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©The Author(s) 2021.
World J Gastroenterol. Jul 28, 2021; 27(28): 4504-4535
Published online Jul 28, 2021. doi: 10.3748/wjg.v27.i28.4504
Published online Jul 28, 2021. doi: 10.3748/wjg.v27.i28.4504
Table 1 Incidence of common gastrointestinal symptoms in patients with severe acute respiratory syndrome coronavirus 2 infection
| Ref. | Patient number | Anorexia, nausea or vomiting, n (%) | Diarrhea, n (%) | Abdominal pain, n (%) |
| Kujawski et al[207], 2020 | 12 | Nausea: 3 (25) | 4 (33.3) | 2 (16.7) |
| Hajifathalian et al[44], 2020 | 1059 | Anorexia: 240 (22.7) | 234 (22.1) | 72 (6.8) |
| Nausea: 168 (15.3) | ||||
| Vomiting: 91 (8.6) | ||||
| Young et al[208], 2020 | 18 | NA | 3 (17) | NA |
| Tabata et al[209], 2020 | 104 | NA | 8 (9.6) | NA |
| Wölfel et al[210], 2020 | 9 | NA | 2 (22) | NA |
| Chen et al[26], 2020 | 99 | Nausea and vomiting: 1 (1) | 2 (2) | NA |
| Xu et al[27], 2020 | 62 | NA | 3 (8) | NA |
| Gritti et al[211], 2020 | 21 | NA | 5 (23.8) | NA |
| COVID-19 National Incident Room Surveillance Team[212] | 295 | Nausea: 34 (11.5) | 48 (16.3) | 6 (1) |
| COVID-19 National Emergency response Center[213] | 28 | NA | 2 (7) | 1 (4) |
| Sierpiński et al[214], 2020 | 1942 | NA | 470 (24.2) | NA |
| Wu et al[28], 2020 | 80 | Nausea and vomiting: 1 (1.25) | 1 (1.3) | NA |
| Wang et al[12], 2020 | 138 | Anorexia: 55 (39.9) | 14 (10.1) | 3 (2.2) |
| Nausea: 14 (10.1) | ||||
| Shi et al[29], 2020 | 81 | Anorexia: 1 (1) | 3 (4) | NA |
| Vomiting: 4 (5) | ||||
| Yang et al[30], 2020 | 50 | Vomiting: 2 (4) | NA | NA |
| Mo et al[31], 2020 | 155 | Anorexia: 26 (31.7) | 7 (4.5) | NA |
| Nausea: 3 (3.7) | ||||
| Vomiting: 3 (3.7) | ||||
| Qi et al[215], 2020 | 267 | Anorexia: 46 (14.2) | 10 (3.7) | NA |
| Nausea: 6 (2.2) | ||||
| Wen et al[216], 2020 | 417 | NA | 29 (7) | NA |
| Dan et al[217], 2020 | 305 | Anorexia: 101(50.2) | 146 (49.5) | 12 (6) |
| Nausea: 59 (29.4) | ||||
| Vomiting: 3 (2) | ||||
| Ma et al[218], 2020 | 81 | NA | 6(7.41) | NA |
| Luo et al[41], 2020 | 1141 | Anorexia: NA | 68 (6) | 45 (3.9) |
| Nausea: 134 (11.7) | ||||
| Vomiting: 119 (10.4) | ||||
| Liu et al[219], 2020 | 238 | Anorexia: 14 (9.2) | 14 (9.2) | 1 (0.7) |
| Nausea: 2 (1.3) | ||||
| Vomiting: 3 (2) | ||||
| Ai et al[220], 2020 | 102 | Anorexia: NA | 15 (14.3) | 3 (2.9) |
| Nausea: 9 (8.8) | ||||
| Vomiting: 2 (2) | ||||
| Zhao et al[221], 2020 | 75 | NA | 7 (9.3) | 1 (1.3) |
| Li et al[222], 2020 | 83 | NA | 7 (8.4) | 7 (8.4) |
| Lin et al[223], 2020 | 95 | Anorexia: 17 (17.8) | 23 (24.2) | 2 (2.1) |
| Nausea: 17 (17.9) | ||||
| Vomiting: 4 (4.2) | ||||
| Cholankeril et al[224], 2020 | 207 | Anorexia: NA | 22 (10.8) | 14 (7.1) |
| Nausea: 22 (10.8) | ||||
| Vomiting: NA | ||||
| Ferm et al[43], 2020 | 892 | Anorexia: 105 (11.8) | 177 (19.8) | 70 (7.8) |
| Nausea: 148 (16.6) | ||||
| Vomiting: 91 (10.2) | ||||
| Redd et al[225], 2020 | 318 | Anorexia: 110 (34.8) | 107 (33.7) | 46 (14.5) |
| Nausea: 84 (26.4) | ||||
| Vomiting: 49 (15.4) | ||||
| Kluytmans et al[226], 2020 | 86 | NA | 16 (18.6) | 5 (5.8) |
Table 2 Therapy-specific considerations for inflammatory bowel disease patients
| Drug | Effects |
| Aminosalicylate acid derivatives (5-ASA) | No proof of increased risk of COVID-19 infection |
| Continue treatment even in the case of COVID-19 infection | |
| Corticosteroids | Their safety during COVID-19 infection is uncertain |
| They can be used at a low dose and for a short period to treat disease relapses | |
| Discontinue as soon as possible | |
| Ileo-cecal CD patients can be treated with Budesonide; IUC patients can be treated with Budesonide MMX | |
| Immunomodulators (Thiopurines and Methotrexate) | No proof of increased risk of COVID-19 infection |
| Accompanied by increased risk of other viral infection | |
| Not recommended to start with monotherapy | |
| Combination therapy with biologics should be maintained | |
| Recommendations in stopping | |
| Stable disease | |
| Sustained reduction in the case of elderly patients and/or significant comorbidities | |
