key: cord-1045880-mh3h1c3g
authors: Teima, Ahmed Abozaid Ahmed; Amer, Amany Abas; Mohammed, Lamiaa I.; Kasemy, Zeinab A.; Aloshari, Samar HA.; Ahmed, Mohamed Meligy; Abuamer, Ahmed; Shabaan, Ahmed; Elzohry, Hassan Ahmed; Abdelwahab, Sayed F.; Abdallah, Heba Mohamed; Abdelmageed, Sabry Moawad; Sakr, Mohamed A.; Abdel-Samiee, Mohamed
title: A cross-sectional study of gastrointestinal manifestations in COVID-19 Egyptian patients
date: 2022-01-11
journal: Ann Med Surg (Lond)
DOI: 10.1016/j.amsu.2021.103234
sha: c4283fe7b24e950bffe2bc6ddeab662f61dd70ab
doc_id: 1045880
cord_uid: mh3h1c3g

BACKGROUND: The latest novel corona virus disease (COVID-19) pandemic shows a significant health concern. We aimed to study the prevalence of gastrointestinal symptoms among COVID-19 Egyptian patients. METHODS: A cross-sectional study was carried out on 860 patients with COVID-19 infection classified according to Ministry of Health Program (MOHP) into three groups (280 patients with mild disease, 258 patients with moderate disease and 322 patients with severe disease). All patients were subjected to medical history, clinical examination, laboratory investigations, high-resolution computed tomography chest (HRCT chest) and other investigations when needed in some patients e.g., upper gastro-intestinal (GI) endoscopy, abdomino-pelvic ultrasound and ECHO. RESULTS: Gastro-intestinal symptoms were present in 27.2% of the studied patients. The most common reported GIT symptoms were vomiting, diarrhea, abdominal/gastric pain, followed by nausea.GIT symptoms presence was significantly higher in severe cases in comparison to mild or moderate cases. C-reactive protein (CRP), serum ferritin, Aspartate aminotransferase (AST), bilirubin and creatinine were significantly associated with the presence of GI symptoms. CONCLUSIONS: GI symptoms are prevalent among COVID-19 patients, the most common which were vomiting and diarrhea and were associated with COVID-19 severity.

pandemic with incubation periods of 6.4 days (mean average), from 2.1 and 11.1 27 days, was caused by the SARS-CoV-2 disease . 2 The primary route of 28 transmission of COVID-19 is by aerosolized droplets that can be transmitted fecally 29 orally. 3 SARS-CoV-2 has been shown to last for up to nine days on inanimate 30 surfaces. It can also be infective with an infected individual without near contact. 4

The asymptomatic individual can transmit COVID-19 infections and can be detected 32 even after the negative viral RNA in stools. Before signing the index case, more than 33 40% of COVID-19 infections can be transmitted. 5

A wide range of clinical events and x-rays make the identifying of COVID-19 35 and other more common respiratory infections hard for clinicians. The usual 36 symptoms are fever, cough, breathing difficulties, and myalgia and tiredness. 37 However, sudden anosmia and a loss of taste were also recorded atypically isolated. 6 38 Interestingly, the gastrointestinal (GI) presentation of diarrhoea, vomiting and 39 abdominal pain also occurred in Studies have shown that GI 40 epithelial cells are expressed in the COVID-19 receptor, i.e., an angiotensin convertor 41 enzyme 2 (ACE2). 8 These data also indicate the ability of COVID-19 to be proactive receptor. 9 ACE2 is considered to be wealthy in human lung epithelial cells and GI 47 tracts that may promote confirmation of the potential route to infection by This is highly expressed in gastric, duodenal and rectal cells, which promote the 49 introduction of COVID-19 into the host cells. 10

The Cohort Study showed that the expression of ACE2 in cholangiocytes 51 (59.7 percent of cells in cholangiocytes) was considerably increased relative to the 52 liver cells (2.6 percent of cells). However, there was not any viral involvement in liver In a recent study analyzing COVID-19 patients, the length of positive stool 57 varying from one to 12 days was found to be positive in 53.4% of the patients for 58 Interestingly, even after an adverse polymearase chain reaction (PCR) 59 examination in their respiratory specimen, 23.3% of the patients were persistently 60 positive for COVID-19 infection in stool. Eight children persistently tested positively 61 in rectal swabs even after neopharyngeal clearance of the virus in another study, 62 which followed 10 pediatric patients and analyzed their rectal and rectal 63 swabs. 13 There was also evidence of fecal-oral transmission in 

Age significantly differed as regard COVID-19 severity where old age patients 132 had a severe disease. As regard presentation symptoms, cough, dyspnea, fatigue /bone 133 ache and chest pain were significantly higher in severe cases while fever and anosmia 134 were significantly higher in mild and moderate cases. Presence of GIT symptoms was 135 significantly higher in severe cases (34.2%) in comparison to 21.4% in mild COVID-136 19 patients and moderate cases (24.8%). Diarrhea and melena were significantly high 137 in severe COVID-19 patients (Table 2) . 138 Severe COVID-19 patients showed significantly higher laboratory 139 investigations and lower Oxygen saturation in comparison to mild and moderate 140 COVID-19 patients (P<0.001) ( Table 3) .

Regarding GIT symptoms presence and clinical data of studied patients, there 142 was no significant difference in age, and gender. However, there was a significant 143 difference in COVID-19 Reporting and Data System (CO-RAD) grading (36.8% with 144 GIT symptoms had grade V CO-RAD) ( Table 4) . 145 CRP, D-Dimer, LDH, serum ferritin, ALT, AST, and creatinine were 146 significantly higher in patients with GIT symptoms than patients without GI 147 symptoms. Oxygen was significantly lower in patients with GI symptoms (P<0.05) 148 ( Table 5) . In this study, the most reported symptom was cough (33%) followed by shortness of in COVID-19 patients with GI symptoms compared to those without. These findings 182 were backed up by evidence from Ghoshalet al. 42 , who found that patients with GI 183 symptoms were more likely to have serious, critical illness, irregular laboratory 184 findings, and a fatal outcome than those who did not have GI symptoms.

The findings of this study revealed that the COVID-19 severity of symptoms 186 was mild (32.6 percent), with patients having some of the signs and symptoms of 187 COVID-19 (e.g., fever, cough, sore throat, malaise, headache, muscle pain, nausea, 

Hyperferritinemia is linked to admission to the intensive care unit and a high 218 mortality rate, and it can be used to identify high-risk patients and direct clinical 219 action to reduce inflammation.CRP and D-dimer were also discovered to be two 220 additional independent risk factors for disease severity in one study 47 , and serum 221 ferritin levels were found to be positively correlated with CRP levels.

According to a recent study, COVID-19 cases were classified into two categories 223 (severe and mild) based on the need for mechanical ventilation, and reported that, In this study, there was no significant difference for age or gender regarding GIT 239 symptoms presence. This result agrees with one report examining the influence of 240 age, gender, racial and co-morbidities existence on COVID-19 where they found that 241 these factors (male gender, age and other chronic co-morbid illnesses)are associated 242 with increased morbidity, severity risk and decreased rate of COVID-19 patients' 243 survival but with no significant relationship with clinical presentation at admission. 50

There was no significant difference in CO-RAD grading in the studied patients 245 regarding GIT symptoms presence. A recent report showed that CO-RAD is a J o u r n a l P r e -p r o o f 

Evaluation of the 517 Usefulness of CO-RADS for Chest CT in Patients Suspected of Having 518 COVID-19.Diagnostics (Basel)

J o u r n a l P r e -p r o o f