The COVID-19 infection has struck the world involving 199 countries and infecting more than 1.8 million individuals to date. About 100,000 deaths have already been reported globally and the numbers are increasing on a daily basis. The entire world is gearing up to fight this battle at an unprecedented scale. In this scenario, it’s heartening to see endless debates, discussions, education programs relating to the infection on the entire media including social media. It is correct that the emphasis in the media has been on:

1. Prevention – with self-isolation, social distancing, sanitation, hand washing and the use of masks.

2. Respiratory illness – which commonly presents with fever, cough & breathlessness.

3. Strategies for testing, personal protective equipment for healthcare professionals, treatment modalities & the research for a vaccine.

Since, the typical presentation of this disease revolves around the respiratory system, hence the importance of gastrointestinal and liver features related to COVID-19 infection has been largely ignored. The purpose of this article is to draw attention to the gastrointestinal and liver effects of COVID-19 infection so that the knowledge is able to help with preventive strategy, early diagnosis and management of such patients.

Globally various studies have focused on GI symptoms and the detection of the virus in feces. About 50% of patients with COVID-19 infection have GI symptoms such as diarrhea, nausea, vomiting & abdominal pain and about a third of patients with GI symptoms do not have respiratory symptoms. Around 40% of the patients with GI involvement do not have a fever. Diarrhea (19%) remains the predominant GI symptom and often it precedes the chest symptoms and hence may be considered an initial presentation of COVID-19 infection. Besides, there is evidence to suggest that patients with GI involvement have more severe disease and took a longer duration for viral clearance than those without GI involvement. This may be attributed to the high viral load in patients with extra-pulmonary organ involvement. COVID-19 viral RNA was detected in the stool of more than half the hospitalized patients in the study in Wuhan. Other studies have shown edematous changes in stomach, duodenum & rectum with viral RNA detected in the biopsy specimen of the epithelium. The viral host receptor ACE-2 and viral nucleocapsid protein have been found in the GI epithelium. All the above findings suggest that the virus is present in the gut and has effects on the GI tract.

This brings us to the question has to whether fecal-oral transmission may also occur. Fecal shedding of the virus has been seen in more than 20% of patients who had recovered the respiratory illness with negative antigen test, Thus, the fecal-oral transmission remains possible even after recovery from respiratory illness and this will have clear implication regarding prevention of transmission especially in hospitalized patients.

Previous experience with SARS in 2004 had shown that about 60% of patients had liver dysfunction and liver biopsies in these patients had shown viral nucleic acid particles. Abnormalities in the liver function test with elevated transaminase / Gama GT is seen in about 15-54% patient with COVID-19 infection. Patients with severe disease have higher rates of liver dysfunction. In a study by Huang, et.al about 62% of patients in ICU settings had liver abnormalities as compared to only 25% of patients who did not require ICU care. Thus, liver injury is more common in severe disease as compared to mild cases. In a study, 54% of COVID-19 patients had elevated Gama GT levels. The viral host receptor ACE-2 expression is high in biliary tract epithelium suggesting a higher likelihood of biliary injury as evidenced by a rise in Gama GT levels. The mechanism of liver dysfunction is either direct viral related hepatocyte toxicity or an immune-mediated response with high oxidative stress on the hepatocytes. In a clinical setting, the drug-induced hepatic injury should also be considered. In addition, it should be remembered that both COVID-19 infection and non-alcoholic fatty liver disease (NAFLD) have common comorbidities and more severe disease consequences in the elderly, diabetics & hypertensive. Given that NAFLD is commonly prevalent in the community it’s likely that NAFLD makes COVID-19 patients more suspectable to liver dysfunction in COVID-19 infection.

1. In this pandemic, patients presenting with diarrhea should raise suspension about COVID-19 infection. Close questioning regarding contact with COVID-19 patients or travel history must be obtained. Patients should be isolated at home and monitored for development of fever, cough or dyspnoea and if present, then RT-PCR testing should be considered as per ICMR protocol. If positive, proceed with the standard treatment protocol.

2. Consider the possible risk of fecal-oral transmission even after the resolution of respiratory illness. A more prolong isolation of additional 7-14 days may be considered esp. in hospitalized patients.

3. Considering the possibility of fecal-oral transmission in such patients, certain measures must be emphasized particularly if the toilet is being used by others

a. Advices to close the toilet cover before flushing.

b. Regular and proper sanitization of commode button/handle and toilet door handles after using the toilet.

c. Normally the gastric acid has the ability to kill the virus. Hence infection is more likely in patients who are taking acid-reducing medications such as ranitidine or PPI such as pantoprazole etc. Therefore, the unnecessary use of PPI should be avoided.

4. Look for evidence of liver dysfunction in all patients with COVID-19 infection.

5. Avoid agents that may cause liver toxicity such as alcohol, NSAIDs, etc.

6. Patients with NAFLD should be considered high-risk factors for liver dysfunction in patients with COVID-19 infection and LFT should be monitored closely. Comorbid conditions such as diabetes and dyslipidemia should be treated meticulously.

7. Due care should be given for prescribing antibiotics and/ or antiviral keeping in view the liver dysfunction.