Skip to main content

Impact of COVID-19 on digestive system: prevalence, clinical characteristics, outcome, and relation to the severity of COVID-19



Coronavirus disease 2019 (COVID-19) is commonly associated with respiratory symptoms. However, gastrointestinal (GI) symptoms are increasingly recognized in COVID-19 patients. The aim is to study the prevalence and features of gastrointestinal manifestations in severe acute respiratory coronavirus 2 (SARS-CoV-2) infected patients and evaluate the outcome among the studied population.


We enrolled adult patients with laboratory-confirmed COVID-19 admitted to Ain Shams University designated hospitals, Cairo, Egypt, from March 2021 to June 2021. The patients were assigned to a GI group and a non-GI group based on the presence or absence of one or more digestive symptoms. A total of 300 hospitalized COVID-19 patients were included, of which 104 (34.7%) had one or more digestive symptoms. They were compared with 196 COVID-19 patients without GI symptoms. The most common reported GI symptom was diarrhea (82.7%). GI symptoms’ presence was higher in moderate cases. Patients with digestive symptoms presented for care later than those without (7.9±3.8 vs 7.4±7.2 days, P=0.5). Moreover, they have lower mortality, though non-significant (7.7 vs 12.8%, P=0.18). Patients with digestive symptoms had lower total leucocytic count (TLC), neutrophil count, neutrophil to lymphocyte ratio (NLR), platelet count, and higher serum sodium than those without digestive symptoms.


GI symptoms are prevalent among COVID-19 patients, and the most common was diarrhea. The presence of GI manifestations was not associated with increased mortality.


The current outbreak of coronavirus disease 2019 (COVID-19) is responsible for the present global pandemic, which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a newly emergent coronavirus, that was first recognized in Wuhan, Hubei Province of China in early December 2019 [1]. In March 2020, COVID-19 spread to 166 other countries with a declaration as a pandemic by the World Health Organization (WHO) [2].

COVID-19 is primarily a respiratory disease generating a wide spectrum of symptoms, ranging from asymptomatic patients to critically ill patients with respiratory failure, shock, or multiorgan failure, passing through having mild to moderate symptoms of pneumonia, and to severe patients with dyspnea and hypoxia [3].

However, reports from both the source outbreak of COVID-19 in China and emerging data from other international sites have notified subgroups of COVID-19 patients with gastrointestinal (GI) symptoms [4] that can occur with and without pulmonary manifestations of COVID-19 [5]. The reported prevalence of GI symptoms has been highly variable ranging from 3.8 to 61.3% [6,7,8,9,10,11,12].

Research showed that angiotensin-converting enzyme 2 (ACE-2) is the receptor for SARS-CoV-2. ACE-2 is not only expressed in alveolar type II cells of the lung [13] but also in intestinal epithelial cells, and its expression in the intestine is more than four times that of other tissues [14]. Given that viral nucleic acid was detected in patients’ stool samples, raising the possibilities that SARS-CoV-2 could be also transmitted by the feco-oral route causing GI infection [15].

The most frequently reported GI symptom with COVID-19 is diarrhea ranging from 3 to 30% [16]. The possible underlying mechanisms for GI involvement are the direct invasion of GI epithelial cells leading to malabsorption, unbalanced intestinal secretion, and an activated enteric nervous system causing diarrhea [17]. Other mechanisms include antibiotic-associated diarrhea, changes in the composition and function of digestive tract flora, and indirect inflammatory damage [18].

Limited data exist regarding the prevalence and potential gastrointestinal implications of COVID-19 among the Egyptian population. Therefore, we aimed to assess the prevalence and clinical features of digestive manifestations in patients hospitalized with COVID-19 and to evaluate the association between digestive symptoms and laboratory results and outcomes among the studied population.


A cross-sectional study based on identifying COVID-19 cases admitted to Ain Shams University designated hospitals, Cairo, Egypt.

The study was conducted over 4 months duration from March 2021 through June 2021, enrolling 300 adult patients “≥18 years” with laboratory-confirmed COVID-19 based on real-time reverse transcriptase-polymerase chain reaction (PCR) assay for nasopharyngeal and oropharyngeal swab specimens. We further categorized the patients into two groups based on the presence of GI symptoms: the GI group and non-GI group.

COVID-19 severity was classified as moderate, severe, or critical according to WHO guidelines [19]. Moderate cases are patients with clinical signs of pneumonia and pneumonic manifestations that can be seen in chest imaging, but no signs of severe pneumonia including SpO2 ≥90% on room air. Severe cases include patients with clinical signs of pneumonia and one of the following: respiratory rate >30 breaths/minute, severe respiratory distress, or SpO2 <90% on room air. Critical cases are patients meeting any of the following criteria: occurrence of respiratory failure requiring mechanical ventilation, presence of septic shock, and multi-organ failure that requires monitoring and treatment in the intensive care unit (ICU).

