S1260 Do New Gastrointestinal Symptoms Warrant COVID-19 Testing? A Systematic Review and Meta-Analysis

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INTRODUCTION: Infection with the novel coronavirus SARS-CoV-2, known as COVID-19, was initially considered a primary respiratory illness, but recent studies have increasingly described COVID-19 associated gastrointestinal (GI) symptoms. With prioritization of respiratory symptoms in current testing and isolation algorithms, GI patients may represent a source of continued undetected viral spread. This review aims to determine the prevalence of GI and hepatic involvement in COVID-19, particularly in the absence of respiratory symptoms. METHODS: We searched PubMed, Embase, and the Cochrane library for entries from December 1, 2019 to May 18, 2020. We included any study that reported the presence of GI symptoms in a sample of >5 COVID-positive patients, regardless of respiratory viral symptoms. Where ≥3 studies reported data sufficiently similar to allow calculation of a pooled prevalence, we performed random effects meta-analysis, including subgroup analyses by study design, sample characteristics, study location and publication date. RESULTS: We identified 91 studies for inclusion in our review, comprising 14,469 COVID-19 patients from 13 countries. The majority of studies focused on adult patients (66 studies) and the hospital setting (86 studies). Overall, GI involvement was common in COVID-19, with 19% (95% CI 14–24%) of patients reporting some GI symptom and 25% (95% CI 17–34%) of patients demonstrating transaminase elevations. Isolated GI symptoms only occurred in 3% (95% CI 1–7%) of patients, though only 2% (95% CI 0–7%) without fever. Higher prevalence of GI symptoms were reported in studies conducted outside of China and/or published after April 15th. In eight Chinese studies that reported this outcome, presence of GI symptoms was associated with greater odds (odds ratio 1.98, 95% CI 1.31–2.99) of severe COVID. CONCLUSION: Given the overall burden of COVID-19 in the US, patients with isolated GI symptoms may represent a significant population of cases. Isolated GI symptoms may not be sufficiently common to warrant COVID-19 testing when testing resources are scarce. However, such patients should consider self-quarantine to monitor for development of other symptoms such as fever, cough, and dyspnea. However, clinicians should be aware of GI involvement in COVID-19 and a possible association with severe disease, and consider testing patients with isolated GI symptoms or unexplained transaminase elevations when testing resources are adequate.Figure 1.: Legend: Overall incidence of COVID-19 infection with a period of only GI symptoms, with or without fever but where the presence of fever was defined, was 3% (95%CI 1-7%). Whether anorexia was included in the definition of GI symptoms or not did not affect the proportion with GI symptoms, P = 0.48. GI, gastrointestinal; COVID, coronavirus disease; CI, confidence interval.Figure 2.: Legend: Overall incidence of elevated transaminases in COVID-19 infection was 25% (95% CI 17–34%). This was only 22% (95% CI 17–28%) in studies from East Asia, but 61% (95% CI 58–64%) in US studies (though only two US studies, P = 0.03 for difference). GI, gastrointestinal; COVID, coronavirus disease; CI, confidence interval.Figure 3.: Legend: Odds of mortality were significantly less (OR 0.68, 95% CI 0.48–0.97) in COVID-infected patients with GI symptoms compared to those without. This was driven by US studies, in which the pooled odds ratio for mortality with GI symptoms was 0.51 (95% CI 0.35–0.73), versus OR 1.07 (95% CI 0.63–1.81) in studies from China (P = 0.09 for difference). GI, gastrointestinal; COVID, coronavirus disease; OR, odds ratio; CI, confidence interval.