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Should patients with only gastrointestinal symptoms be tested for COVID-19?

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‘Basically, anything that looks like a viral infection is something that doctors should consider testing.’
 
That is Associate Professor Hassan Vally, an epidemiologist at La Trobe University with a special interest in infectious diseases.
 
He is talking to newsGP about potential testing for COVID-19, following the addition of three new symptoms to the recognised list managed by the US Centers for Disease Control and Prevention (CDC).
 
The new symptoms are:

• congestion or runny nose
• nausea or vomiting
• diarrhoea.

This is the first time the CDC has added gastrointestinal symptoms to its list of recognised COVID-19 symptoms, though the World Health Organization (WHO) already lists diarrhoea – but not nausea or vomiting – as a potential symptom.
 
The Federal Department of Health also currently lists all three as potential coronavirus symptoms, but the Communicable Diseases Network Australia (CDNA) stops shorts of including them in its clinical criteria for suspect cases.
 
Yet, Victoria’s recent sharp increase in cases – another 73 were added overnight – raises the question of whether patients with gastrointestinal symptoms only should be tested for COVID-19.
 
So far the outbreak has prompted a series of drastic containment measures from health authorities, including targeted lockdowns and a mass-testing blitz that has collected samples from 113,000 people in the past week alone.
 
But, despite the spike, Dr Antony Friedman doesn’t think Australia has a high enough volume of cases to warrant such a major change to testing criteria – yet.
 
The gastroenterologist at the Alfred Hospital and Epworth Healthcare told newsGP the number of reported cases of COVID-19 with purely gastrointestinal symptoms – in the absence of respiratory ones – still appears to be ‘incredibly low; probably less than 10%’.
 
‘Does that mean that all patients in Australia with a gastrointestinal illness should be checked for COVID? At this stage, I think that an Australian jury would say no,’ he said.
 
This assessment differs to that of Martin Veysey, professor of gastroenterology at the University of Hull, who believes standalone gastrointestinal symptoms may indicate infection with COVID-19.
 
In an article published in The Conversation, he wrote that although we tend to think of respiratory symptoms when it comes to COVID-19, the infection could also cause gastrointestinal symptoms.
 
That is because the Angiotensin Converting Enzyme 2 (ACE2) receptor, which is how the SARS-CoV-2 virus enters cells, is present in both the lungs and the gastrointestinal tract.
 
‘This is what could be behind the significant number of cases in which patients show gastrointestinal symptoms such as diarrhoea, nausea and vomiting,’ he wrote.
 
Research published in June in Clinics and Research in Hepatology and Gastroenterology backs that notion.
 
In a retrospective study of 114 patients conducted from 1–17 March, nearly half (48%) had diarrhoea. Of those 55 patients, 29 had at least one other simultaneous gastrointestinal symptom such as nausea, abdominal pain or vomiting.
 
Professor Veysey also referenced a recent commentary in Gut, which highlighted evidence from China that showed more than one quarter of COVID-19 patients with gastrointestinal issues like diarrhoea, nausea and vomiting, may not have had respiratory symptoms.

Gastroenterologist Dr Antony Friedman believes there aren’t enough cases in Australia to warrant testing people who only present with gastrointestinal symptoms.
 
In light of the evolving situation, Associate Professor Vally says if a patient presents with purely gastrointestinal symptoms in the absence of respiratory ones, it may be worth considering testing.
 
‘We shouldn’t across the board test those with solely gastrointestinal symptoms, but there should be recognition that people could have this symptom alone,’ he said.
 
‘[For example], there could be a case made for testing some people who have only these symptoms, [if they are] from a hot spot or from a high-risk occupation or industry.
 
‘It’s really an extension of the “test everyone” strategy, but you are factoring in clinical presentation along with epidemiological information.’
 
Associate Professor Vally also believes the recognised symptom list of COVID-19 may keep evolving as we learn more about the illness.
 
‘Ten million people have got this infection,’ he said.
 
‘So even with the flu, if you infect 10 million people you’re going to see just about every symptom under the sun because that’s what viruses do.
 
‘Presumably it’s a case of trying to make the distinction as to whether a symptom is just an unusual one in a few people, or whether it’s starting to [become] a trend where a decent number of people have it.’
 
At this stage, Dr Friedman does not believe Australian patients with purely gastrointestinal symptoms should be tested for COVID-19.
 
‘In Australia we have a very low prevalence of coronavirus, so the likelihood of a patient with purely gastrointestinal symptoms actually having coronavirus are still incredibly low,’ he said.
 
However, he said if the number of COVID-19 patients in Australia increases, then that answer may change accordingly.
 
‘It is not unreasonable when you look at the data from high-prevalence societies such as North America, Europe and China – where there have been cases reported of purely gastrointestinal symptoms and patients subsequently test positive,’ he said.
 
‘[So] if we do see a genuine second spike and this takes off … then [the answer would be] probably yes.’
 
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CDC coronavirus COVID-19 gastrointestinal

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