Patients who were unable to provide a history of presenting illness, with mild COVID-19 disease severity and with organic gastrointestinal diseases (e.g., peptic ulcer disease, inflammatory bowel disease), were excluded from the study.

An informed consent was obtained from all patients before enrollment. The study was approved by the Ethical Review Board of Ain Sham University (Reference Number: FMASU R 55/2020). The study protocol conformed to the ethical guidelines of the Declaration of Helsinki.

Data collection

The study population was subjected to a well-designed data sheet covering the following topics: demographic data as (age and gender), clinical data as (digestive, respiratory, and constitutional symptoms), comorbidities, vital signs at presentation, baseline laboratory and radiological investigations, inpatient medications, and clinical outcomes.

Baseline investigations included complete blood count (CBC), neutrophil to lymphocyte ratio (NLR), alanine aminotransferase (ALT), aspartate aminotransferase (AST), serum total and direct bilirubin, serum albumin, international normalization ratio (INR), serum creatinine, sodium (Na), potassium (K), serum ferritin, C-reactive protein (CRP), lactate dehydrogenase (LDH), erythrocyte sedimentation rate (ESR), D-dimer, and cardiac enzymes. A high-resolution computed tomography (HRCT) chest was done to determine the COVID-19 Reporting and Data System (CORADs).

Data were recorded both electronically and in the patient report form. The date of symptom onset, length of hospital stay, and the severity of the patient’s condition were also recorded.


We monitored the clinical outcome of COVID-19 patients in both groups whether discharge, transfer to ICU, or death. The criteria for hospital discharge were 10 days after symptom onset and resolution of fever for at least 3 days without the use of fever-reducing medications and with the improvement of other symptoms.

Statistical analysis

Data were analyzed using IBM SPSS statistics version 24. Numerical data were expressed as mean and standard deviation. Qualitative data were expressed as frequency and percentage. Chi-square test (Fisher’s exact test) was used to examine relations between qualitative variables. For quantitative data normally distributed, a comparison between paired data was done using paired t test (parametric t test). The test is considered statistically significant when P < 0.05.


Demographic and clinical characteristics

A total of 300 patients with confirmed COVID-19 admitted to Ain Shams University designated hospitals were included. The mean age of the total sample was 56.95±14.3 years, and 165 (55%) of them were males. Hypertension was the most common comorbidity (45.7%) followed by diabetes mellitus (36.3%). Chronic liver disease was reported in 16 (5.3%) patients (Table 1).

Table 1 Demographics of patients with COVID-19

Regarding COVID-19, 294 (98%) had moderate disease, and 6 (2%) had severe disease. The most common symptoms were fever (80%), cough (68.7%), and dyspnea (65%). Based on the presence of GI symptoms, the patients were classified into a GI group (n=104) and non-GI group (n=196).

Among the 104 patients with GI symptoms, 11 (10.58%) patients had digestive symptoms only, and 93 (89.4%) were presented with both digestive and respiratory symptoms. Out of 196 patients, 176 (89.8%) developed respiratory symptoms alone and 20 (10.2%) patients presented with constitutional symptoms alone. There were two patients in the non-GI group who had been reinfected with COVID-19. There were similar comorbidities between the two groups (Tables 1 and 2).

Table 2 Treatment of patients with COVID-19

The respiratory rate on admission ranged from 14 to 42 breaths/minute. A total of 206 patients presented with cough, most of them (56.3%) had dry cough with an average duration of 10.96±5.56 days.

Clinical characteristics of patients with gastrointestinal symptoms

Gastrointestinal symptoms were observed in 104 (34.7%) patients. The most frequently reported GI manifestations were diarrhea (82.7%), vomiting (17.3%), nausea (15.4%), and abdominal pain (14.4%). Patients with GI symptoms reported significantly higher frequency of fever (88.5% vs 75.5%, P = 0.008), anosmia (12.5% vs 3.1%, P = 0.001), and bony-aches and myalgia (53.8% vs 38.8%, P = 0.01). Ninety-nine percent of patients with GI symptoms had moderate COVID-19, with fewer mortality (7.7%); (Tables 1, 3, and 4).

