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Diarrhea is first sign of illness for some COVID-19 patients

A person holding their stomach.
(Image: © Shutterstock)

Some patients with COVID-19 experience gastrointestinal symptoms, particularly diarrhea, as the first sign of illness, according to a new study.

Among this subset of patients — who have mild disease overall — respiratory symptoms show up only later in the illness, and some never develop respiratory symptoms at all, the authors said.

The findings are important because those without classic symptoms of COVID-19 — such as cough, shortness of breath and fever — may go undiagnosed and could potentially spread the illness to others, the researchers said.

Still, they note that digestive problems are common overall and don't necessarily mean that a person has COVID-19. But doctors should recognize that sudden digestive symptoms in people with a possible COVID-19 contact "should at least prompt consideration of the illness," the authors wrote in their paper, published ahead of print Monday (March 30) in The American Journal of Gastroenterology. "Failure to recognize these patients early and often may lead to unwitting spread of the disease." 

The study is not the first to report digestive symptoms as a sign of COVID-19. For example, a study posted March 18 in the same journal found that, among about 200 COVID-19 patients at three hospitals in Wuhan, China, around 50% reported at least one digestive symptom, and 18% reported diarrhea, vomiting or abdominal pain. However, that study and others have tended to focus on patients with severe illness, rather than those with mild disease.

In the new study, the researchers analyzed information from 206 patients at Union Hospital, Tongji Medical College in Wuhan, which was designated as a hospital for COVID-19 patients. To be included in the study, patients needed to have a mild illness, without difficulty breathing or low blood oxygen levels.

Overall, 48 patients (23%) were admitted with digestive symptoms only, 89 (43%) with respiratory symptoms only and 69 (33%) with both respiratory and digestive symptoms.

Among all patients with digestive symptoms (117 patients), about 67 (58%) had diarrhea, and of these, 13 (20%) experienced diarrhea as the first symptom of their illness. Patients' diarrhea lasted from one to 14 days, with an average duration of five days, the report said. About one-third of patients with digestive symptoms never experienced a fever.

Patients with digestive symptoms tended to seek health care later than those with respiratory symptoms, an average of 16 days from the start of their symptoms, compared with 11 days for those with respiratory symptoms, the study found. Those with digestive symptoms also took longer to clear the virus from their body (test negative for COVID-19), taking about 41 days on average, compared with 33 days for those with respiratory symptoms only.

Finally, those with digestive symptoms were much more likely to have the new coronavirus, SARS-CoV-2, detected in their stool, with about 73% having positive stool samples, compared with 14% of those with respiratory symptoms only. This finding suggests, but does not definitely confirm, that that virus infects the gastrointestinal tract, the authors said.

Overall, "these data emphasize that patients with new-onset diarrhea after a possible COVID-19 contact should be suspected for the illness, even in the absence of cough, shortness of breath, sore throat or even fever," the authors concluded. "Optimally, testing for COVID-19 should be performed using both respiratory and stool samples, if available." 

The authors note that their study was relatively small, and larger studies are needed to further describe digestive symptoms in patients with mild COVID-19.

Originally published on Live Science. 

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  • ejbriel
    Question for someone with subject knowledge:

