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The Forgotten Gastrointestinal Tract in COVID-19 Infection

Pedro-Botet, Juan MD, PhD1; Climent, Elisenda MD, PhD1

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Clinical and Translational Gastroenterology: July 2020 - Volume 11 - Issue 7 - p e00216
doi: 10.14309/ctg.0000000000000216
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Although fever and respiratory symptoms are the main clinical manifestations of coronavirus disease 2019 (COVID-19), a non-negligible number of patients present with gastrointestinal (GI) symptoms with diarrhea, vomiting, and abdominal pain, often in the prodromal period of the disease (1). The prevalence of these GI symptoms varies in patient series and are frequently underestimated. Coronavirus RNA has been identified in anal-rectal smears (2) and stool samples (3) from COVID-19-infected patients, even after virus clearance in the upper respiratory tract (2). In addition, the viral receptor angiotensin-converting enzyme 2 is expressed in GI epithelial cells that COVID-19 can actively infect and replicate (4). Therefore, this coronavirus exhibits a special GI tropism.

In light of the above, there are 2 major epidemiological and clinical implications. First, the importance of fecal source in the transmission of the disease. In this respect, an environmental study suggested that COVID-19 could remain viable in aerosols for hours and could stay stable on plastic and stainless steel for at least 72 hours (5). Second, the weight of the viral load on the GI tract in the infectivity of the disease.

These considerations will be relevant to beat COVID-19. Physicians should be aware of the GI symptomatology of COVID-19, especially because they may occur before the onset of pyrexia and respiratory symptoms. Furthermore, the authors encourage researchers to study the viral dynamic of this coronavirus in the GI tract because it could explain at least in part the different clinical severity among infected patients. Finally, the authors want to point out the possibility of including therapies aimed to detoxify the GI tract in the therapeutic protocols against COVID-19.


Guarantor of the article: Juan Pedro-Botet, MD, PhD.

Specific author contributions: Both authors contributed to the letter.

Financial support: None to report.

Potential competing interests: None to report.


1. Wong SH, Lui RN, Sung JJ. Covid-19 and the digestive system. J Gastroenterol Hepatol 2020;35:744–8.
2. Zhang W, Du RH, Li B, et al. Molecular and serological investigation of 2019-nCoV infected patients: Implication of multiple shedding routes. Emerg Microbes Infect 2020;9:386–9.
3. Young BE, Ong SWX, Kalimuddin S, et al. Epidemiologic features and clinical course of patients infected with SARS-CoV-2 in Singapore. JAMA 2020;323:1488–94.
4. Xiao F, Tang M, Zheng X, et al. Evidence for gastrointestinal infection of SARS-CoV-2. Gastroenterology 2020;158:1831–3.
5. van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med 2020;382:1564–7.
© 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology