AGA Releases New COVID-19 Guidelines for Gastroenterologists

Shahnaz Sultan, MD

The American Gastroenterology Association (AGA) has released new coronavirus disease 2019 (COVID-19) guidelines for dealing with gastrointestinal (GI) and liver manifestations.

The AGA Institute Clinical Guideline Committee and Clinical Practices Updates Committee, led by Shahnaz Sultan, MD, Division of Gastroenterology, Hepatology, and Nutrition at the University of Minnesota, performed a systematic literature search to identify published and unpublished studies for the new AGA guidelines prior to crafting a new set of 7 recommendations.

The investigators analyzed the prevalence of diarrhea, nausea, vomiting, and abdominal pain, along with LFT abnormalities using a fixed effect model and assessed the certainty of evidence in 118 studies.

The team used a hierarchal study selection process to identify unique cohorts and performed a meta-analysis of 47 studies, including 10,890 patients.

It has been noted since the beginning of the COVID-19 pandemic that various gastrointestinal symptoms including diarrhea nausea and vomiting, abdominal pain, and liver enzyme abnormalities have been found in patients.

The pooled prevalence of diarrhea was also lower (4.0%).

However, the new review shows gastrointestinal symptoms may not be as common as previously estimated. The overall prevalence of gastrointestinal symptoms was 7.7% (95% CI, 7.4-8.6%) for diarrhea, 7.8% (95% CI, 7.1-8.5%) for nausea/vomiting, and 3.6% (95% CI, 3.0-4.3%) for abdominal pain.

The investigators concluded COVID-19 can present atypically with gastrointestinal symptoms, where the virus can present with diarrhea as an initial symptom. This was found in a pooled prevalence of 7.9% across studies involving 9717 patients.

Most often, diarrhea is presented along with other upper respiratory infection symptoms.

However, in some cases diarrhea precedes other symptoms by a few days. COVID-10 may also present as isolated gastrointestinal symptoms before the development of the common upper respiratory infection symptoms and obtain a detailed history of symptoms associated with COVID-19 including fever cough shortness of breath, chills, muscle pain, headache, sore throat, and new loss of taste or smell.

The guidelines call for doctors to monitor patients with new diarrhea, nausea, or vomiting for other COVID-19 symptoms.

Patients should also inform gastroenterologists if they experience a new fever, cough, shortness of breath, or other upper respiratory infection symptoms after the onset of gastrointestinal symptoms.

The authors also said liver function abnormalities should prompt a thorough evaluation because liver test abnormalities are seen in approximately 15% of COVID-19 patients thus far. However, available data supporting these abnormalities are often attributable to secondary effects from severe disease, instead of primary virus-mediated liver injuries.

For hospitalized patients with suspected or known infections, gastroenterologists should obtain a thorough history of GI symptoms, including onset, characteristics, duration, and severity.

The authors also concluded that there is inadequate evidence supporting stool testing for diagnosis or monitoring of COVID-19 as part of route clinical practices.

Patients with elevated LFTs in context of suspected or known infections should be evaluated for alternative etiologies.

The final recommendation is hospitalized patients undergoing drug treatment for COVID-19 should be evaluated for treatment-related GI and hepatic adverse effects.

“GI symptoms are associated with COVID-19 in less than 10% of patients,” the authors wrote. “In studies outside of China, estimates are higher. Further studies are needed with standardized GI symptoms questionnaires and LFT checks on admission to better quantify and qualify the association of these symptoms with COVID-19.”

The guidelines, “AGA Institute Rapid Review of the GI and Liver Manifestations of COVID-19, MetaAnalysis of International Data, and Recommendations for the Consultative Management of Patients with COVID-19,” was published online in Gastroenterology.