| Symptom progression of COVID-19 infection | |
| Anti-TNF therapy | No proof of increased risk of COVID-19 infection |
| Infusion and dose intervals should be maintained | |
| Starting with monotherapy (adalimumab or certolizumab) | |
| Stop in the case of developing symptoms of COVID-19 | |
| Anti-IL-12/23p40 therapy (Ustekinumab) | No proof of increased risk of COVID-19 infection |
| Monotherapy is recommended | |
| Stop in the case of developing symptoms of COVID-19 | |
| Anti-a4b7 integrin therapy (Vedolizumab) | No proof of increased risk of COVID-19 infection |
| Monotherapy is recommended | |
| Stop in the case of developing symptoms of COVID-19 | |
| Janus Kinase inhibitors (tofacitinib) | Although there is no proof of increasing the risk of COVID-19 infection, it may inhibit the immune reaction against viral infections |
| Starting is not recommended | |
| Therapy should be maintained without elevating the dose | |
| Stop if symptoms of COVID-19 develop |
Table 3 Incidence of hepatic abnormalities in patients with severe acute respiratory syndrome coronavirus 2 infection
| Ref. | Patient number | ALT (U/L) | AST (U/L) | TB (mg/dL) |
| Zhou et al[32], 2020 | 191 | ↑59 (31%) | None | NA |
| Shu et al[227], 2021 | 545 | ↑41 (7.5%) | ↑35 (10.1%) | ↑189 (34.7%) |
| Huang et al[25], 2020 | 41 | NA | ↑15 (37%) | NA |
| Huang et al[228], 2020 | 36 | 4 (13.3%) | 18 (58%) | ↑4 (12.9%) |
| Chen et al[26], 2020 | 99 | ↑28 (28%) | ↑35 (35%) | ↑18 (18%) |
| Ai et al[64], 2020 | 102 | ↑20 (19.6%) | ↑26 (25.5%) | NA |
| Xu et al[27], 2020 | 62 | ↑3 (3.75%) | ↑3 (3.75%) | NA |
| Yang et al[3], 2020 | 168 | ↑9 (8%) | ↑18 (17.3%) | ↑7 (6.4%) |
| Wu et al[28], 2020 | 80 | ↑3 (3.75%) | ↑3 (3.75%) | NA |
| Yao et al[229], 2020 | 40 | ↑21 (52.5%) | ↑16 (40%) | |
| Xu et al[230], 2020 | 355 | ↑91 (25.6%) | ↑102 (28.7%) | ↑10 (25%) |
| Cai et al[231], 2020 | 298 | ↑39 (13.1%) | ↑25 (8.4%) | ↑66 (18.6) |
| Richardson et al[1], 2020 | 5700 | ↑2176 (39.0%) | ↑3263 (58.4%) | ↑24 (8.1%) |
| NA | ||||
| Fan et al[1], 2020 | 40 | ↑27 (18.2%) | ↑32 (21.6%) | ↑9 (6.1%) |
| Guan et al[39], 2020 | 355 | ↑158 (21.3%) | ↑168 (22.2%) | ↑76 (10.5%) |
Table 4 Outcome of the patients with severe elevation of aminotransferases in coronavirus disease 2019
| Ref. | Outcome of patients | SARS-CoV-2 patients with hypertransaminasemia (n = 20) | COVID-19 patients without hypertransaminasemia (n = 125) | P value |
| Ramachandran et al[169], 2020 | Shock | 9 (45%) | 38 (30.4%) | 0.207 |
| Mechanical ventilation | 10 (50%) | 30 (24%) | 0.028 | |
| Died | 10 (50%) | 46 (36.8%) | 0.324 | |
| Length of stay in days, median (IQR) | 7 (4.3, 10.3) | 7 (5, 10) | 0.78 |
Table 5 Recommendations of the American Association for the Study of Liver Diseases, Asian Pacific Association for the Study of the Liver, and European Association for the Study of the Liver for management of liver disease during coronavirus disease 2019
| Selected recommendations | |
| To limit nosocomial spread | (1) Decrease in-person visits via other alternatives such as virtual platforms |
| (2) Symptom investigation before entering hospitals to identify COVID-19 patients | |
| (3) Reduce staffing to essential staff only | |
| (4) Reduce the frequency of screening and laboratory examinations | |
| (5) Adhere to recommended PPE by HCW and patients | |
| (6) Maintain proper social distancing in hospitals | |
| (7) Postpone unnecessary or elective operations | |
| Management of CLD patients with COVID-19 | (1) These patients should be admitted to hospital early |
| (2) Prioritization of COVID-19 testing for patients with cirrhosis, CLD patients taking immunosuppressive agents and acute decompensated patients | |
| (3) Repeated LFTs are advisable | |
| (4) Early registration in clinical trials as much as possible | |
| (5) COVID-19 patients with NAFLD should be kept under supervision | |
| (6) Screening of hepatitis B surface antigen should be taken into consideration | |
| (7) Drug-induced liver injury should be monitored | |
