Sr amylase, lipase, LFT, USG, CECT as per guidelines.

People who have persistent symptoms after recovering from COVID-19 are becoming more widely recognised as a rising group in need of care. Many people have been reported to be suffering from short to long-term effects of the illness. Some people continue to have side effects or symptoms that may or may not be related to COVID-19. It is essential to assess severity, hydration, haemodynamic status, relationship to COVID-19 illness, drug intake and pre-existing abdominal symptoms.

The guidelines for post COVID sequel by MoHFW will be discussed in this series pertaining to different organ systems- Cardiovascular, Gastrointestinal, Nephrological, Neurological, and Respiratory. Click here to read the previous part- Post-COVID cardiovascular sequelae: Latest MoHFW updates

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author is a practising super specialist from New Delhi.

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