Analysis of Gastrointestinal and Hepatic Manifestations of SARS-CoV-2 Infection in 892 Patients in Queens, NY

Abstract

S evere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an RNA virus responsible for coronavirus disease 2019 (COVID-19). 1,2 The virus enters cells via the angiotensin-converting enzyme 2 receptor, which is present in enterocytes in the ileum and colon. 3 Gastrointestinal (GI) manifestations include diarrhea, nausea, vomiting, and abdominal pain, and the prevalence of GI symptoms varies greatly, with a range between 2% and 57%. 4 In addition, abnormal liver chemistries are reported commonly. 4 As a medical center at the forefront of the early epidemic in the United States, we seek to contribute to the growing body of literature that outlines the gastrointestinal and hepatic manifestations of COVID-19. Methods We performed a retrospective review of consecutive adult nonpregnant patients admitted to New York-Presbyterian Queens Hospital in Flushing, NY, for SARS-CoV-2 between March 14, 2020, and April 1, 2020 (Supplementary Methods). The Fisher exact, chi-square, and Wilcoxon rank-sum tests were used to compare groups, and a P value less than .05 was considered statistically significant. This study was approved by the New York-Presbyterian Queens Institutional Review Board.

Hepatic Predictors of Mortality in Severe Acute Respiratory Syndrome Coronavirus 2: Role of Initial Aspartate Aminotransferase/Alanine Aminotransferase and Preexisting Cirrhosis

“…There has only been one U.S.‐based study analyzing the relationship between elevated AST and ALT in conjunction with COVID‐19 outcome. ( 33 ) There have also been prior studies characterizing the effect of medical conditions on patients infected with SARS‐CoV2. ( 7,8,10 ) Advanced age, cardiopulmonary disease, and metabolic syndrome are all associated with risk of death and morbidity in COVID‐19.…”

Potential intestinal infection and faecal–oral transmission of SARS-CoV-2

“…It is worth mentioning that different studies have adopted different criteria for what constitutes gastrointestinal symptoms. In some studies, gastrointestinal symptoms only included diarrhoea, nausea and vomiting 16 , 19 , 23 , whereas in others, symptoms such as loss of taste, abdominal pain and loss of appetite were also included 17 , 24 , 25 , 29 . For example, a multicentre study in China reported gastrointestinal symptoms, including diarrhoea (3.8%), nausea and vomiting (5%), as less common symptoms 11 , whereas one single-centre study in Baltimore, USA, reported gastrointestinal symptoms, including nausea, vomiting, diarrhoea, abdominal pain, anorexia, haematochezia, and loss of smell or taste, in more than 70% of patients with COVID-19 (ref.…”

Hepatic manifestations of COVID-19

“…7 In a large retrospective study out of New York City, levels of aspartate aminotransferase (AST) were frequently higher than levels of ALT, suggesting that AST may be a useful indicator of COVID-19 infection. 8 A cholestatic pattern of injury, however, is rarely associated with COVID-19. 6,9 Other abnormalities in liver enzymes include elevations in gamma-glutamyl transferase (GGT), which, in one study, occurred in 13.6% of patients with COVID-19.…”

“…[13][14][15] Lopinavir/ritonavir, hydroxychloroquine (less commonly), azithromycin, and tocilizumab have also been associated with abnormal AST and ALT levels in this setting. 3,8 Although it is important to note that abnormal liver biochemistries are not a contraindication to using COVID-19 therapies, liver enzymes should be monitored regularly in all hospitalized COVID-19 patients. 1 A summary of recommendations for the evaluation of patients with abnormal liver enzymes and COVID-19 can be found in Table 1.…”

“…6,18 In addition, peak ALT was found to be associated with death or discharge to hospice in a large US cohort study, 6 while an elevated baseline AST level has been associated with ICU admission, intubation, and death in another study. 8 Finally, alkaline phosphatase peak values have also been shown to correlate with the risk of death 19 In addition, metabolic-associated fatty liver disease (MAFLD, previously termed non-alcoholic fatty liver disease) appears to be associated with an increased risk of severe disease. 1,20 In a study of 202 COVID-19-positive patients, those with MAFLD had an increased risk of severe disease and a longer viral shedding time.…”