COVID-19-associated nausea and vomiting

SARS-CoV-2 mainly causes severe acute respiratory syndrome but may also present with gastrointestinal symptoms like diarrhea. It invades through the angiotensin-converting enzyme 2 (ACE2) and the serine protease TMPRSS2 receptors present abundantly not only in the lungs but also in the enterocytes of the small intestine. Nausea and vomiting are the less common gastrointestinal symptoms associated with COVID-19. Anorexia and diarrhea are more common.

• The etiological agent of COVID-19 infection is SARS-CoV-2, named for the similarity of its symptoms to those induced by the severe acute respiratory syndrome, it is a virus identified as the cause of an outbreak of respiratory illness first detected in Wuhan, China.^[1][2]
• The growing number of patients however, suggest that human-to-human transmission is actively occurring.^[3][4]
• The outbreak was declared a Public Health Emergency of International Concern on 30 January 2020.
• On March 12, 2020, the World Health Organization declared the COVID-19 outbreak a pandemic.

There is no established system for the classification of nausea and vomiting in COVID-19.

• SARS-CoV-2 uses the Angiotensin-converting enzyme 2 (ACE2) and the serine protease TMPRSS2 receptors for cell entry.
• These receptors are present abundantly not only in the lungs but also in the enterocytes of the small intestine.
• Other sites of expression of the receptors in the gastrointestinal tract are-the upper esophagus, liver, and colon.^[5][6]
• Entry of the virus causes disruption of the enterocytes and may lead to inflammation and alteration of intestinal permeability.
• The gastrointestinal symptoms of COVID-19 are thought to arise due to the invasion of enterocytes.^[7]

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

COVID-19 associated nausea and vomiting must be differentiated from other diseases that cause nausea and vomiting in a hospitalized patient inlclude:

• Medication-induced nausea and vomiting
• Food poisoning
• Gastroenteritis (viral or bacterial)
• Migraine
• Indigestion
• Acute liver failure

• The prevalence of nausea in COVID-19 patients is 26%.
• The more common GI symptoms include anorexia (35% prevalence) and diarrhea (34% prevalence).^[8]
• 16% of patients presented only with GI symptoms such as diarrhea, nausea, and vomiting without any respiratory symptoms. ^[9]

Some gastrointestinal factors may predispose patients to infection with COVID-19. Common risk factors in the development of nausea and vomiting include:^[10]

• Inflammatory bowel disease patients- due to use to glucocorticoids, but not TNF-alpha inhibitors
• Increasing age
• Other comorbidities
• Use of glucocorticoids

• There is insufficient evidence to recommend routine screening.

• There is not enough data on the natural history, complications, and prognostic implications of nausea and vomiting in COVID-19.
• To view natural history, complications, and prognosis of COVID-19, click here.

• COVID-19 nausea and vomiting can be diagnosed based on the history of gastrointestinal symptoms like anorexia, diarrhea and a positive stool test for SARS-CoV-2
• There are no established criteria for the diagnosis of nausea and vomiting in COVID-19.

• According to a study by Redd et al, the prevalence of nausea in COVID-19 patients was 26%. The most common GI symptoms include anorexia and diarrhea.^[8]
• Another study by Luo et al reported that 16% of patients presented with GI symptoms like diarrhea, nausea, vomiting without any respiratory symptoms. ^[9]

Patients with gastrointestinal symptoms of COVID-19 usually appear listless. Physical examination of patients is non-specific.

• Infectious virions released from the GI tract can be monitored by real-time reverse transcriptase polymerase chain reaction (rRT-PCR).
• A study by Xiao et al assessed the clinical significance of measuring SARS-CoV-2 RNA in the feces. The fecal test remained positive until 12 days after the disease onset in patients with diarrhea.^[11]
• Notably, stool test for viral RNA remained positive despite negative respiratory tests. This suggests the possibility of gastrointestinal transmission via the fecal-oral route despite clearance from the respiratory tract.
• It was recommended transmission-based precautions for hospitalized COVID-19 patients should be continued till the rRT-PCR for SARS-CoV-2 turns negative.

There are no ECG findings associated with nausea and vomiting in patients with COVID-19.

• The chest X-ray findings in a suspected case of coronavirus infection can mimic the findings in pneumonia, which can include:^[12]

• Consolidation
• Interstitial infiltration

There are no echocardiography/ultrasound findings associated with nausea and vomiting in COVID-19.

There are no CT scan findings associated with nausea and vomiting in COVID-19.

There are no MRI findings associated with nausea and vomiting in COVID-19.

There are no other imaging findings associated with nausea and vomiting in COVID-19.

There are no other diagnostic studies associated with nausea and vomiting in COVID-19.

• Supportive management is the mainstay of treatment of nausea and vomiting.
• 5-HT3 antagonists such as ondansetron, granisetron, dolasetron, and palonosetron are commonly used for symptomatic relief.
• Rehydration, fluid repletion, and potassium monitoring are essential.

• Effective measures for the primary prevention of COVID-19 include:^[13]
  • Frequent handwashing with soap and water for at least 20 seconds or using a alcohol based hand sanitizer with at least 60% alcohol
  • Staying at least 6 feet (about 2 arms’ length) from people who do not live with you
  • Covering your mouth and nose with a cloth face cover when around others and covering sneezes and coughs
  • Cleaning and disinfecting
• There have been rigorous efforts in order to develop a vaccine for novel coronavirus and several vaccines are in the later phases of trials.^[14]

• Presence of the virus in the stool raises suspicion for fecal-oral transmission of SARS-CoV-2.
• Appropriate personal protective equipment (PPE) must be used while handling sources of contamination like feces.
• Elective appointments and endoscopies should be rescheduled and extreme care must be taken by health care professionals of the endoscopy units to avoid spreading the virus from one patient to another. ^[15]
• Patients listed for fecal microbiota transplantation and donors should be screened for the SARS-CoV-2.

• Effective measures for the secondary prevention of COVID-19 include:
  • Use of personal protective equipment (PPE) by the personnel handling the fecal matter.
  • Screening of fecal microbiota transplant donors for COVID-19 is also recommended.^[16]
  • Contact tracing helps reduce the spread of the disease.^[17]

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