Gastrointestinal and Hepatobiliary Manifestations of Coronavirus Disease-19: Potential Implications for Healthcare Resource-Deficient Countries

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Mohammad K. Parvez


It is believed that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has evolved and developed with broad tissue tropism as hospitalized coronavirus disease (COVID)-19 patients have been showing non-respiratory manifestations. As evidenced in recent clinical studies, even if the results of oral or nasal swab test were negative, the tests on rectal swab, feces, and blood samples in recovered patients could still be positive. The viral shedding in these specimens provides a cautionary warning that fecal-oral route may represent a hidden trigger of rampant spread of COVID-19 in developing countries with poor sanitization. In addition, the presence of SARS-CoV-2 in rectal, fecal, and blood samples endorses gastrointestinal and hepatic origins for the pathogenesis of COVID-19. These observations highlight the importance for the infected patients to obtain accurate and timely diagnosis as well as the treatment of COVID-19 and its associated non-respiratory symptoms to reduce the risk of spreading the infection through unexpected routes. This review also discusses the potential implications of fecal-oral transmission of COVID-19 for healthcare resource-deficient countries.


COVID-19, SARS-CoV-2, Gastrointestinal manifestations, Hepatobiliary manifestations

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World Health Organization. Coronavirus Disease (COVID-19) Outbreak Situation. Available from: [Last assessed on 2020 May 27].

Ren LL, Wang YM, Wu ZQ, et al., 2020, Identification of a Novel Coronavirus Causing Severe Pneumonia in Human: A Descriptive Study. Chin Med J (Engl), 111(9):1015-24.

Chen Y, Liu Q, Guo D, 2020, Emerging Coronaviruses: Genome Structure, Replication and Pathogenesis. J Med Virol, 92:418-23. DOI: 10.1002/jmv.25681.

Li W, Shi Z, Yu M, et al., 2005, Bats are Natural Reservoirs of SARS-Like Coronaviruses. Science, 310:676-967. DOI: 10.1126/science.1118391.

Huang C, Wang Y, Li X, et al., 2020, Clinical Features of Patients Infected with 2019 Novel Coronavirus in Wuhan, China. Lancet, 395:497-506.

Chan JF, Kok KH, Zhu Z, et al., 2020. Genomic Characterization of the 2019 Novel Human-pathogenic Coronavirus Isolated from a Patient with Atypical Pneumonia after Visiting Wuhan. Emerg Microbes Infect, 9:221-36. DOI: 10.1080/22221751.2020.1719902.

Cardenas-Conejo Y, Linan-Rico A, Garcia-Rodriguez DA, et al., 2020. An Exclusive 42 Amino Acid Signature in pp1ab Protein Provides Insights into the Evolutive History of the 2019 Novel Human-pathogenic Coronavirus (SARS-CoV-2). J Med Virol, 2020:25758. DOI: 10.1002/jmv.25758.

Kumar S, Maurya VK, Prasad AK, et al., 2020. Structural, Glycosylation and Antigenic Variation between 2019 Novel Coronavirus (2019-nCoV) and SARS Coronavirus (SARS-CoV). Virus Dis, 31:13-21. DOI: 10.1007/s13337-020- 00571-5.

Walls AC, Park YJ, Tortorici MA, et al., 2020. Structure, Function, and Antigenicity of the SARS-CoV-2 Spike Glycoprotein. Cell, 181:281-92.e286. DOI: 10.1016/j. cell.2020.02.058.

Wong HY, Lam HY, Fong AH, et al., 2019. Frequency and Distribution of Chest Radiographic Findings in COVID-19 Positive Patients. Radiology, 2019:201160.

Ng SC, Tilg H, 2020, COVID-19 and the Gastrointestinal Tract: More than Meets the Eye. Gut, 69:973-4. DOI: 10.1136/gutjnl-2020-321195.

Lin L, Jiang X, Zhang Z, et al., 2020. Gastrointestinal Symptoms of 95 Cases with SARS-CoV-2 Infection. Gut, 69:997-1001.

Zhang W, Du RH, Li B, et al., 2020, Molecular and Serological Investigation of 2019-nCoV Infected Patients: Implication of Multiple Shedding Routes. Emerg Microbes Infect, 9:386-9. DOI: 10.1080/22221751.2020.1729071.

Xu Y, Li X, Zhu B, et al., 2020, Characteristics of Pediatric SARS-CoV-2 Infection and Potential Evidence for Persistent Fecal Viral Shedding. Nature Med, 26(4):502-5. DOI: 10.1038/s41591-020-0817-4.

Holshue ML, DeBolt C, Lindquist S, et al., 2020, First Case of 2019 Novel Coronavirus in the United States. N Engl J Med, 382:929-36.

