Over the course of the past few months, there are several things we’ve come to learn about COVID-19. It has generally been classified as a respiratory illness, with patients presenting with shortness of breath and dry cough. But, a new study suggests there are other, very different presenting symptoms that we should also be watching for. What’s more, patients who first experience these non-respiratory symptoms may have a longer time between symptom onset and hospitalization. According to a cross-sectional, multicenter study done by researchers from the Wuhan Medical Treatment Expert Group for COVID-19, approximately 50% of patients with COVID-19 may initially present with a gastrointestinal symptom as their chief complaint—a prominent red flag that clinicians should be monitoring for, in addition to respiratory symptoms, for identifying potential cases of COVID-19. They published their results in The American Journal of Gastroenterology. Researchers—led by Lei Pan, MD, PhD, Department of Respiratory and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China—studied the medical records of 204 patients (mean age: 52.9 years; 107 men) with confirmed COVID-19. All patients presented to and were hospitalized at three heavily affected hospitals during the initial outbreak of COVID-19 in Hubei province—where 83% of the cases in China occurred. “Our initial purpose in this study was to investigate the prevalence and characteristics or extra-pulmonary digestive symptoms that might otherwise be under-recognized, thus helping to bring attention to these symptoms, to facilitate earlier recognition of COVID-19, and thus to offer earlier treatment before mild disease progresses to severe illness,” wrote Dr. Pan and fellow researchers. For all patients, the average time from symptom onset to hospital admission was 8.1 days. Those who manifested gastrointestinal symptoms, however, had a significantly longer time from symptom onset to hospitalization than those without symptoms (9.0 vs 7.3 days, respectively; P = 0.013). According to Dr. Pan and colleagues, some patients with gastrointestinal symptoms may have delayed seeking care because they did not suspect COVID-19 due to the absence of respiratory symptoms (like coughing and shortness of breath). Six patients with COVID-19 presented with digestive symptoms but no respiratory symptoms. No studies have yet been done to assess the effects of delayed hospitalization in patients with COVID-19 and how it may impact the severity of infection or prognosis. Among patients presenting with gastrointestinal illness, symptoms included anorexia (78.6%), diarrhea (34.0%), vomiting (3.9%), and abdominal pain (2.0%). As COVID-19 disease became more severe, so did digestive symptoms, researchers observed. Importantly, however, there were no significant differences between patients with and patients without gastrointestinal symptoms in the number discharged from the hospital (81.55% vs 83.16%, respectively; P = 0.762) or in mortality (18.45% vs 16.83%, P = 0.762). When they measured liver function, Dr. Pan et al also found that significantly more patients with digestive symptoms had elevated levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST), which led them to conclude that these patients were also more likely to suffer liver injury despite having mean ALT and AST levels within the normal range. No patients, however, demonstrated liver damage. No significant differences were seen in complete blood count, electrolytes, and kidney function among patients with and without digestive symptoms. Prothrombin time prolongation, however, was more significant in patients with digestive symptoms (13.1 vs 12.5 s). Dr. Pan and colleagues stressed the importance of clinicians being vigilant for gastrointestinal symptoms during the pandemic: “Our results indicate that nearly one-half of COVID-19 patients admitted to the hospital reported digestive symptoms, most commonly anorexia and diarrhea. This is important because if clinicians solely monitor for respiratory symptoms to establish case definitions for COVID-19, they may miss cases initially presenting with extra-pulmonary symptoms, or the disease may not be diagnosed later until respiratory symptoms emerge. This theory is supported by our finding that patients with digestive symptoms had a significantly longer time from onset to admission than those without digestive symptoms, possibly because they did not initially exhibit typical respiratory symptoms and thus did not receive timely diagnoses and treatment for COVID-19.” Source