Table 3 Clinical characteristics of patients with COVID-19
Table 4 Outcome of patients with COVID-19

Eighty-six patients presented with diarrhea that lasted from 1 to 21 days with a mean duration of 7±5.11 days. The daily frequency was 3.08±1.11 bowel movements. Not all patients with diarrhea had an accompanying fever. A total number of 57 patients (66.3%) had both diarrhea and fever occurred simultaneously, while 22 (25.6%) patients had diarrhea after fever, and only 1 (1.2%) before fever.

Vomiting was observed in 18 patients with an average of 2.89±1.32 vomitus daily. Abdominal pain was reported in 15 patients, where the majority (86.7%) described the pain as colicky in character.

Laboratory and radiological findings

Patients with GI symptoms exhibited significantly lower total leucocytic count (TLC), neutrophil count, NLR, platelet count, and higher serum sodium than those with non-GI symptoms (P < 0.05). The mean ferritin level was higher in the GI group but had not reached a statistical significance (707.14±1063.52 vs 682.31±795.83 ng/ml, P = 0.82). Moreover, we found that the mean value of ALT was higher in patients with digestive symptoms but non-significant (43.16±36.23 vs 41.08±45.59 IU/L, P = 0.69). However, mean CRP, LDH, ESR, troponin, and D-dimer were lower but not statistically significant (Table 5).

Table 5 Laboratory and radiological findings in patients with COVID-19

Out of the total patients, 114 (38%) were CORADs category 3 in the HRCT chest at initial presentation, and 6 patients (2%) did not show any CT imaging features of COVID-19 pneumonia (Table 5).


Among patients with COVID-19, patients with gastrointestinal symptoms had lower mortality compared to those without (7.7% vs 12.8%, P = 0.18). Regarding the length of the hospital stay, there was no difference between the two groups (10.2±7 vs 10.2±6.4 days, P = 0.97). The duration from symptom onset to hospital admission was longer in the GI group (7.9±3.8 days) than in the patients with other symptoms (7.4±7.2 days) (Table 4).


Research on the disease has been accelerated because of its significant health and economic burden. Studies conducted at the early stage of the COVID-19 outbreak indicated that respiratory symptoms were common at the onset of the disease [20]. The fact that gastrointestinal manifestations can be a presentation of COVID-19 patients created a significant challenge in practice. In daily practice, a high index of suspicion for COVID-19 infection is currently considered while dealing with cases presenting with fever, anorexia, vomiting, and diarrhea instead of considering them as gastroenteritis [21]. Therefore, patients with digestive symptoms require special attention, and understanding the differences in clinical characteristics and outcomes between patients with and without these symptoms is critical.

Our study showed that the most common presentations of SARS-CoV-2 infection were fever (80%), cough (68.7%), and dyspnea (65%) which was consistent with previous studies [22,23,24]. Moreover, middle-aged, and elderly people were more susceptible to COVID-19, which may be contributed to the lower immunity in these populations.

Within our cohort, 104 (34.7%) patients presented with GI symptoms which is lower than the results reported by other studies conducted in the USA and China which were in the range of 50.5–61.3% [10, 12]. In contrast, this prevalence was higher than other studies conducted in China, Italy, and Egypt [7, 22, 24, 25].

Diarrhea was the most common GI symptom in our cohort (82.7%) which was similar to findings from Wang et al. [26]. Moreover, Shousha et al. [24], an Egyptian multicentric cohort study, agreed with our results where 86.67% had diarrhea. In contrast, a cross-sectional study conducted on 860 patients with COVID-19 infection reported that the most common GI symptom was vomiting (40.1%) followed by diarrhea (37.6%) [25].

There are several possible mechanisms for the gastrointestinal symptoms in COVID-19 patients. ACE-2, a receptor for SARS-CoV-2, is highly expressed not only in alveolar epithelial cells but also in the epithelium of the esophagus, small intestine, and colon suggesting that coronavirus has a tropism to the gastrointestinal tract [27]. Severe COVID-19 is known to cause a cytokine storm, in which over-activated lymphocytes secrete many cytokines such as interleukins (ILs); (IL2, IL6, IL7, etc.), and tumor necrosis factor (TNF). These proinflammatory cytokines can alter the gut-brain axis by getting their access via the vascular and lymphatic systems, resulting in systemic inflammatory response syndrome, which causes inflammation and damage of the digestive tract [28].

Moreover, the COVID-19 patients are commonly treated with antibiotics for secondary bacterial infections [29]. These microbial agents (such as fluoroquinolones and cephalosporins) can cause antibiotic-associated diarrhea as an adverse effect. Furthermore, antiviral agents such as hydroxychloroquine and remdesivir are increasingly used among these patients, and diarrhea is a common side effect of these drugs [28].

