Covid vomiting

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COVID-19 and Vomiting: A Comprehensive Overview

Prevalence of Vomiting in COVID-19 Patients

Global Prevalence of Gastrointestinal Symptoms

Vomiting is a recognized gastrointestinal (GI) symptom associated with COVID-19, although its prevalence varies across different studies. A meta-analysis by the AGA Institute found that nausea and vomiting occur in approximately 7.8% of COVID-19 patients . Another study reported a similar prevalence, with vomiting occurring in 6.7% of patients . These findings suggest that while vomiting is not the most common symptom, it is still significant and warrants attention.

Regional Variations

Interestingly, the prevalence of GI symptoms, including vomiting, appears to be higher in studies conducted outside of China. For instance, the AGA Institute's meta-analysis noted that the prevalence of nausea and vomiting was higher in countries other than China . This regional variation could be due to differences in healthcare reporting practices or genetic factors influencing symptom presentation.

Mechanisms Behind Vomiting in COVID-19

Viral Interaction with the Gastrointestinal Tract

The mechanisms behind vomiting in COVID-19 are complex and multifaceted. The virus's spike protein interacts with the angiotensin-converting enzyme 2 (ACE2) receptors, which are highly expressed in the gastrointestinal tract. This interaction can lead to the release of mediators from the intestinal epithelium, activating vagal afferents that project to the brainstem, thereby inducing vomiting 24.

Central Nervous System Involvement

Additionally, the virus may directly affect the central nervous system (CNS). Increased levels of plasma angiotensin II, a centrally acting emetic, have been observed in COVID-19 patients, providing another potential mechanism for vomiting . The possibility of viral invasion of the dorsal brainstem, although more likely in delayed onset symptoms, also cannot be ruled out .

Vomiting as an Indicator of Disease Severity

Early Symptom and Disease Progression

Vomiting can sometimes be an early symptom of COVID-19, appearing before more common symptoms like fever and dyspnea. In a clinical study, 10% of patients experienced gastrointestinal symptoms, including vomiting, 1-2 days before the onset of fever and dyspnea . This early presentation can serve as a clinical predictor for the progression towards severe disease, emphasizing the need for early intervention .

Association with Severe Disease

Patients with severe COVID-19 are more likely to present with gastrointestinal symptoms, including vomiting. A systematic review found that the odds of experiencing GI symptoms were significantly higher in patients with severe disease compared to those with non-severe disease . This association underscores the importance of monitoring GI symptoms as potential indicators of disease severity.

Long-term Impact and Management

Prolonged Symptoms in Survivors

Even after recovery, some COVID-19 survivors continue to experience prolonged gastrointestinal symptoms. A systematic review found that 3.19% of COVID-19 survivors reported persistent vomiting, raising concerns about the long-term impact of the virus on the gastrointestinal system . These prolonged symptoms can significantly affect the quality of life, necessitating ongoing medical attention and management.

Recommendations for Healthcare Providers

Given the prevalence and potential severity of vomiting in COVID-19 patients, healthcare providers should be vigilant in monitoring and managing these symptoms. Early recognition and intervention can help mitigate the progression to severe disease and improve patient outcomes. Additionally, caution should be exercised when collecting fecal samples or performing endoscopic procedures, as viral RNA can be present in stool samples even after respiratory samples test negative .

Conclusion

Vomiting is a notable gastrointestinal symptom in COVID-19 patients, with a prevalence that varies globally. The mechanisms behind this symptom involve both peripheral and central pathways, and its presence can serve as an early indicator of disease severity. Long-term gastrointestinal symptoms in survivors highlight the need for continued medical attention. Healthcare providers should remain vigilant in recognizing and managing vomiting in COVID-19 patients to improve overall outcomes.

Sources and full results

Most relevant research papers on this topic

AGA Institute Rapid Review of the Gastrointestinal and Liver Manifestations of COVID-19, Meta-Analysis of International Data, and Recommendations for the Consultative Management of Patients with COVID-19

Gastrointestinal symptoms are associated with COVID-19 in less than 10% of patients, with higher prevalence estimates outside of China.

Meta-AnalysisHighly Cited

2020·

358citations

·S. Sultanet al.

Gastroenterology

COVID‐19, nausea, and vomiting

Nausea is an early symptom of COVID-19, comparable to diarrhea, and may be influenced by GI effects of SARS-CoV-2.

Observational StudyRigorous Journal

2020·

49citations

·P. Andrewset al.

Journal of Gastroenterology and Hepatology

Gastrointestinal symptoms associated with severity of coronavirus disease 2019 (COVID-19): a pooled analysis

Gastrointestinal symptoms, such as abdominal pain, nausea, and vomiting, may increase the odds of severe COVID-19.

Meta-AnalysisRigorous JournalHighly Cited

2020·

80citations

·B. Henryet al.

Internal and Emergency Medicine

The roles of nausea and vomiting in COVID-19: did we miss something?

COVID-19 can cause gastrointestinal symptoms, including nausea and vomiting, and recognizing these symptoms is crucial for effective management and prevention.

2020·

27citations

·Tongyue Zhanget al.

