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AGA Institute Rapid Review of the Gastrointestinal and Liver Manifestations of COVID-19, Meta-Analysis of International Data, and Recommendations for the Consultative Management of Patients with COVID-19.
Gastroenterology. 2020 Jul; 159(1):320-334.e27.G

Abstract

BACKGROUND & AIMS

Multiple gastrointestinal (GI) symptoms, including diarrhea, nausea/vomiting, and abdominal pain, as well as liver enzyme abnormalities, have been variably reported in patients with coronavirus disease 2019 (COVID-19). This document provides best practice statements and recommendations for consultative management based on a systematic review and meta-analysis of international data on GI and liver manifestations of COVID-19.

METHODS

We performed a systematic literature search to identify published and unpublished studies using OVID Medline and preprint servers (medRxiv, LitCovid, and SSRN) up until April 5, 2020; major journal sites were monitored for US publications until April 19, 2020. We pooled the prevalence of diarrhea, nausea, vomiting, and abdominal pain, as well as liver function tests abnormalities, using a fixed-effect model and assessed the certainty of evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework.

RESULTS

We identified 118 studies and used a hierarchal study selection process to identify unique cohorts. We performed a meta-analysis of 47 studies including 10,890 unique patients. Pooled prevalence estimates of GI symptoms were as follows: diarrhea 7.7% (95% confidence interval [CI], 7.2%-8.2%), nausea/vomiting 7.8% (95% CI, 7.1%-8.5%), and abdominal pain 2.7% (95% CI, 2.0%-3.4%). Most studies reported on hospitalized patients. The pooled prevalence estimates of elevated liver abnormalities were as follows: aspartate transaminase 15.0% (95% CI, 13.6%-16.5%) and alanine transaminase 15.0% (95% CI, 13.6%-16.4%). When we compared studies from China to studies from other countries in subgroup analyses, diarrhea, nausea/vomiting, and liver abnormalities were more prevalent outside of China, with diarrhea reported in 18.3% (95% CI, 16.6%-20.1%). Isolated GI symptoms were reported rarely. We also summarized the Gl and liver adverse effects of the most commonly utilized medications for COVID-19.

CONCLUSIONS

GI symptoms are associated with COVID-19 in <10% of patients. In studies outside of China, estimates are higher. Further studies are needed with standardized GI symptoms questionnaires and liver function test checks on admission to better quantify and qualify the association of these symptoms with COVID-19. Based on findings from our meta-analysis, we provide several Best Practice Statements for the consultative management of COVID-19.

Authors+Show Affiliations

Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis Veterans Affairs Healthcare System, Minneapolis, Minnesota.Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri.Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.Division of Gastroenterology, Northeast Ohio Veterans Affairs Healthcare System, Case Western Reserve University School of Medicine, Cleveland, Ohio.Division of Gastroenterology and Center for Inflammatory Bowel Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts.Yale Liver Center and Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut.Division of Gastroenterology, Northeast Ohio Veterans Affairs Healthcare System, Case Western Reserve University School of Medicine, Cleveland, Ohio.Department of Medicine, Baylor College of Medicine, Houston, Texas.No affiliation info available

Pub Type(s)