Tang A, Tong ZD, Wang HL, et al., 2020, Detection of Novel Coronavirus by RT-PCR in Stool Specimen from Asymptomatic Child, China. Emerg Infect Dis, 26(6):1337- 9. DOI: 10.3201/eid2606.200301.

Young BE, Ong SW, Kalimuddin S, et al., 2020, Epidemiologic features and clinical course of patients infected with SARS-CoV-2 in Singapore. J Am Med Assoc, 323(15):1488-94.

Gu J, Han B, Wang J, 2020, COVID-19: Gastrointestinal Manifestations and Potentialfecal-oral Transmission. Gastroenterology, 158(6):1518-9. DOI: 10.1053/j. gastro.2020.02.054.

Wang D, Hu B, Hu C, et al, 2020, Clinical Characteristics of 138 Hospitalized Patients with 2019 Novel Coronavirus-infected Pneumonia in Wuhan, China. J Am Med Assoc, 323(11):1061-9. DOI: 10.1001/jama.2020.1585.

Guan WJ, Ni ZY, Hu Y, et al, 2020, Clinical Characteristics of 2019 Novel Coronavirus Infection in China. N Engl J Med, 382:1708-20.

Zhang C, Shi L, Wang FS, 2020, Liver Injury in COVID-19: Management and Challenges. Lancet Gastroenterol Hepatol, 5(5):428-30.

Qi F, Qian S, Zhang S, et al., 2020, Single Cell RNA Sequencing of 13 Human Tissues Identify Cell Types and Receptors of Human Coronaviruses. Biochem Biophys Res Commun, 526(1):135-40. DOI: 10.1101/2020.02.16.951913.

Zhang H, Shang W, Liu Q, et al., 2020, Clinical Characteristics of 194 Cases of COVID-19 in Huanggang and Taian, China. Infection, 1:1-8. DOI: 10.21203/

Xu L, Liu J, Lu M, et al., 2020, Liver Injury during Highly Pathogenic Human Coronavirus Infections. Liver Int, 40:998-1004. DOI: 10.1111/liv.14435.

Jin YH, Cai L, Cheng ZS, et al., 2020, A Rapid Advice Guideline for the Diagnosis and Treatment of 2019 Novel Coronavirus (2019-nCoV) Infected Pneumonia (Standard Version). Mil Med Res, 7:505.

Norris CA, He M, Kang LI, et al., 2014, Synthesis of IL-6 by Hepatocytes is a Normal Response to Common Hepatic Stimuli. PLoS One, 9:e96053. DOI: 10.1371/journal. pone.0096053.

Duan Z, Chen Y, Zhang J, et al., 2023, Clinical Characteristics and Mechanism of Liver Injury in Patients with Severe Acute Respiratory Syndrome. Chin J Hepatol, 11:493-6.

Gudowska-Sawczuk M, Wrona A, Gruszewska E, et al., 2018, Serum Level of Interleukin-6 (IL-6) and N-terminal Propeptide of Procollagen Type I (PINP) in Patients with Liver Diseases. Scand J Clin Lab Invest, 78:125-30. DOI: 10.1080/00365513.2017.1420217.

Zhang Y, Li J, Zhan Y, et al., 2004, Analysis of Serum Cytokines in Patients with Severe Acute Respiratory Syndrome. Infect Immun, 72:4410-5.

Lau SK, Lau CC, Chan KH, et al., 2013, Delayed Induction of Proinflammatory Cytokines and Suppression of Innate Antiviral Response by the Novel Middle East Respiratory Syndrome Coronavirus: Implications for Pathogenesis and Treatment. J Gen Virol, 94:122679-90. DOI: 10.1099/ vir.0.055533-0.

Jamilloux Y, Henry T, Belot A, et al., 2020, Should we Stimulate or Suppress Immune Responses in COVID-19? Cytokine and Anti-cytokine Interventions. Autoimmun Rev, 19(7):102567. DOI: 10.1016/j.autrev.2020.102567

Xu X, Han M, Li T, et al., 2020, Effective Treatment of Severe COVID-19 Patients with Tocilizumab. Proc Natl Acad Sci USA, 117:10970-5. DOI: 10.1073/pnas.2005615117.

Clinical Trials. Available from: https://www.clinicaltrials. gov/ct2. [Last accessed on 2020 May 27].

Xiao F, Sun J, Xu Y, et al., 2020, Infectious SARS-CoV-2 in Feces of Patient with Severe COVID-19. Emerg Infect Dis, 26(8) :2020 Aug. DOI: 10.3201/eid2608.200681.

Note: This is an early release article as of June 17, 2020.

Yu IT, Li Y, Wong TW, et al., 2004, Evidence of Airborne Transmission of the Severe Acute Respiratory Syndrome Virus. N Engl J Med, 350:1731-9.



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