Gastrointestinal manifestations of COVID-19 and possibility of feco-oral route of transmission

Zubair Ahmed

Student, 5th Year MBBS, FMH College of Medicine and Dentistry Shadman, Lahore

Corresponding Author: Zubair Ahmed, Student, 5th Year MBBS, FMH College of Medicine and Dentistry Shadman, Lahore, 54610, Pakistan. Contact Author.
Twitter: @zubairXfmh

Submission: May 01, 2020
Acceptance: Feb 26, 2021
Publication: Mar 10, 2021

© Author(s) (or their employer(s) 2021. Re-use permitted under CC BY. No commercial re-use. Published by Pak J Surg Med.

Article Citation: Ahmed Z. Gastrointestinal manifestations of COVID-19 and possibility of feco-oral route of transmission. Pak J Surg Med. 2021;1(4):e183. doi: 10.37978/pjsm.v1i4.183

At the end of 2019, the humankind faced the biggest threat of modern era. COVID-19, which started from Wuhan, China and became a pandemic with social, economic and healthcare impacts. The causative virus was SARS Cov-2 and the resulting disease coronavirus disease, which acquired pandemic status by March 31, 2020.[1] The centers for disease control and prevention (CDC) report the respiratory droplets to be the major mode of transmission of COVID-19.[2] Other transmission sources are being discovered and the purpose of this article is to briefly outline the gastrointestinal (GI) manifestations feco-oral transmission of COVID-19.

COVID-19 has relatively short incubation period and after initial exposure, the symptoms can appear from 2 days to 14 days.[3] The clinical features of COVID-19 include fever, cough, muscle fatigue, acute respiratory distress syndrome (ARDS), diarrhea, hemoptysis, headache, sore throat and shock.[4] The prevalence of GI symptoms in COVID-19 has been reported to be 39.6% and commonly reported symptoms include nausea (17.3%), diarrhea (12.9%), anorexia (12.2%) and vomiting (5%).[5] A meta-analysis of clinical characteristics of COVID-19 showed 17.6% patients had GI symptoms.[6] In a cohort of 41 hospitalized patients, diarrhea (3%) was reported as the most common GI manifestation of COVID-19.[7] Another study reported similar findings with diarrhea (2%) and nausea/vomiting (1%) as the GI manifestations of the disease.[8] Wong et al., reported a higher frequency of diarrhea (2-10%) and nausea (1-10%). They reported that that GI symptoms could precede onset of pyrexia and respiratory symptoms.[9] Liver involvement has also been reported as GI manifestation of COVID-19 with incidence ranging from 14.8% to 53%.[10] In a study conducted by Lin et al, out of 95 patients, 11 had GI symptoms on admission and 47 developed similar symptoms later on during the course of hospital stay. These symptoms included diarrhea (24.3%), anorexia(17.9%) and nausea(17.9%).[11]

Asymptomatic individuals in incubation period can be a source of transmission.(12) SARS CoV2 RNA is detectable in stool specimen even when serum tests negative for virus.[13] Tang A et al., reported an asymptomatic child whose stool specimen was positive for COVID-19 on PCR, 17 days after last virus exposure and stool specimen remained positive for 9 days after the respiratory specimen had turned negative.[14] COVID-19 RNA has been detected in anal as well as serum samples. A study carried out on fecal samples of 65 hospitalized patients for presence of SARS CoV-2 RNA including 42 with and 23 without GI symptoms described 22 and 19 patients to be positive respectively and postulated that GI tract might be a potential route of transmission and a target organ for SARS CoV-2.[15] The work of Xu Y et al., described a small cohort of eight children who persistently tested positive on rectal swabs even after nasopharyngeal swabs were negative raising possibility of feco-oral route postulating that viral shedding for GI tract may be greater and last longer.[16]

It is of utmost importance that healthcare provider should be aware of variability of clinical presentation for COVID-19 positive patients. Feco-oral route as another route of transmission needs to be investigated further since it can have serious implications for public health.