Journal Article
Meta-Analysis
Systematic Review

Language

eng

PubMed ID

32407808

Citation

Sultan, Shahnaz, et al. "AGA Institute Rapid Review of the Gastrointestinal and Liver Manifestations of COVID-19, Meta-Analysis of International Data, and Recommendations for the Consultative Management of Patients With COVID-19." Gastroenterology, vol. 159, no. 1, 2020, pp. 320-334.e27.
Sultan S, Altayar O, Siddique SM, et al. AGA Institute Rapid Review of the Gastrointestinal and Liver Manifestations of COVID-19, Meta-Analysis of International Data, and Recommendations for the Consultative Management of Patients with COVID-19. Gastroenterology. 2020;159(1):320-334.e27.
Sultan, S., Altayar, O., Siddique, S. M., Davitkov, P., Feuerstein, J. D., Lim, J. K., Falck-Ytter, Y., & El-Serag, H. B. (2020). AGA Institute Rapid Review of the Gastrointestinal and Liver Manifestations of COVID-19, Meta-Analysis of International Data, and Recommendations for the Consultative Management of Patients with COVID-19. Gastroenterology, 159(1), 320-e27. https://doi.org/10.1053/j.gastro.2020.05.001
Sultan S, et al. AGA Institute Rapid Review of the Gastrointestinal and Liver Manifestations of COVID-19, Meta-Analysis of International Data, and Recommendations for the Consultative Management of Patients With COVID-19. Gastroenterology. 2020;159(1):320-334.e27. PubMed PMID: 32407808.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - AGA Institute Rapid Review of the Gastrointestinal and Liver Manifestations of COVID-19, Meta-Analysis of International Data, and Recommendations for the Consultative Management of Patients with COVID-19. AU - Sultan,Shahnaz, AU - Altayar,Osama, AU - Siddique,Shazia M, AU - Davitkov,Perica, AU - Feuerstein,Joseph D, AU - Lim,Joseph K, AU - Falck-Ytter,Yngve, AU - El-Serag,Hashem B, AU - ,, Y1 - 2020/05/11/ PY - 2020/5/15/pubmed PY - 2020/8/8/medline PY - 2020/5/15/entrez KW - COVID-19 KW - Gastrointestinal and Liver Manifestations SP - 320 EP - 334.e27 JF - Gastroenterology JO - Gastroenterology VL - 159 IS - 1 N2 - BACKGROUND & AIMS: Multiple gastrointestinal (GI) symptoms, including diarrhea, nausea/vomiting, and abdominal pain, as well as liver enzyme abnormalities, have been variably reported in patients with coronavirus disease 2019 (COVID-19). This document provides best practice statements and recommendations for consultative management based on a systematic review and meta-analysis of international data on GI and liver manifestations of COVID-19. METHODS: We performed a systematic literature search to identify published and unpublished studies using OVID Medline and preprint servers (medRxiv, LitCovid, and SSRN) up until April 5, 2020; major journal sites were monitored for US publications until April 19, 2020. We pooled the prevalence of diarrhea, nausea, vomiting, and abdominal pain, as well as liver function tests abnormalities, using a fixed-effect model and assessed the certainty of evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. RESULTS: We identified 118 studies and used a hierarchal study selection process to identify unique cohorts. We performed a meta-analysis of 47 studies including 10,890 unique patients. Pooled prevalence estimates of GI symptoms were as follows: diarrhea 7.7% (95% confidence interval [CI], 7.2%-8.2%), nausea/vomiting 7.8% (95% CI, 7.1%-8.5%), and abdominal pain 2.7% (95% CI, 2.0%-3.4%). Most studies reported on hospitalized patients. The pooled prevalence estimates of elevated liver abnormalities were as follows: aspartate transaminase 15.0% (95% CI, 13.6%-16.5%) and alanine transaminase 15.0% (95% CI, 13.6%-16.4%). When we compared studies from China to studies from other countries in subgroup analyses, diarrhea, nausea/vomiting, and liver abnormalities were more prevalent outside of China, with diarrhea reported in 18.3% (95% CI, 16.6%-20.1%). Isolated GI symptoms were reported rarely. We also summarized the Gl and liver adverse effects of the most commonly utilized medications for COVID-19. CONCLUSIONS: GI symptoms are associated with COVID-19 in <10% of patients. In studies outside of China, estimates are higher. Further studies are needed with standardized GI symptoms questionnaires and liver function test checks on admission to better quantify and qualify the association of these symptoms with COVID-19. Based on findings from our meta-analysis, we provide several Best Practice Statements for the consultative management of COVID-19. SN - 1528-0012 UR - https://www.unboundmedicine.com/medline/citation/32407808/AGA_Institute_Rapid_Review_of_the_Gastrointestinal_and_Liver_Manifestations_of_COVID_19_Meta_Analysis_of_International_Data_and_Recommendations_for_the_Consultative_Management_of_Patients_with_COVID_19_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0016-5085(20)30593-X DB - PRIME DP - Unbound Medicine ER -