Diarrhea in Patients With COVID-19 Suggests Possible Oral-Fecal Transmission Route

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The fact that diarrhea is a symptom in the disease course of some patients with COVID-19 highlights the importance of adhering to preventative measures.

The fact that diarrhea is a symptom in the disease course of some patients with 2019 novel coronavirus disease (COVID-19) highlights the importance of adhering to preventative measures to control orofecal transmission between patients and healthcare workers. This is according to a review published in Clinical Gastroenterology and Hepatology.

The review included published literature discussing the pathogenesis, epidemiology, prevention, and treatment of COVID-19 and its related symptoms. Only studies that reported documented cases of diarrhea in patients with a confirmed diagnosis of COVID-19 infection were included.

Incidence rates of diarrhea across studies of patients with COVID-19 ranged between 2% and 50%. Pooled analysis showed an overall incidence rate of diarrhea totaling 10%. Studies reported the occurrence of diarrhea both prior to and after the onset of respiratory symptoms. The protein angiotensin-converting enzyme 2 (ACE2), which is involved in SARS-CoV, is expressed in the small intestinal epithelia. Studies indicate that the binding affinity of SARS-CoV-2 to ACE2 is between 10 and 20 times higher than SARS-CoV.

Reports also suggest that the viral RNA shedding in the stool is detectable for a longer span of time than it is observed in nasopharyngeal swabs. The presence of SARS-CoV-2 in the stool and the lengthy duration of time for which it persists suggest the possibility of orofecal transmission. Investigators note that greater attention should be paid to hygiene and sterilization of all potential sources of contamination to prevent this form of transmission. In addition, personal protective equipment, such as gloves and facial masks, should be used, especially in endoscopy units.

Limitations of this review included its retrospective nature and the variation of diagnostic methods used in the included studies.

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Based on their findings, the researchers wrote that “the presence of diarrhea should generate suspicion of a possible SARS-CoV-2 infection and should be investigated in order to reach an early diagnosis of COVID-19.”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


D’Amico F, Baumgart DC, Danese S, Peyrin-Biroulet L. Diarrhea during COVID-19 infection: pathogenesis, epidemiology, prevention and management [published online April 8, 2020]. Clin Gastroenterol Hepatol. doi: 10.1016/j.cgh.2020.04.001.