key: cord-0841453-ga1a0wxp
authors: Weng, Jingrong; Li, Yichen; Li, Jie; Shen, Lihan; Zhu, Lixin; Liang, Yufan; Lin, Xutao; Jiao, Na; Cheng, Sijing; Huang, Yibo; Zou, Yifeng; Yan, Guangjun; Zhu, Ruixin; Lan, Ping
title: Gastrointestinal sequelae 90 days after discharge for COVID-19
date: 2021-03-10
journal: Lancet Gastroenterol Hepatol
DOI: 10.1016/s2468-1253(21)00076-5
sha: 008165d484091ead2aa0e0d60a4c3bbb671d9076
doc_id: 841453
cord_uid: ga1a0wxp

nan

Huang and colleagues recently reported that as many as 76% of patients discharged after hospitalisation for COVID-19 had at least one symptom persisting 6 months after disease onset, 1 including fatigue or muscle weakness (63%), sleep difficulties (26%), and anxiety or depression (23%). Additionally, more than 50% of the patients had abnormal chest CT images indicating impaired pulmonary function.

Although SARS-CoV-2 mainly affects the lungs, many other organs are also affected. Enteric symptoms are common in COVID-19, and gastrointestinal symptoms can be the only symptom, or can be present before respiratory symptoms. 2 The cellular receptor for SARS-CoV-2, ACE2, is highly expressed in the gut, and SARS-CoV-2 has been observed in the colonic tissue 3 and faeces 4 of patients with COVID-19. Therefore, we examined the long-term gastrointestinal sequalae of SARS-CoV-2 infection in patients who were admitted for COVID-19 to 12 hospitals in the Hubei and Guangdong provinces, China, between Jan 16 and March 7, 2020, and subsequently discharged (appendix pp 1-3).

117 patients with COVID-19 who had been discharged (53 [45%] of whom were aged 60 years or older) completed one return visit (usually 1 month after discharge) and a telephone interview around 90 days after discharge; their baseline characteristics are shown in the appendix (pp [4] [5] Patients with gastrointestinal sequelae at 90 days were similar in age, sex, body-mass index, and incidence of comorbidities to those without gastrointestinal sequelae, and had similar lengths of hospital stay (appendix pp 4-5). Blood test results on admission showed that white blood cell count, neutrophil count, and procalcitonin concentration were higher in patients with gastrointestinal sequelae at 90 days, although values in both groups were in the normal range (appendix p 6). C-reactive protein concentrations were higher in patients with gastrointestinal sequelae at 90 days than in those without gastrointestinal sequelae. 90 days after discharge, blood tests showed that alanine aminotransferase was higher in patients with gastrointestinal sequelae (appendix p 7). No other differences were noted; procalcitonin and C-reactive protein were not tested at 90 days.

Compared with patients without gastrointestinal sequelae at 90 days, patients with gastrointestinal sequelae more frequently presented with dyspnoea (23% vs 12%) and myalgia (17% vs 11%) on admission, although these differences were not significant. Patients with gastrointestinal sequelae were less frequently severely ill than were those without gastrointestinal sequelae (17% vs 37%; p=0·021), although after adjustment for confounding factors, this difference was not significant (p=0·051). Patients with gastrointestinal sequelae at 90 days exhibited a lower frequency of supplemental oxygen therapy (79% vs 94%; p=0·016), and a trend of lower frequency of intensive care unit admission during hospitalisation (appendix p 4). Patients with gastrointestinal sequelae at 90 days were treated more often with proton pump inhibitors (PPIs) and corticosteroids and were less frequently treated with enteral nutrition than were patients without such sequelae (appendix pp 4-5).

Gastrointestinal sequelae including loss of appetite, nausea, acid reflux, and diarrhoea are common in patients 3 months discharge from hospitalisation due to COVID-19. 

6-month consequences of COVID-19 in patients discharged from hospital: a cohort study

Manifestations and prognosis of gastrointestinal and liver involvement in patients with COVID-19: a systematic review and meta-analysis

Evidence for gastrointestinal infection of SARS-CoV-2

Prolonged presence of SARS-CoV-2 viral RNA in faecal samples

That severe illness during hospitalisation was not associated with post-discharge gastrointestinal sequelae was unexpected. Decreased blood oxygen saturation, a symptom closely related to severe pneumonia, was found to be associated with gastrointestinal sequelae. This association might involve hypoxia mediating the multi-organ injuries frequently observed with COVID-19. 5 It is important to note that hypoxia not only occurs in patients with COVID-19 with dyspnoea, but also in many patients without dyspnoea. 6 Asymptomatic hypoxaemia could explain the apparent discrepancy in our observation that decreased blood oxygen saturation, but not severe illness, is associated with gastrointestinal sequelae.PPIs were often used for aspiration prophylaxis in patients admitted for suspected COVID-19 receiving anaesthesia, parenteral nutrition, or other acid-related treatments. Acid rebound is a known consequence of deprescribing PPIs, 7 so it might be expected that PPI treatment during hospitalisation was associated with acid reflux after discharge.Nutritional interventions during hospitalisation appeared to be associated with a lower incidence of subsequent gastrointestinal sequelae. As many as 78% of patients hospitalised for COVID-19 report lack of appetite. 8 In addition to lack of appetite, other common gastrointestinal symptoms such as nausea, vomiting, and diarrhoea during hospitalisation 5,8 can lead to malnutrition, which has been linked to increased mortality in patients with COVID-19. 9,10 Nutritional support could be critical in sustaining patients' lives. Reduced gastrointestinal sequelae is probably a part of the overall benefit from nutritional support.Our study has several limitations. Being retrospective, data were missing for several relevant blood biochemical tests, such as blood markers for inflammation and serum titres of SARS-CoV-2. Another important