Journal of Microbiology, Immunology, and Infection

Global prevalence of prolonged gastrointestinal symptoms in COVID-19 survivors and potential pathogenesis: A systematic review and meta-analysis

Prolonged gastrointestinal symptoms are prevalent in COVID-19 survivors, highlighting the long-term impact of the infection on their quality of life.

Meta-AnalysisRigorous Journal

2021·

50citations

·F. Yusufet al.

F1000Research

A systematic review and meta‐analysis of children with coronavirus disease 2019 (COVID‐19)

Pediatric COVID-19 patients may experience milder illness with atypical symptoms, rare lymphopenia, and high incidence of critical illness and vomiting symptoms.

Meta-AnalysisHighly Cited

2020·

303citations

·Xiaojian Cuiet al.

Journal of Medical Virology

Manifestations and prognosis of gastrointestinal and liver involvement in patients with COVID-19: a systematic review and meta-analysis

Summary Background The prevalence and prognosis of digestive system involvement, including gastrointestinal symptoms and liver injury, in patients with COVID-19 remains largely unknown. We aimed to quantify the effects of COVID-19 on the digestive system. Methods In this systematic review and meta-analysis, we systematically searched PubMed, Embase, and Web of Science for studies published between Jan 1, 2020, and April 4, 2020. The websites of WHO, CDC, and major journals were also searched. We included studies that reported the epidemiological and clinical features of COVID-19 and the prevalence of gastrointestinal findings in infected patients, and excluded preprints, duplicate publications, reviews, editorials, single case reports, studies pertaining to other coronavirus-related illnesses, and small case series (<10 cases). Extracted data included author; date; study design; country; patient demographics; number of participants in severe and non-severe disease groups; prevalence of clinical gastrointestinal symptoms such as vomiting, nausea, diarrhoea, loss of appetite, abdominal pain, and belching; and digestive system comorbidities including liver disease and gastrointestinal diseases. Raw data from studies were pooled to determine effect estimates. Findings We analysed findings from 35 studies, including 6686 patients with COVID-19, that met inclusion criteria. 29 studies (n=6064) reported gastrointestinal symptoms in patients with COVID-19 at diagnosis, and the pooled prevalence of digestive system comorbidities was 4% (95% CI 2–5; range 0–15; I 2=74%). The pooled prevalence of digestive symptoms was 15% (10–21; range: 2–57; I 2=96%) with nausea or vomiting, diarrhoea, and loss of appetite being the three most common symptoms. The pooled prevalence of abnormal liver functions (12 studies, n=1267) was 19% (9–32; range 1–53; I 2=96%). Subgroup analysis showed patients with severe COVID-19 had higher rates of gastrointestinal symptoms (odds ratio [OR] 1·60 [95% CI 1·09–2·36]; p=0·0020; I 2=44%) and liver injury (2·20 [1·60–3·02]; p<0·00001; I 2=36%) compared with those with non-severe disease. Patients in Hubei province, where the initial COVID-19 outbreak occurred, were more likely to present with abnormal liver functions (p<0·0001) compared with those outside of Hubei. Paediatric patients with COVID-19 had a similar prevalence of gastrointestinal symptoms to those of adult patients. 10% (95% CI 4–19; range 3–23; I 2=97%) of patients presented with gastrointestinal symptoms alone without respiratory features. Patients who presented with gastrointestinal system involvement had delayed diagnosis (standardised mean difference 2·85 [95% CI 0·22–5·48]; p=0·030; I 2=73%). Patients with gastrointestinal involvement had a higher prevalence of complication (OR 2·51 [95% CI 1·62–3·89]; p<0·0001; I 2=0%). Interpretation Our study showed that digestive symptoms and liver injury are not uncommon in patients with COVID-19. Increased attention should be paid to the care of this unique group of patients. Funding None.

Meta-AnalysisRigorous JournalHighly Cited

2020·

853citations

·R. Maoet al.

The Lancet. Gastroenterology & Hepatology

Gastrointestinal involvement in COVID-19: a systematic review and meta-analysis

A percentage of COVID-19 patients experience digestive symptoms, suggesting the GI tract may be a target organ and potential transmission route, impacting disease management and transmission.

Meta-AnalysisHighly Cited

2020·

89citations

·T. Rokkas

Annals of Gastroenterology

Neurological Manifestations in COVID-19 Patients: A Meta-Analysis

COVID-19 patients experience various neurological manifestations related to the central and peripheral nervous systems, with high heterogeneity among studies.

Meta-Analysis

2021·

53citations

·Vitalakumar Det al.

ACS Chemical Neuroscience

Gastrointestinal Manifestations of SARS-CoV-2 Infection and Virus Load in Fecal Samples From a Hong Kong Cohort: Systematic Review and Meta-analysis

17.6% of COVID-19 patients in Hong Kong had gastrointestinal symptoms, and 48.1% had virus RNA detected in their stool samples, highlighting the need for caution in fecal sample collection and endoscopic procedures.

Meta-AnalysisHighly Cited

2020·

1442citations

·K. Cheunget al.

Gastroenterology

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