Gastrointestinal and liver involvement in patients with COVID-19

Abstract

We read with interest the systematic review and meta-analysis by Ren Mao and colleagues1Mao R Qiu Y He JS et al.Manifestations and prognosis of gastrointestinal and liver involvement in patients with COVID-19: a systematic review and meta-analysis.Lancet Gastroenterol Hepatol. 2020; 5: 667-678Summary Full Text Full Text PDF PubMed Scopus (536) Google Scholar that aimed to quantify the effect of COVID-19 on the digestive system. The study concluded that digestive symptoms and liver injury are common among patients with COVID-19 and that patients with severe disease have a higher risk of developing gastrointestinal symptoms and liver injury than do patients with non-severe COVID-19. However, we would like to highlight a couple of potential limitations to the method. First, although the authors used a rigorous and comprehensive search strategy and selection process for identification of relevant articles, they do not appear to have assessed whether some patients had been included in more than one study. This finding is a common pitfall during the current global health emergency, possibly because of the rush to communicate clinical findings. The possibility of reporting the same patients in multiple reports has raised concerns,2Bauchner H Golub RM Zylke J Editorial concern—possible reporting of the same patients with COVID-19 in different reports.JAMA. 2020; 3231256Crossref PubMed Scopus (99) Google Scholar because it could compromise the internal validity of meta-analyses aiming to summarise the body of evidence, and could result in substantial underestimation or overestimation of the results. This consideration is particularly important during major public health emergencies, in which there is an imperative need for reliable information to manage patients and to allow proper allocation of health-care resources in a cost-effective manner. Our second concern regards the analysis that aimed to determine whether severe COVID-19 is associated with gastrointestinal symptoms and liver injury—namely, the definition of severity. There is a substantial heterogeneity in the definitions used for severe COVID-19, such as those from WHO interim guidelines for COVID-19,3WHOClinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: interim guidance.https://apps.who.int/iris/handle/10665/331446Date: 13 March 2020Date accessed: June 8, 2020Google Scholar the community-acquired pneumonia guidelines from the American Thoracic Society,4Metlay JP Waterer GW Long AC et al.Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America.Am J Respir Crit Care Med. 2019; 200: e45-e67Crossref PubMed Scopus (1267) Google Scholar or the Chinese novel coronavirus pneumonia prevention and control programme.5National Health Commission of the People's Republic of ChinaDiagnosis and treatment protocol for COVID-19.http://en.nhc.gov.cn/2020-03/29/c_78469.htmDate accessed: June 15, 2020Google Scholar Additionally, some primary studies have used their own definitions for severity, whereas others do not provide their definition. We think that a sensitivity analysis including only studies with similar severity definitions might be appropriate. We declare no competing interests. Manifestations and prognosis of gastrointestinal and liver involvement in patients with COVID-19: a systematic review and meta-analysisOur study showed that digestive symptoms and liver injury are not uncommon in patients with COVID-19. Increased attention should be paid to the care of this unique group of patients. Full-Text PDF Gastrointestinal and liver involvement in patients with COVID-19 – Authors' replyWe thank Yongxing Xu and colleagues and Francisco J Barrera and colleagues for their comments on our meta-analysis about gastrointestinal and liver involvement in patients with COVID-19.1 Full-Text PDF Gastrointestinal and liver involvement in patients with COVID-19Gastrointestinal symptoms and liver injury are not uncommon in patients with COVID-19, as stated in the systematic review and meta-analysis reported by Ren Mao and colleagues.1 However, we have some concerns about the study. Full-Text PDF