In our study, 99% of patients with digestive symptoms had moderate COVID-19. Shousha et al. [24] also reported that most patients with digestive symptoms (83.4%) had non-severe COVID-19. Our results disagree with previous reports [30, 31] that showed that GI symptoms were found to be associated with severe COVID-19. They speculated that GI symptoms are related to the degree of viral replication, with increased severity of the disease associated with high viral load.

Furthermore, this study noted that the presence of GI symptoms was associated with significantly lower TLC, neutrophil count, NLR, and platelet count, and no significant differences in serum ferritin, CRP, LDH, ESR, troponin, and D-dimer compared to patients without GI symptoms. In a multicenter study of 191 patients by Zhou et al. [32], the presence of GI symptoms was associated with significantly elevated CRP, ALT, and lower hemoglobin level when compared to patients without digestive symptoms. Moreover, Teima et al. [25] showed that the inflammatory markers (CRP, LDH, and ferritin) and D-dimer were significantly higher in patients with digestive symptoms. However, in the study by Redd and colleagues [12], there were no significant differences in the leucocytic count, hemoglobin, platelets, or liver function tests in groups with or without GI symptoms.

In consistent with the published literature [7, 24], no significant difference was detected in the mean level of transaminases among patients with and without digestive symptoms. In contrast, a meta-analysis by Wijarnpreecha et al. [33] and a cross-sectional study by Teima et al. [25] showed a higher level of transaminases in patients with GI symptoms.

Similar to previous reports [34,35,36], the presence of gastrointestinal symptoms although non-significant was associated with a longer duration from symptom onset till admission and lower mortality. These combined findings suggest that GI symptoms are associated with an indolent form of COVID-19. In contrast, Zheng et al. [22] demonstrated that the rate of clinical deterioration was significantly higher in the GI group than in the non-GI group (15.6% vs 10.1%, P = 0.032).

Limitations of our study are the lack of SARS-CoV-2 RNA in the stool of COVID-19 patients, so we did not determine the hypothesis that the severity of GI symptoms may be related to the presence of viral replication in stool since this test was not routinely performed in our institution.


The prevalence of GI symptoms in our cohort of Egyptian patients was 34.7%. The significance of GI symptoms should not be underestimated in clinical practice. We recommend physicians to be aware of COVID-19 infection in patients with acute GI illness. We also recommend that appropriate personal protective equipment (PPE) should be worn by all gastroenterologists.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.



Coronavirus disease 2019




Severe acute respiratory coronavirus 2


World Health Organization


Angiotensin-converting enzyme 2


Polymerase chain reaction


Intensive care unit


Complete blood count


Neutrophil lymphocyte ratio


Alanine aminotransferase


Aspartate aminotransferase


International normalization ratio






C-reactive protein


Lactate dehydrogenase


Erythrocyte sedimentation rate


High-resolution computed tomography


COVID-19 Reporting and Data System


Total leucocytic count




Tumor necrosis factor


Personal protective equipment


  1. Wu F, Zhao S, Yu B, Chen YM, Wang W, Song ZG et al (2020) A new coronavirus associated with human respiratory disease in China. Nature 579(7798):265–269 [cited 2022 Feb 13]. Available from:

    Article  CAS  Google Scholar 

  2. Kopel J, Perisetti A, Gajendran M, Boregowda U, Goyal H (2020) Clinical insights into the gastrointestinal manifestations of COVID-19. Dig Dis Sci 65(7):1932–1939 [cited 2022 Feb 8]. Available from:

    Article  CAS  Google Scholar 

  3. Zhang J, Garrett S, Sun J (2021) Gastrointestinal symptoms, pathophysiology, and treatment in COVID-19. Genes Dis 8(4):385–400

    Article  CAS  Google Scholar 

  4. Xiao F, Tang M, Zheng X, Liu Y, Li X, Shan H (2020) Evidence for gastrointestinal infection of SARS-CoV-2. Gastroenterology. 158(6):1831–1833.e3 [cited 2022 Feb 13]. Available from:

    Article  CAS  Google Scholar 

  5. Young BE, Ong SWX, Kalimuddin S, Low JG, Tan SY, Loh J et al (2020) Epidemiologic features and clinical course of patients infected with SARS-CoV-2 in Singapore. JAMA. 323(15):1488–1494 [cited 2022 Feb 13]. Available from:

    Article  CAS  Google Scholar 

  6. Guan W, Ni Z, Hu Y, Liang W, Ou C, He J et al (2020) Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 382(18):1708–1720 [cited 2022 Feb 13]. Available from:

