Gastrointestinal Manifestations of SARS-CoV-2 Infection and Virus Load in Fecal Samples From a Hong Kong Cohort: Systematic Review and Meta-analysis
Open accessAbstract
Background & aims Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19), which has been characterized by fever, respiratory, and gastrointestinal symptoms as well as shedding of virus RNA into feces. We performed a systematic review and meta-analysis of published gastrointestinal symptoms and detection of virus in stool and also summarized data from a cohort of patients with COVID-19 in Hong Kong.Methods We collected data from the cohort of patients with COVID-19 in Hong Kong (N = 59; diagnosis from February 2 through February 29, 2020),and searched PubMed, Embase, Cochrane, and 3 Chinese databases through March 11, 2020, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We analyzed pooled data on the prevalence of overall and individual gastrointestinal symptoms (loss of appetite, nausea, vomiting, diarrhea, and abdominal pain or discomfort) using a random effects model.Results Among the 59 patients with COVID-19 in Hong Kong, 15 patients (25.4%) had gastrointestinal symptoms, and 9 patients (15.3%) had stool that tested positive for virus RNA. Stool viral RNA was detected in 38.5% and 8.7% among those with and without diarrhea, respectively (P = .02). The median fecal viral load was 5.1 log 10 copies per milliliter in patients with diarrhea vs 3.9 log 10 copies per milliliter in patients without diarrhea (P = .06). In a meta-analysis of 60 studies comprising 4243 patients, the pooled prevalence of all gastrointestinal symptoms was 17.6% (95% confidence interval [CI], 12.3-24.5); 11.8% of patients with nonsevere COVID-19 had gastrointestinal symptoms (95% CI, 4.1-29.1), and 17.1% of patients with severe COVID-19 had gastrointestinal symptoms (95% CI, 6.9-36.7). In the meta-analysis, the pooled prevalence of stool samples that were positive for virus RNA was 48.1% (95% CI, 38.3-57.9); of these samples, 70.3% of those collected after loss of virus from respiratory specimens tested positive for the virus (95% CI, 49.6-85.1).Conclusions In an analysis of data from the Hong Kong cohort of patients with COVID-19 and a meta-analysis of findings from publications, we found that 17.6% of patients with COVID-19 had gastrointestinal symptoms. Virus RNA was detected in stool samples from 48.1% patients, even in stool collected after respiratory samples had negative test results. Health care workers should therefore exercise caution in collecting fecal samples or performing endoscopic procedures in patients with COVID-19, even during patient recovery.
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Durojaiye, A. B., Clarke, J. D., Stamatiades, G. A., & Wang, C. (2020) · Journal of Biomolecular Structure and Dynamics · doi:10.1080/07391102.2020.1777904 · Cited by 52 · see citing works
Interferon beta-1a for COVID-19: critical importance of the administration route
Jalkanen, J. M., Hollmén, M., & Jalkanen, S. (2020) · Critical Care · doi:10.1186/s13054-020-03048-5 · Cited by 47 · see citing works
COVID ‐19 and its effects on the digestive system and endoscopy practice
Aguila, E. J. T., Cua, I. H. Y., Dumagpi, J. E., Francisco, C. P. D., Raymundo, N. T., Sy‐Janairo, M. L. L., Cabral‐Prodigalidad, P. A., & Lontok, M. A. (2020) · JGH Open · doi:10.1002/jgh3.12358 · Cited by 46 · see citing works
[Epidemiological analysis on a family cluster of COVID-19].
Qiu, Y., Wang, S., Wang, X., et al. (2020) · PubMed · doi:10.3760/cma.j.cn112338-20200221-00147 · Cited by 30 · see citing works
Ling, K. L., Hilmi, I. N., Ali, R. A. R., Leong, R. W. L., Leung, W. K., Ng, S. C., Wu, K., Chen, M. H., Ran, Z. H., Hisamatsu, T., et al. (2020) · JGH Open · doi:10.1002/jgh3.12362 · Cited by 26 · see citing works
Self-citation[A case report of aplastic anemia accompanied with COVID-19].