    Corona virus pathway is ACE-2 receptor. These receptors are located in numerous human cells -- but prominently in lungs. As to reports of patients with gastro-intestinal symptoms only -- there are ACE-2 receptors in stomach and small intestine. Would a corona infection acquired in the GI tract lead to a lung infection -- or is there a "firewall" between GI tract and lungs? If you could get immunity via a GI tract infection vs lung, would that be a crude vaccine? -- basically choosing the lesser of 2 evils. Pneumonia being the prime killer...
    Reply
  • Schumann
    Hi ejbriel, thank you for your smart idea. That was exactly what I was thinking today. I have been suffering from gastrointestinal symptoms for three weeks now, after I had visited France near the Mulhouse Corona hotspot. No breathing, flu, fever, or coughing symptoms. However, I wondered why I am still suffering from prolongued GI problems and a (very) slighty burning throat for three weeks by now. Never had similar symptoms before; no underlying health problems. My taste buds and smell is ok, albeit somewhat compromised by the throat burning. I had also very short and very slight neck pain 3 weeks ago. By then there was no mention of atypical symptoms. While reading the news during the past few days, I wondered whether I might still have been slightly caught by the Coronavirus back then, primarily being infected in the GI tract. After 3 weeks have elapsed, I should be on the safe side by now, being immunized by an "informal" GI vaccination. Hopefully there is a barrier between the GI tract and the breathing system similar to the blood-brain barrier. If so, one could theoretically "vaccinate" a person with a low live-dose of Coronavirus via a suppository into the GI tract. However, I am not a doctor, just my two cents.
    Reply
  • Astitchintime
    I have been reviewing my recent medical history and, in light of new theories about the coronavirus. I am thinking that it is very possible that I had contracted it back in January prior to testing. I am now wondering if I could be tested to see if that is the case. It would be very helpful for me to know if I am immune so that my life could be less restricted ….. very difficult at my age (87) as I am still blessed with an active lifestyle. It might also help the scientific studies that are being done to track the spread and better understand the symptoms of the disease.

    Here is the history to which I am referring:

    From December 28 through January 4 a couple from Venice were staying at my apartment with me. On January 21 I suddenly woke up in the middle of the night feeling very ill….nauseous, sweaty, dizzy, weak. I tried to get up and almost fainted. Thinking I might be having a heart attack, I called 911 and was taken to NYU Hospital by ambulance. I spent the night there undergoing various tests and, although they could not determine the cause of the symptoms, I was told that it was not a heart attack. They indicated that it might be some kind of virus. I was sent home and immediately began to experience severe diarrhea which lasted about a week in addition to the nausea, weakness and dizziness. I all of my 87 years I have never felt so sick. When I saw my doctor on January 27, as advised by the ER doctor, I was still wobbly. At that time, he did some additional tests (not sure what they were)….corona virus was not really on the radar yet).

    How can I be tested now to check my immunity?
    Reply
  • ejbriel
    I think an antibody test will eventually be available. That would tell you if you recovered from a COVID-19 infection and theoretically have immunity.
    Reply
  • swigo
    Schumann said:
    Hi ejbriel, thank you for your smart idea. That was exactly what I was thinking today. I have been suffering from gastrointestinal symptoms for three weeks now, after I had visited France near the Mulhouse Corona hotspot. No breathing, flu, fever, or coughing symptoms. However, I wondered why I am still suffering from prolongued GI problems and a (very) slighty burning throat for three weeks by now. Never had similar symptoms before; no underlying health problems. My taste buds and smell is ok, albeit somewhat compromised by the throat burning. I had also very short and very slight neck pain 3 weeks ago. By then there was no mention of atypical symptoms. While reading the news during the past few days, I wondered whether I might still have been slightly caught by the Coronavirus back then, primarily being infected in the GI tract. After 3 weeks have elapsed, I should be on the safe side by now, being immunized by an "informal" GI vaccination. Hopefully there is a barrier between the GI tract and the breathing system similar to the blood-brain barrier. If so, one could theoretically "vaccinate" a person with a low live-dose of Coronavirus via a suppository into the GI tract. However, I am not a doctor, just my two cents.

