May 5, 2020

AGA publishes recommendations for consultative management of patients with COVID-19

The American Gastroenterological Association (AGA) has published new expert recommendations for the consultative management of patients with COVID-19 in Gastroenterology.

The AGA Institute Clinical Guideline Committee and Clinical Practice Updates Committee performed a systematic review and meta-analysis of international data on gastrointestinal (GI) and liver manifestations of COVID-19.

A total of 118 studies were identified and a hierarchical study selection process was used to identify unique cohorts. The committee performed a meta-analysis of 47 studies including 10,890 unique patients. The majority of studies (70%) in the analysis were from China, with most studies reporting on hospitalized patients.

The prevalence of diarrhea, nausea, vomiting, and abdominal pain as well as liver function test (LFT) abnormalities were analyzed using a fixed effect model and the certainty of evidence was assessed using GRADE.

Findings from the meta analysis showed that:

  • GI symptoms are not as common in COVID-19 as previously estimated. The overall prevalence was 7.7% (95% CI 7.4 to 8.6%) for diarrhea, 7.8% (95% CI: 7.1 to 8.5%) for nausea/vomiting, and 3.6% (95% CI 3.0 to 4.3%) for abdominal pain. Notably, in outpatients, the pooled prevalence of diarrhea is lower (4.0%). 
  • COVID-19 can present atypically, with GI symptoms: COVID-19 can present with diarrhea as an initial symptom, with a pooled prevalence of 7.9% across 35 studies, encompassing 9,717 patients. Most often, diarrhea is accompanied by other upper respiratory infection symptoms. However, in some cases, diarrhea can precede other symptoms by a few days, and COVID-19 may present as isolated GI symptoms prior to the development of upper respiratory infection symptoms. 
  • Liver test abnormalities can be seen in COVID-19 (in approximately 15% of patients): However, available data support that these abnormalities are more commonly attributable to secondary effects from severe disease, rather than primary virus-mediated liver injury. Therefore, it is important to consider alternative etiologies, such as viral hepatitis, when new elevations in aminotransferases are observed. 

The committee also noted that diarrhea, nausea/vomiting, liver abnormalities were more prevalent outside of China when they compared data from China to studies from countries other than China. 

Based on findings from the meta analysis, the committee has made the following Best Practice Statements for the consultative management of COVID-19.

  1. In outpatients with new onset diarrhea:
    1. ascertain information about high risk contact exposure 
    2. obtain a detailed history of symptoms associated with COVID19, including fever, cough, shortness of breath, chills, muscle pain, headache, sore throat, or new loss of taste or smell 
    3. obtain a thorough history for other Gl symptoms, including nausea, vomiting, and abdominal pain. 
  2. In outpatients with new onset Gl symptoms (e.g., nausea, vomiting, abdominal pain, diarrhea), monitor for symptoms associated with COVID-19 as GI symptoms may precede COVID-related symptoms by a few days. In a high COVID-19 prevalence setting, COVID-19 testing should be considered. 
  3. In hospitalized patients with suspected or known COVID-19, obtain a thorough history of GI symptoms (nausea, vomiting, abdominal pain, diarrhea) including onset, characteristics, duration, and severity. 
  4. There is presently inadequate evidence to support stool testing for diagnosis or monitoring of COVID-19 as part of routine clinical practice. 
  5. In patients (outpatients or inpatients) with elevated LFTs in context of suspected or known COVID-19, evaluate for alternative etiologies. 
  6. In hospitalized patients with suspected or known COVID-19, obtain baseline LFTs at the time of admission, and consider LFT monitoring throughout the hospitalization, particularly in the context of drug treatment for COVID-19. 
  7. In hospitalized patients undergoing drug treatment for COVID-19, evaluate for treatment-related Gl and hepatic adverse effects.

“These findings inform time-sensitive clinical guidance in context of this pandemic to pursue careful evaluation of patients with new-onset gastrointestinal complaints for classic and atypical symptoms of COVID-19”, the committee concluded. It added that all hospitalized patients with COVID-19 may benefit from liver enzyme monitoring, particularly in the context of drug treatment with known hepatotoxic potential. 

The committee also added that further research is needed to clarify the implications of SARS-CoV-2 in stool and potential impact on transmission and clinical management and that further studies are needed with standardized GI symptoms questionnaires and LFT checks on admission to better quantify and qualify the association of these symptoms with COVID-19. 

The committee said that it will also conduct periodic reviews of the literature and monitor the evidence to determine if recommendations require modification.

SOURCE: American Gastroenterological Association