| (8) These patients can receive 2-3 g/d of acetaminophen, while limiting the use of NSAIDs when possible | |
| (9) HBV prophylaxis should be considered before starting immunosuppressive agents | |
| (10) Stopping Remdesivir in decompensated liver disease patients with ALT more than 5 times the upper limit of normal | |
| Management of chronic viral hepatitis (HCV and HBV) | (1) Despite COVID-19 status, treatment continuity of chronic HCV and HBV is recommended |
| (2) In the absence of flare, HBV treatment should be stopped | |
| (3) For uninfected individuals, HCV and HBV treatment should be continued according to guidelines | |
| Management of HCC | (1) HCC treatment should be continued according to guidelines; however, it can be delayed if necessary |
| (2) In the case of COVID-19 patients, delaying elective transplants and resection surgery, and stopping immunotherapy are advisable | |
| (3) Early admission to hospital is recommended for HCC patients | |
| Management of pre- and post-transplant recipients | (1) Screening donor and recipient for COVID-19 is suggested |
| (2) For donors testing positive for COVID-19, transplantation surgery should be postponed | |
| (3) Prioritization of patients with short-term prognosis | |
| (4) For post-transplant patients, a reduction in immunosuppressive dose can be considered for moderate COVID-19 cases, while for mild COVID-19 cases, the dose should not be reduced | |
| (5) For post-transplant recipients, vaccination against pneumonia and influenza is advisable |
Table 6 Recommendations of the American Association for the Study of Liver Diseases and European Association for the Study of the Liver for the management of auto-immune hepatitis during coronavirus disease 2019
| Selected recommendations | |
| Virtual platforms are recommended to minimize in-person visits as much as possible | |
| COVID-19 testing is advised in cases of acute deterioration and liver failure | |
| Patients with low risk of complications (patients on chronic immunosuppressive therapy) | (1) Frequent patient-provider communications should be closely supervised; (2) Virtual platforms should be used to decrease contact; and (3) Ensure enough drug supply and refills to decrease running out of medications |
| Patients with moderate risk of complications (symptomatic disease without cirrhosis) | (1) Empiric therapy via virtual healthcare platforms as much as possible; and (2) Preventing liver biopsy whenever possible |
| Patients with high risk of complications (acute flare, decompensated cirrhosis) | (1) Reduce invasive procedures as much as possible; (2) In the case of COVID-19 patients, if lymphopenia develops, dose reduction of antimetabolites is recommended; and (3) In the case of infection, corticosteroids should be attenuated |
Table 7 Recommendations of the American Association for the Study of Liver Diseases and European Association for the Study of the Liver on the use of immunosuppressive therapies in chronic liver disease during coronavirus disease 2019
| Suggestions | |
| (1) Starting with corticosteroids and immunomodulators should proceed; and (2) Risk benefit ratio assessments should be carried out | |
| Patients on immunosuppressive treatment and not infected with COVID-19 | Decreases or adjustment of doses is not advisable |
| Patients infected with COVID-19 on immunosuppressive drugs | (1) Reduce corticosteroids dose after specialist physician (consider tapering to prevent adrenal insufficiency); and (2) Decreasing the doses of cyclosporine, mycophenolate, and azathioprine is recommended in severe COVID-19 (especially patients with lymphopenia) |
| Patients requiring initiation of immunosuppressive agents | Starting treatment is suggested in these patients regardless of COVID-19 status |
- Citation: Mohamed DZ, Ghoneim MES, Abu-Risha SES, Abdelsalam RA, Farag MA. Gastrointestinal and hepatic diseases during the COVID-19 pandemic: Manifestations, mechanism and management. World J Gastroenterol 2021; 27(28): 4504-4535
- URL: https://www.wjgnet.com/1007-9327/full/v27/i28/4504.htm
- DOI: https://dx.doi.org/10.3748/wjg.v27.i28.4504