    For seemingly several weeks now I've had exactly the same symptoms of GI issues....gas, bloating, diarrhea...along with the slightly burning throat. All else is fine. And now reading that flatulence can carry the virus, which makes complete sense if your stool can carry the virus. But it makes you wonder if testing facilities will allow you to test based on a claim of diarrhea? According to the paper I can be shedding the virus for 41 days? I wonder if the hydroxychloroquine/azithromycin treats GI infections?
    Reply
  • Rosey11
    Schumann said:
    Hi ejbriel, thank you for your smart idea. That was exactly what I was thinking today. I have been suffering from gastrointestinal symptoms for three weeks now, after I had visited France near the Mulhouse Corona hotspot. No breathing, flu, fever, or coughing symptoms. However, I wondered why I am still suffering from prolongued GI problems and a (very) slighty burning throat for three weeks by now. Never had similar symptoms before; no underlying health problems. My taste buds and smell is ok, albeit somewhat compromised by the throat burning. I had also very short and very slight neck pain 3 weeks ago. By then there was no mention of atypical symptoms. While reading the news during the past few days, I wondered whether I might still have been slightly caught by the Coronavirus back then, primarily being infected in the GI tract. After 3 weeks have elapsed, I should be on the safe side by now, being immunized by an "informal" GI vaccination. Hopefully there is a barrier between the GI tract and the breathing system similar to the blood-brain barrier. If so, one could theoretically "vaccinate" a person with a low live-dose of Coronavirus via a suppository into the GI tract. However, I am not a doctor, just my two cents.

    I have had similar symptoms for 10-12 days, perhaps a bit longer. Usually at night I wake up, almost always at 4:00, with what feels like heartburn and a gurgling stomach with need to go to the bathroom, it's not always diarrhea but often is. But no other major symptoms aside from a little fatigue. Taste and smell are fine, breathing seems fine, I've even been cycling a number of times the last couple of weeks.

    I was in Spain for the first half of March and woke up one night there feeling unusually warm and I think I had a little of this same thing for a couple of days then.

    I guess I'll just keep monitoring symptoms and wait out the 30 days or so.

    One precaution that comes to mind is to be very thorough about cleaning your hands and toilet after you use it. Close the lid when you flush and cover or remove your toothbrushes, etc. I'm just thinking of taking steps to ensure I don't eject it into the air where I can then infect my lungs.
    Reply
  • Polly Styrene
    There does appear to be a pattern from the posts here.

    Towards the middle of March, I woke up one morning feeling noticeably dizzy, sweaty, weak and called in sick. I also had a mild sore throat. I was on day 2 or 3 of a headache which i'd put down to migraine weather. My colleague had called in the day before, similar thing.

    A few days later a different colleague went home - diarrhea and general malaise/tiredness. Another went home a few days later, similar symptoms.

    At about the same time I noticed not quite diarrhea, but unusually more than 'regularity'. I still have this. No noticeable loss of taste or smell that I recall.

    Even now - mid April - still have the mild sore throat that sometimes flares up and feels a bit like its deep in my chest. If i breathe out all the air in my lungs I will cough -- I feel as if there's some congestion. And tiredness ... headache could still be due to migraine weather. None of the foregoing were severe enough (other than the day I called i sick) that I'd be alarmed.

    I've had rapid onset of truly hard hitting flu like symptoms in the past, including norovirus which is a nasty gastro thing. This that I have now is so very mild compared to the severity of those incidents. I don't know anyone who has been diagnosed, but I do feel that so many people are experiencing very similar mild symptoms that I ask: Is this perhaps the average coronavirus experience? Or something else entirely off the radar, but concurrent with corona.
    Reply
  • zapdrz
    Got sick after returning from a family trip to Florida in early March right before all this craziness started. I’ve been mildy sick for over a month now. Symptoms started with a headache, sore throat, tiredness and aches and proceeded over a couple of days to GI symptoms (nausea and diarrhea) and low grade fever (never much above 100). No respiratory symptoms at all. The GI stuff and fever have lasted on and off for 35 days. I can’t remember ever being sick for more than 2 or 3 days! Was finally feeling better a few days ago and then it came back. Was tested for Covid last week and results were negative, but my doc still thinks that’s what I’m battling... and that because of being tested late and never having respiratory stuff the test was a false negative. Who knows at this point. I just wanna kick it. I did have a flu shot in the fall. Feels like Groundhog Day as I’ve been quarantined in my bedroom the whole time because a family member is immunocompromised. What’s kept me sane is hearing of other healthy people like myself who have been battling similar symptoms for similar lengths of time. I’m 44, male, and healthy with no underlying med issues. Prior to getting sick I got regular exercise (biking, etc.) I have two other acquaintances in other parts of the country who have been dealing with very similar symptoms and duration of illness.
    Reply
  • CharlieBeach
    zapdrz said:
    Got sick after returning from a family trip to Florida in early March right before all this craziness started. I’ve been mildy sick for over a month now. Symptoms started with a headache, sore throat, tiredness and aches and proceeded over a couple of days to GI symptoms (nausea and diarrhea) and low grade fever (never much above 100). No respiratory symptoms at all. The GI stuff and fever have lasted on and off for 35 days. I can’t remember ever being sick for more than 2 or 3 days! Was finally feeling better a few days ago and then it came back. Was tested for Covid last week and results were negative, but my doc still thinks that’s what I’m battling... and that because of being tested late and never having respiratory stuff the test was a false negative. Who knows at this point. I just wanna kick it. I did have a flu shot in the fall. Feels like Groundhog Day as I’ve been quarantined in my bedroom the whole time because a family member is immunocompromised. What’s kept me sane is hearing of other healthy people like myself who have been battling similar symptoms for similar lengths of time. I’m 44, male, and healthy with no underlying med issues. Prior to getting sick I got regular exercise (biking, etc.) I have two other acquaintances in other parts of the country who have been dealing with very similar symptoms and duration of illness.



