Low-Severity COVID-19 May Be Associated With Gastrointestinal Symptoms

A subset of patients with coronavirus disease 2019 (COVID-19) may present with low disease severity marked only by digestive symptoms.

A subset of patients with coronavirus disease 2019 (COVID-19) may present with low disease severity marked only by digestive symptoms, and patients with possible COVID-19 contact who present with new-onset acute digestive symptoms should be tested, according to research published in the American Journal of Gastroenterology.

While respiratory symptoms are most common signs of COVID-19, investigators believe that there may be a large cohort of patients experiencing low-severity illness with mainly digestive symptoms, such as diarrhea, who unknowingly contribute to the spread of the virus. As such, researchers set out to better understand both the prevalence and clinical characteristics of these patients.

A retrospective study was conducted in Wuhan, China, at a hospital designated for the management of patients with COVID-19. Investigators reviewed clinical records from 850 consecutively hospitalized patients who were admitted between February 13 and February 29, 2020, who had laboratory-confirmed COVID-19. Patients were included if they met criteria for mild disease severity, and were then evaluated to identify digestive symptoms including diarrhea, nausea, and vomiting. Patients were then matched with another patient with confirmed COVID-19 who experienced only respiratory symptoms (cough, expectoration, chest discomfort, sore throat, and shortness of breath). Patients were subdivided into 1 of 3 groups: digestive symptoms only, digestive plus respiratory symptoms, and respiratory symptoms only.

The final study cohort included 206 patients, all of whom were residents of Wuhan (mean age 62.5 years; 56.8% older than 60 years; 55.8% women). A total of 10.2% of patients were aware of clear, direct exposure to individuals with known or highly suspected COVID-19 infection.

Clinical features were similar across the 3 groups, although those with digestive plus respiratory symptoms were more likely to report shortness of breath and constitutional symptoms compared with those in the respiratory symptoms only group.

In total, 67 patients reported diarrhea; 19.4% of those experienced diarrhea as their first symptom, appearing before the onset of respiratory symptoms. Women were more likely to report diarrhea than men (65.7% vs 51.1%), the symptoms of which lasted from 1 to 14 days, overall (mean duration 5.4±3.1 days; mean daily frequency of bowel movements 4.3±2.2 per day).

Of patients with digestive symptoms, 62.4% had an accompanying fever. Among patients with specifically diarrhea, 73.1% experienced concurrent fever. Patients with both upper and lower digestive symptoms were more likely to experience a fever compared with those who had either upper or lower symptoms alone (94.4% vs 57.1% vs 63.3%, respectively).

Results showed that the mean interval between symptom onset and viral clearance across the study cohort was 38.1±8.7 days, with an average hospital stay of 23.7 days. Those with digestive symptoms experienced a longer period between initial symptom onset and hospital admission compared with patients with respiratory symptoms only. Patients with only digestive symptoms and those with digestive plus respiratory symptoms also experienced a significantly longer time between symptom onset and viral clearance compared with the respiratory-only group (40.9 days vs 42.0 days vs 33.5 days, respectively).

All patients received fecal leukocyte and occult blood testing, and 1.9% of patients demonstrated abnormal results consistent with viral diarrhea. In a subgroup of 22 patients with COVID-19, stool RNA was tested using real time reverse-transcriptase polymerase-chain-reaction. Of these, 54.5% of patients tested positive for viral RNA in their stool. These patients had a significantly longer time to viral clearance compared with the 10 patients who tested negative.

Study limitations included the limited sample size, an inability to perform correlations between fecal virus RNA and digestive symptom severity, and the limitations inherent in retrospective studies. Investigators also cautioned that this study “does not directly confirm that viral particles in stool are infections and capable of disease transmission,” but rather provides further elucidation of how COVID-19 may present.

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“These data emphasize that patients with new-onset diarrhea after a possible COVID-19 contact should be suspected for the illness, even in the absence of cough, shortness of breath, sore throat, or even fever,” the researchers concluded. “These patients should self-quarantine and seek medical care if not already under evaluation.”


Han C, Duan C, Zhang S, et al. Digestive symptoms in COVID-19 patients with mild disease severity: Clinical presentation, stool viral RNA testing, and outcomes [published online March 30, 2020]. Am J Gastroenterol. In press.