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Diarrhea prevalent among COVID-19 patients with IBD

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Is it an IBD exacerbation or viral superinfection?

Diarrhea is one of the hallmark features in inflammatory bowel disease (IBD). The systematic review and meta-analysis by D’Amico and colleagues highlights an increased prevalence of diarrhea in IBD patients with COVID-19. We have learned that SARS-CoV-2 enters the gastrointestinal tract through angiotensin converting enzyme 2, which has been found in absorptive enterocytes of the ileum and colon. The subsequent invasion can cause a change in intestinal microbiota (dysbiosis) and trigger diarrhea. Prior studies also reported SARS-CoV-2 being isolated in the duodenum and rectum while showing RNA shedding in approximately 40% of patients. Clinicians may now face the diagnostic challenge of distinguishing the cause of diarrhea as an exacerbation from underlying IBD versus viral superinfection. The authors astutely hypothesized that having access to fecal polymerase chain reaction tests may be particularly useful to guiding clinical treatment decisions.

Dr. Lukasz Kwapisz is an assistant professor of gastroenterology at Baylor College of Medicine, Houston

Dr. Lukasz Kwapisz

The study further showed that the mortality rate in IBD patients with COVID-19 (3.8%) was lower, compared with the general population (approximately 10%). This is a similar trend observed in the international SECURE-IBD database, which now includes more than 2,500 patients worldwide. Importantly, IBD patients who are elderly, have multiple comorbidities, or are on high-dose corticosteroids were most at risk of severe COVID outcomes, including intensive care admission and death. Ultimately, this meta-analysis along with expert consensus statements from organizations like the International Organization For the Study of Inflammatory Bowel Disease and the American Gastroenterology Association, demonstrate that IBD patients (including those on biologic treatments) were not at higher risk of contracting COVID-19, compared with the non-IBD population. These findings should encourage IBD patients and clinicians to continue maintenance biologic and immunosuppressant treatments.

Lukasz Kwapisz, MD, FRCPC, is assistant professor of medicine and gastroenterology at Baylor College of Medicine, Houston. He has no conflicts of interest.



Diarrhea affected one in every five patients with inflammatory bowel disease (IBD) and COVID-19, compared with only 7%-10% of all patients with COVID-19 in prior studies, researchers reported in Clinical Gastroenterology and Hepatology.

In a systematic review and meta-analysis of 23 studies incorporating data from 449 patients with IBD and COVID-19, their most common symptoms were fever (affecting 48.3% of patients), cough (46.5%), and diarrhea (20.5%), and diarrhea was approximately twice as prevalent as dyspnea, nausea, abdominal pain, and fatigue, wrote Ferdinando D’Amico of Humanitas University in Milan and his associates. “[S]ymptoms experienced by IBD patients with COVID-19 are similar to those occurring in the general population, except for a higher percentage of diarrhea,” they wrote. This increased prevalence might result from IBD itself or from inflammatory effects of viral gut tropism, they noted. “Currently, the diagnostic–therapeutic approach does not differ between IBD and non-IBD patients, but further studies are needed to evaluate whether fecal research of viral RNA and treatment with IBD drugs may play a role in the management of COVID-19 patients.”

To characterize the clinical presentation and course of patients with IBD and COVID-19, the researchers searched PubMed, Embase, Web of Science, and MedRxiv through July 29, 2020, for keywords related to COVID-19, Crohn’s disease, ulcerative colitis, and IBD. They identified 23 studies presenting clinical data from adults or children with a confirmed IBD diagnosis and least one case of COVID-19. Among 243,760 patients with IBD, 1,028 patients had COVID-19 infection, including 509 patients with Crohn’s disease, 428 patients with ulcerative colitis, 49 patients with indeterminate colitis, and 42 patients for whom the IBD subtype was not recorded.

In all, 0.4% of patients with IBD had COVID-19. Nearly all had been diagnosed by polymerase chain reaction of nasopharyngeal swabs, and approximately 40% also had received chest CT scans. Most were male (56.5%), and 43.5% were older than 65 years. Patients were receiving a wide range of IBD therapies, most commonly anti–tumor necrosis factor (TNF) agents, mesalamine, thiopurine (alone or in combination with biologics), vedolizumab, ustekinumab, steroids, methotrexate, and tofacitinib. Results from six studies indicated that patients with IBD were significantly more likely to be diagnosed with COVID-19 if they were older than 66 years (odds ratio, 21.3) or had other comorbidities (OR, 1.24). The most commonly used drugs for managing COVID-19 were hydroxychloroquine, lopinavir/ritonavir, steroids, antibiotics, chloroquine, tofacitinib, and infliximab.

A total of 30.6% of patients with IBD and COVID-19 were hospitalized, 11.4% stayed in the ICU, 3.7% required mechanical ventilation, and 3.8% died from COVID-19. Significant risk factors for death from COVID-19 included older age, active IBD, and a Charlson Comorbidity Index score above 1. Similarly, risk factors for severe COVID-19 included older age, having two or more comorbidities, receiving systemic steroids, and receiving mesalamine/sulfasalazine. In one study, a recent (3-month) history of corticosteroid treatment was associated with a 60% increase in the risk for severe COVID-19. Other immune-mediated therapies did not show this association. Patients with ulcerative colitis were significantly more likely to be seen in the ED or hospitalized, compared with patients with other forms of IBD (adjusted OR, 12.7).

No funding sources were disclosed. Dr. D’Amico reported having no conflicts of interest. Two coinvestigators disclosed ties to AbbVie, MSD, Schering-Plough, UCB Pharma, and several other pharmaceutical companies.

SOURCE: D’Amico F et al. Clin Gastroenterol Hepatol. 2020 Aug 7. doi: 10.1016/j.cgh.2020.08.003.

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