Wu, T., Kang, S. C., Feng, W., et al. (2020) · PubMed · doi:10.3760/cma.j.issn.0253-2727.2020.0003 · Cited by 6 · see citing works
Flagged first, then by citations
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Alterations in Gut Microbiota of Patients With COVID-19 During Time of Hospitalization
Zuo, T., Zhang, F., Lui, G. C. Y., Yeoh, Y. K., Li, A. Y. L., Zhan, H., Wan, Y., Chung, A. C. K., Cheung, C. P., Chen, N., et al. (2020) · Gastroenterology · doi:10.1053/j.gastro.2020.05.048 · Cited by 1,537 · see citing works
Self-citationLong COVID or post-COVID-19 syndrome: putative pathophysiology, risk factors, and treatments
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Role of angiotensin-converting enzyme 2 (ACE2) in COVID-19
Ni, W., Yang, X., Yang, D., Bao, J., Li, R., Xiao, Y., Hou, C., Wang, H., Liu, J., Yang, D., et al. (2020) · Critical Care · doi:10.1186/s13054-020-03120-0 · Cited by 1,175 · see citing works
TMPRSS2 and TMPRSS4 promote SARS-CoV-2 infection of human small intestinal enterocytes
Zang, R., Castro, M. F. G., McCune, B. T., Zeng, Q., Rothlauf, P. W., Sonnek, N. M., Liu, Z., Brulois, K. F., Wang, X., Greenberg, H. B., et al. (2020) · Science Immunology · doi:10.1126/sciimmunol.abc3582 · Cited by 982 · see citing works
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Regulation, risk and safety of Faecal Microbiota Transplant
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Algae-derived bioactive molecules for the potential treatment of SARS-CoV-2
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Abdominal imaging findings in patients with SARS-CoV-2 infection: a scoping review
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COVID-19 and the digestive system: A comprehensive review
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Bowel ischemia in COVID‐19: A systematic review
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Bowel ischemia in COVID-19 infection: one-year surgical experience
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Pneumatosis Intestinalis in the Setting of COVID-19: A Single Center Case Series From New York
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Pneumatosis Intestinalis Due to COVID-19 Infection in Kidney Transplant Recipient: A Case Report
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- Authors
- Cheung, K. S., Hung, I. F. N., Chan, P. P. Y., Lung, K. C., Tso, E., Liu, R., Ng, Y. Y., Chu, M. Y., Chung, T. W. H., Tam, A. R., Yip, C. C. Y., Leung, K.-H., Fung, A. Y.-F., Zhang, R. R., Lin, Y., Cheng, H. M., Zhang, A. J. X., To, K. K. W., Chan, K.-H., Yuen, K.-Y., & Leung, W. K.
- Affiliations
- Queen Mary Hospital (CN)
- Ruttonjee Hospital (CN)
- Pamela Youde Nethersole Eastern Hospital (CN)
- United Christian Hospital (CN)
- Tuen Mun Hospital (CN)
- Queen Elizabeth Hospital (CN)
- University of Hong Kong (HK)
- University of Hong Kong - Shenzhen Hospital (CN)
- Corresponding author
- Leung, Wai K.
- ORCID
- Venue
- Gastroenterology
- Publisher
- Elsevier BV
- Published
- 2020-07
- Volume
- 159
- Issue
- 1
- Pages
- 81-95
- ISSN
- 0016-5085 (ISSN-L)
- PMC
- PMC7194936
- OpenAlex
- W3014486521
- Cited by
- 1,631
- References
- 91
- Citations by year
- 2026: 23 · 2025: 54 · 2024: 110 · 2023: 208 · 2022: 348 · 2021: 487 · 2020: 399 · 2019: 1
- FWCI
- 17.05
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Gastroenterology (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Infectious Diseases › COVID-19 Clinical Research Studies
- Health Sciences › Medicine › Neurology › Long-Term Effects of COVID-19
- Health Sciences › Medicine › Infectious Diseases › Viral gastroenteritis research and epidemiology
- Keywords
- COVID-19 pandemic, SARS-CoV-2, gastrointestinal symptoms, viral shedding in stool, fecal-oral transmission, viral load, diarrhea, abdominal pain, nausea and vomiting, appetite loss, disease severity
- MeSH terms
- Betacoronavirus, COVID-19, SARS-CoV-2, COVID-19 Testing, Diarrhea, Feces, Hong Kong, Humans, Pneumonia, Viral, RNA, Viral, Prevalence, Endoscopy, Gastrointestinal, Infection Control, Infectious Disease Transmission, Patient-to-Professional, Coronavirus Infections, Clinical Laboratory Techniques, Viral Load, Gastrointestinal Tract, Pandemics
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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