By Dr. A.K. Satheesh Rao, Senior Consultant in Gastroenterology, Narayana Multispeciality Hospital, Mysuru

A 40-year-old man came to my OPD in the end of June with complaints of  nausea and severe tiredness  since  one week. I got  all routine  investigations done for him. The reports  came  normal. He was given the medicines but came back with no relief. So, covid test was done, which came positive! All his symptoms were due to covid-19. This was my first encounter with covid. Until that time, we thought that it causes symptoms like  cough, fever,  etc. This case was an  eye-opener. 

Similarly, by the end of July, I saw a lot of patients coming with loss of appetite, burning sensation in stomach, abdominal discomfort, weight loss  for more than 2 weeks and most of these patients turned out to be covid positive.

By August end, I saw patients with severe abdominal pain and  jaundice testing positive for the virus. It created diagnostic challenge by elevation of some lab parameters like amylase, lipase which is otherwise usually seen in pancreatic pathologies.

By the end of September, a lot of patients  posted for procedures like endoscopy, colonoscopy,  ERCP and EUS for various gastrointestinal complaints surprisingly  tested positive. Most of these patients did not have any covid related respiratory  symptoms.

The most difficult and tough part of this saga was that the patients were totally in disbelief about COVID positivity. The patients were reluctant to accept  Covid as the diagnosis as they did not have cough, fever or breathlessness. We had to dedicate lot of time for counselling these patients to make them understand the spectrum of COVID-19.

Gut invader

According to early reports  from China, Gastrointestinal symptoms were seen  only in 10 percent cases,  but recent studies show that its incidence is  much higher,  around 60 percent. The symptoms predominantly will be loss of taste, loss of smell, loss of appetite, nausea, abdominal pain, diarrhoea, hiccups  and  mild jaundice.  After respiratory tract,  gastrointestinal tract (also called the GI tract) is the common organ involved in this viral disease. Molecule which the virus attacks in our bodies — Angiotensin Converting Enzyme 2 or ACE2 — is present not just in our lungs, but in our gastrointestinal tract as well. This is what could be behind the significant number of cases in which patients show gastrointestinal symptoms such as diarrhoea, nausea and vomiting. This together with the presence of the virus in the faeces suggest the gastrointestinal tract as another possible route of infection and transmission.

 Most of these patients also had finding in lungs on CT suggesting that both lungs and gastrointestinal tract were involved.  

In a separate study of those with a mild form of COVID-19, researchers compared those who had gastrointestinal or respiratory symptoms or both, with those presenting only with respiratory symptoms. They found that 23 percent of patients had gastrointestinal presentations alone, while 57 percent had both gut and respiratory illness. It also took longer for those with digestive symptoms to clear the virus.

One group of researchers also noted health of our gut bacteria has a critical role in how our immune system reacts to the disease. So it is important to maintain a healthy microbiome to fight COVID-19 also.

I would like to strongly assert that covid-19 pandemic has invariably modified the module of Gastroenterologist’s practice.  We neither wore mask nor wore PPE until the covid pandemic surfaced.  Now since GI involvement of covid-19 is well documented and also it is a aerosol borne infection, we are left with no other options but to follow the standard protocol of PPE. 

It is a tough time even for the patients to undergo covid testing for all gastrointestinal  problems and before procedures. This is how covid has involved gastrointestinal tract and creating stress to both patients and  doctors. During this pandemic,  gastritis cases have increased due to excessive consumption of kashayas !

Gut feeling

With the pandemic continuing, we should all pay more attention to our guts. Much of the focus to date has been on ventilators, intensive care and the respiratory consequences of the Novel Coronavirus infection. However, if you have new onset sickness and vomiting, abdominal pain or diarrhoea, and no other explanation, it may be COVID-19 and you may need to seek help.

And it is true that the gastrointestinal tract is another source for virus transmission in both symptomatic and asymptomatic individuals; it remains paramount that people follow the advice to stay home and stay safe with a combination of shielding, social distancing and regular hand-washing.

Finally, eating plant-based food  and limiting ultra-processed and take-away foods are to be commended, while supplementing your diet with more fruits, fresh vegetables and plenty of water. Eating well may just make a difference to  COVID-19 outcome.

Still the pandemic is not over. It is the responsibility of all citizens to wear mask, follow strict social distancing and getting tested early to prevent its spread. I also appeal all to consider gastrointestinal symptoms as an indication  for COVID-19 testing.