Prevalence of gastrointestinal symptoms and fecal viral shedding in patients with COVID-2019: a systematic review and meta-analysis.

Prevalence of gastrointestinal symptoms and fecal viral shedding in patients with COVID-2019: a systematic review and meta-analysis. Spencer EA, Heneghan C.

Published on July 9, 2020

Reference Parasa S, Desai M, Thoguluva Chandrasekar V, et al. Prevalence of gastrointestinal symptoms and fecal viral shedding in patients with coronavirus disease 2019: A Systematic Review and Meta-analysis. JAMA Netw Open. 2020;3(6):e2011335. Published 2020 Jun 1. 2020
Study type
Country N/A
Setting Mainly Hospital
Funding Details Non reported
Transmission mode Orofecal

Bottom Line

This review reports that the Gastrointestinal tract supports the growth of SARS-CoV-2 to an extent similar to previous SARS infections and that gastric symptoms are frequently experienced in COVID-19.

Evidence Summary

29 relevant studies were included: 23 published and 6 preprints (most of the included studies were of moderate quality).

Approximately 12% of patients with SARS-CoV-2 infection reported gastrointestinal symptoms, including diarrhoea, nausea, and vomiting. SARS-CoV-2. 

Eight studies reported the detection of viral RNA of SARS-CoV-2 in stool and the pooled analysis reported that RNA shedding in stool was detected in up to 41% of COVID-19 patients.

Liver enzyme levels outside reference ranges were observed in 15% to 20% of patients.

What did they do?

This was a systematic review and meta-analysis to estimate the incidence rates of gastrointestinal symptoms among patients with SARS-CoV-2. Methods were reported as follows:

The search was performed using MEDLINE/PubMed and Embase and preprint using bioRxiv and medRxiv from November 1st 2019 to March 30th 2020. The search terms included “COVID-19,” “SARS-Cov-2,” and/or “novel coronavirus.

Eligible studies were those including patients with SARS-CoV-2 infection who reported GI symptoms.

Data on patients with GI symptoms (ie, diarrhoea, nausea, or vomiting), liver enzyme level changes, and fecal shedding of the virus were extracted. 

The quality of the studies was examined using the methodological index for nonrandomized studies. Pooled estimates were reported with 95% CIs with the level of heterogeneity (I2).

Study reliability

Most included studies were from China and were large case series or observational studies, which are subject to methodological biases. The quality of clinical data was often not clear in the included studies.

Clearly defined setting Demographic characteristics described Follow-up length was sufficient Transmission outcomes assessed Main biases are taken into consideration
Yes Yes N/A No No

What else should I consider?

Study and Characteristics of the Included Studies

Source Setting Population Patient numbers
Chen et al Zhongnan Hospital, Wuhan, China Pregnant women with laboratory-confirmed COVID-19 pneumonia 9
Zhang et al Jinhua Hospital, China Patients with laboratory-confirmed COVID-19 pneumonia 14
Wang et al 21 hospitals in 17 cities in, China Children 31
Xiao et al Guangzhou, China Hospitalized patients with SARS-CoV-2 detected in stool 73
Ling et al Shanghai, China All patients with COVID-19 in Shanghai region 66
Liu et al hospitals in Hubei province, China Patients with COVID-19 admitted to the respiratory departments 137
Yang et al Wenzhou, China Patients with SARS-CoV-2 infection confirmed via RT-PCR 149
Xu et al hospitals in Zhejiang, China Hospitalized patients with laboratory-confirmed SARS-Cov-2 62
Liu et al Jianghan University Hospital, Wuhan, China Physicians and nurses 30
Guan et al Wuhan, China Adults with SARS-CoV-2 infection 1099
Huang et al Wuhan, China Adult patients 41
Chen et al Wuhan, China Adult patients 99
Wang et al Zhongnan, Wuhan Adult patients 138
Zhang et al Fever clinic in Beijing, China All patients 9
Chen et al Wuhan, China Patient admitted to the isolation ward 29
Wang et al Shanghai, China Patients receiving combined Chinese and Western medicine 4
Chang et al Beijing, China Hospitalized patients 13
Pan et al Wuhan, China Adult patients 204
Luo et al Wuhan, China Hospitalized patients 1141
Zhou et al Wuhan, China Medical staff and nonstaff patients 254
Jin et al Zhijang province, China Adult patients 651
Preprint studies
Zhang et al Hubei, Shiyan, China Patients aged 0-14 y 34
Qian et al Wuhan, China NA 91
Fan et al Shanghai, China Patients aged 15-88 y 148
Zhao et al Hospital of University of Science and Technology of China Patients aged 16-91 y 75
Han et al Wuhan, China Hospitalized patients aged 27-92 y 206
Xu et al Guangzhou, China Pediatric patients 10
Wu and McGoogan Multicenter CDC database 72 314 case records 44 ,672
Liu et al Union Hospital, Wuhan, China Patients aged 23-63 y 64



About the authors

Carl Heneghan

Carl is Professor of EBM & Director of CEBM at the University of Oxford. He is also a GP and tweets @carlheneghan. He has an active interest in discovering the truth behind health research findings

Elizabeth Spencer

Dr Elizabeth Spencer; MMedSci, PhD. Epidemiologist, Nuffield Department for Primary Care Health Sciences, University of Oxford.