    Hi ! I thing i got the virus around Mars 16. Then i didnt notice since i start to be tired and not breath property ( nothing for call the doctor ) then on Mars 27 i start with pain in the abdomen zone and after 3 days of this pain i got diarrhea for about 5 or 6 days. Then with some advice from my Dr by phone i needed to stay at home for 2 weeks more.
    After that ( 2 weeks ) i start to breath good and feel better, but my poo was not normal. So i didnt give so much attention. That friday i drank some beers at home and in the night i have a huge pain in my chest. OH my good i feel thats it ! I start to drink water and make some breathing exercises. Thanks god i start to feel good. After the hang over and another day i start to feel AGAIN sick. Sooo bad really i fell that was cause the alcohol i drank or something... anyways . with lot of calls to the Dr i start to feel good and bad good and bad passing the days. Now is 30 days with all the symptoms and all the bad feelings. I called today my Dr and she said that needs to go soon and i need to wait. I am 42 year old from Sweden... since here everything its quit normal i juts wonder if some one here is feeling better or how long time it takes to dont have pain at all in the stomatch, with poo in a normal way and sore throat. etc. Hope some one can answer me please. Take good care and thanks. / Charlie
    Reply
  • CharlieBeach
    ejbriel said:
    I think an antibody test will eventually be available. That would tell you if you recovered from a COVID-19 infection and theoretically have immunity.
    admin said:
    Some patients with COVID-19 experience gastrointestinal symptoms, particularly diarrhea, as the first sign of illness.

    Diarrhea is first sign of illness for some COVID-19 patients : Read more

    Hi ! I thing i got the virus around Mars 16. Then i didnt notice since i start to be tired and not breath property ( nothing for call the doctor ) then on Mars 27 i start with pain in the abdomen zone and after 3 days of this pain i got diarrhea for about 5 or 6 days. Then with some advice from my Dr by phone i needed to stay at home for 2 weeks more.
    After that ( 2 weeks ) i start to breath good and feel better, but my poo was not normal. So i didnt give so much attention. That friday i drank some beers at home and in the night i have a huge pain in my chest. OH my good i feel thats it ! I start to drink water and make some breathing exercises. Thanks god i start to feel good. After the hang over and another day i start to feel AGAIN sick. Sooo bad really i fell that was cause the alcohol i drank or something... anyways . with lot of calls to the Dr i start to feel good and bad good and bad passing the days. Now is 30 days with all the symptoms and all the bad feelings. I called today my Dr and she said that needs to go soon and i need to wait. I am 42 year old from Sweden... since here everything its quit normal i juts wonder if some one here is feeling better or how long time it takes to dont have pain at all in the stomatch, with poo in a normal way and sore throat. etc. Hope some one can answer me please. Take good care and thanks. / Charlie
    Reply