CME INDIA presentation: Dr Debashis Nath, Physician, Agartala, Tripura asks on 05/09/2020
Can anybody share experience/ guideline for the management of COVID-19 diarrhoea?
I have tried doxy, ivermectin. Some do improve. But in some cases, I am in a fix. I was wondering whether this diarrhoea is due to micro-capillariitis or something akin to lung injury found in COVID patients. In that case micro ischemia leading to decrease gut immunity or something and resultant diarrhoea. This may sound absurd but being frustrated with constant diarrheal problem. I have raised this issue. Has anybody tried steroid in these patients and got favourable response?
CME INDIA Discussion:
Dr N K Singh: Accepted mechanism is: SARS‐CoV‐2 directly invades the digestive tract through binding with ACE2 receptors in glandular cells of gastric, duodenal and rectal epithelial cells, as well as in enterocytes of small intestinal3. Moreover, after infected with SARS‐CoV‐2, the “gut‐lung” axis and the interaction between intestinal microbiota and pro‐inflammatory cytokines may also lead to the injury of the gastrointestinal tract.
(Zhang D, Li S, Wang N, Tan H, Zhang Z, Feng Y. The cross‐talk between gut microbiota and lungs in common lung diseases. Front Microbial 2020)
(https://doi.org/10.3389/fmicb.2020.00301)
Dr Ambrish Bhattacharya, Kolkata: We are getting good results with cocktail. Doxy 100mg BD 5 days, Ivermectin 12mg Od 3 days, Zinc 50mg OD 1 week. Probiotic BD 1 week
Dr N K Singh: Your experience matters. These drugs being are used to treat COVID cases. Do you use anything specific for diarrhoea?
Dr Ambrish Bhattacharya: Yes sir, Racecadotil 100mg thrice daily. ORS or IV fluid as per dehydration. Average time needed is 3 days for settling
Dr Rahul Raj: I used loperamide 2mg as it usually works on day1 with 2 to 3 tablets
Dr N K Singh: In terms of managing COVID-19 patients with diarrhoea, we don’t specifically target the diarrhoea unless we know it’s caused by a pathogen we can treat. More than 38% of patients with a GI symptom did not present with fever, which is considered a cardinal symptom of COVID-19…..As per one Chinese study. Your experience? The study also indicated that patients with digestive symptoms sought care 16 days after symptom onset, compared with 11.6 days for those with respiratory symptoms alone. Whether the presence of SARS-CoV-2 in the GI tract, and the feco- viral shedding that can occur with COVID-19, in fact translates to fecal–oral transmission?
Dr Raju Sharma, Consulting Physician, Jamshedpur: Interesting thought, Dr Debashish. I give doxy and lactobacillus with or without domperidone
Dr Prabhat Agarwal Agra: Yes, but no response
Dr Anil Motta, Sr Consultant Medicine Delhi: Redotil TDS for 10 days
Dr prabhat Agarwal Agra: Tab ridoltil 2-tab tds works
Dr N K Singh: Shedding in the GI tract doesn’t mean there’s transmissible virus in the stool. Is it? Any idea? It is said that all gastrointestinal symptoms correlate with a more severe disease course and a larger proportion of intensive care unit (ICU) admission. One more aspect, reason for the diarrhoea in COVID-19 patients might be antibiotic-associated diarrhoea. Broad-spectrum antibiotic use can disrupt the gastrointestinal microbiota, resulting in diarrhea. Please tell.
Very Important questions:
- Did you find that the duration of symptoms in patients with diarrhoea was significantly longer than in those without diarrhoea, including fever and dyspnoea?
- Did patients with diarrhoea took much more time to eliminate SARS-CoV-2 from respiratory system, leading to longer hospital stay time? What is Indian experience?
Chinese experience is yes for both questions.
Dr Sanjeev Thakur DM Gastro, Patna: Biopsy studies are in case reports, didn’t show any mucosal damage. Some reports of response to antivirals but not consistent. Thankfully it is usually self-limiting and non-dehydrating. So symptomatic management with fluid replacement and antimotility agents as required. Probiotics gaining role because of multiple antibiotics many of the patients are on.
Dr K S Narayan, DM Gastro Dhanbad: In a nut shell, currently there is no specific treatment for COVID diarrhoea. Treatment is mostly symptomatic however some patients do show improvement with antiviral but exact percentage especially in Indian setup is not known.
Dr Narayan Agrawal, Gastro, Siliguri: Agreed to both
CME INDIA Learning Points:
- Wear gloves, mask, protective gown, and goggles every time you visit a patient with diarrhoea
- Pay attention to hand hygiene before and after visiting a patient with diarrhoea, using alcoholic disinfectants or soap and water
- Patients with diarrhoea should have a personal bathroom and bathroom sanitation should be performed several times per day
- All endoscopes and reusable accessories should be reprocessed with standard reprocessing procedures
[2] Gut symptoms are likely to disappear after antiviral therapy and supports the link between symptom and COVID-19 disease (Observational Study)
[3] There is Prognostic Implications of Diarrhoea
- It is important to remain vigilent. Studies show a greater diarrhoea percentage in patients with severe disease compared with those with no severe disease suggesting an association between presence of symptom and disease severity.
- COVID-19 patients with diarrhoea, nausea, and vomiting are more likely to require mechanical ventilation and acute respiratory distress syndrome compared with patients without gastrointestinal symptoms (Chinese study)
[4] Management
- At present there is no specific treatment for COVID-19 and its management is mainly based on supportive care.
- No evidence on the efficacy of antidiarrheal drugs is available, but an adequate rehydration and potassium monitoring should be performed as in all patients with diarrhoea.
- Antibiotics and antivirals are used for COVID-19 treatment, may alter gut microbiota and may be cause of diarrhea.t is therefore plausible that probiotics could have a role in the management.
CME INDIA Tail Piece:
The evidence of SARS-CoV-2 in the stools and in gastrointestinal histologic samples and its prolonged persistence at the stool compared with nasopharyngeal swabs strongly suggests that orofecal transmission is possible, justifying the execution of fecal polymerase chain reaction in suspect patients.
(Zhu N, Zhang D, Wang W, et al. Clinical Gastroenterology and Hepatology 2020;18:1663–1672Diarrhea During COVID-19 Infection: Pathogenesis, Epidemiology, Prevention, and Management Ferdinando D’Amico.)
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Yes sir, PT with diarrhoea, vomiting have more severe lung infection. Settled after starting Remdisivir