  1. Iqbal MR. COVID-19 Pandemic: How, When and Where? Pakistan J Surg Med. 2020;1(2):127–32.
  2. CDC. Coronavirus Disease 2019 (COVID-19) [Internet]. 2020 [cited 2020 Apr 29]. Available from:
  3. WHO. Pneumonia of unknown cause – China [Internet]. World Health Organization. 2020 [cited 2020 Oct 10]. Available from:
  4. Sun P, Qie S, Liu Z, Ren J, Xi J. Clinical characteristics of 50466 patients with 2019-nCoV infection. medRxiv [Internet]. 2020 Jan 1;2020.02.18.20024539. Available from:
  5. Zhang J-J, Dong X, Cao Y-Y, Yuan Y-D, Yang Y-B, Yan Y-Q, et al. Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan, China. Allergy. 2020 Jul;75(7):1730–41.
  6. Cheung KS, Hung IFN, Chan PPY, Lung KC, Tso E, Liu R, et al. Gastrointestinal Manifestations of SARS-CoV-2 Infection and Virus Load in Fecal Samples From a Hong Kong Cohort: Systematic Review and Meta-analysis. Gastroenterology. 2020 Jul;159(1):81–95.
  7. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet (London, England). 2020 Feb;395(10223):497–506.
  8. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet [Internet]. 2020 Feb 15;395(10223):507–13. Available from:
  9. Wong SH, Lui RN, Sung JJ. Covid-19 and the digestive system. J Gastroenterol Hepatol. 2020 May;35(5):744–8.
  10. Xu L, Liu J, Lu M, Yang D, Zheng X. Liver injury during highly pathogenic human coronavirus infections. Liver Int Off J Int Assoc Study Liver. 2020 May;40(5):998–1004.
  11. Lin L, Jiang X, Zhang Z, Huang S, Zhang Z, Fang Z, et al. Gastrointestinal symptoms of 95 cases with SARS-CoV-2 infection. Gut [Internet]. 2020 Jun 1;69(6):997 LP – 1001. Available from:
  12. Rothe C, Schunk M, Sothmann P, Bretzel G, Froeschl G, Wallrauch C, et al. Transmission of 2019-nCoV Infection from an Asymptomatic Contact in Germany. Vol. 382, The New England journal of medicine. 2020. p. 970–1.
  13. Holshue ML, DeBolt C, Lindquist S, Lofy KH, Wiesman J, Bruce H, et al. First Case of 2019 Novel Coronavirus in the United States. N Engl J Med [Internet]. 2020 Jan 31;382(10):929–36. Available from:
  14. Tang A, Tong Z-D, Wang H-L, Dai Y-X, Li K-F, Liu J-N, et al. Detection of Novel Coronavirus by RT-PCR in Stool Specimen from Asymptomatic Child, China. Emerg Infect Dis. 2020 Jun;26(6):1337–9.
  15. Zhang W, Du R-H, Li B, Zheng X-S, Yang X-L, Hu B, et al. Molecular and serological investigation of 2019-nCoV infected patients: implication of multiple shedding routes. Emerg Microbes Infect. 2020;9(1):386–9.
  16. Xu Y, Li X, Zhu B, Liang H, Fang C, Gong Y, et al. Characteristics of pediatric SARS-CoV-2 infection and potential evidence for persistent fecal viral shedding. Nat Med. 2020 Apr;26(4):502–5.

Author CRediT

ZA: Conceptualization, Investigation, Project administration, Writing – original draft, Writing – review & editing

Conflict of Interest

The author declared no conflict of interest.


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This article has been subjected to extensive editing and double blind peer review process. The following editors were involved in editing of this article;

Lead Editor: A Anwer,
Editor: N A Tehami, Z Sarfraz
Proof: J Siddiq
Bibliography: A Anwer

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