    Article  CAS  Google Scholar 

  7. Greco S, Fabbri N, Bella A, Bonsi B, Parini S, Rocchi C et al (2021) COVID-19 inpatients with gastrointestinal onset: sex and care needs’ differences in the district of Ferrara, Italy. BMC Infect Dis 21(1):1–8 [cited 2022 Feb 13]. Available from:

    Article  Google Scholar 

  8. Luo S, Zhang X, Xu H (2020) Don’t overlook digestive symptoms in patients with 2019 novel coronavirus disease (COVID-19). Clin Gastroenterol Hepatol 18(7):1636 [cited 2022 Feb 13]. Available from: /pmc/articles/PMC7154217/

    Article  CAS  Google Scholar 

  9. Cholankeril G, Podboy A, Aivaliotis VI, Tarlow B, Pham EA, Spencer SP et al (2020) High prevalence of concurrent gastrointestinal manifestations in patients with severe acute respiratory syndrome coronavirus 2: early experience from California. Gastroenterology. 159(2):775–777 [cited 2022 Feb 13]. Available from:

    Article  CAS  Google Scholar 

  10. Pan L, Mu M, Yang P, Sun Y, Wang R, Yan J et al (2020) Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional, multicenter study. Am J Gastroenterol 115(5):766–773 [cited 2022 Feb 13]. Available from:

    Article  Google Scholar 

  11. Marasco G, Cremon C, Barbaro MR, Salvi D, Cacciari G, Kagramanova A et al (2022) Prevalence of gastrointestinal symptoms in severe acute respiratory syndrome coronavirus 2 infection: results of the prospective controlled multinational GI-COVID-19 study. Am J Gastroenterol 117(1):147–157 [cited 2022 Feb 13]. Available from:

    Article  Google Scholar 

  12. Redd WD, Zhou JC, Hathorn KE, McCarty TR, Bazarbashi AN, Thompson CC et al (2020) Prevalence and characteristics of gastrointestinal symptoms in patients with severe acute respiratory syndrome coronavirus 2 infection in the United States: a multicenter cohort study. Gastroenterology. 159(2):765–767.e2 [cited 2022 Feb 13]. Available from:

    Article  CAS  Google Scholar 

  13. Chan JFW, Kok KH, Zhu Z, Chu H, To KKW, Yuan S et al (2020) Genomic characterization of the 2019 novel human-pathogenic coronavirus isolated from a patient with atypical pneumonia after visiting Wuhan. Emerg Microbes Infect 9(1):221 [cited 2022 Feb 13]. Available from: /pmc/articles/PMC7067204/

    Article  CAS  Google Scholar 

  14. Wong SH, Lui RNS, Sung JJY (2020) COVID-19 and the digestive system. J Gastroenterol Hepatol 35(5):744–748 [cited 2022 Feb 13]. Available from:

    Article  CAS  Google Scholar 

  15. Zhang H, Shao B, Dang Q, Chen Z, Zhou Q, Luo H et al (2021) Pathogenesis and mechanism of gastrointestinal infection with COVID-19. Front Immunol 12:4626

    Google Scholar 

  16. Kumar VCS, Harne PS, Mukherjee S, Lamichhane J, Dhamoon AS, Gupta K et al (2020) Transaminitis is an indicator of mortality in patients with COVID-19: a retrospective cohort study. World J Hepatol 12(9):619–627 [cited 2022 Feb 13]. Available from:

    Article  Google Scholar 

  17. Zhang H, Kang Z, Gong H, Xu D, Wang J, Li Z et al (2020) Digestive system is a potential route of COVID-19: an analysis of single-cell coexpression pattern of key proteins in viral entry process. Gut. 69(6):1010–1018 [cited 2022 Feb 13]. Available from:

    Article  CAS  Google Scholar 

  18. Musa S (2020) Hepatic and gastrointestinal involvement in coronavirus disease 2019 (COVID-19): what do we know till now? Arab J Gastroenterol 21(1):3–8

    Article  Google Scholar 

  19. Living guidance for clinical management of COVID-19. [cited 2022 Feb 13]. Available from:

  20. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y et al (2020) Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet (London, England) 395(10223):497–506 [cited 2022 Feb 13]. Available from:

    Article  CAS  Google Scholar 

  21. Tian Y, Rong L, Nian W, He Y (2020) Review article: gastrointestinal features in COVID-19 and the possibility of faecal transmission. Aliment Pharmacol Ther 51(9):843–851 Available from:

    Article  CAS  Google Scholar 

  22. Zheng T, Yang C, Wang HY, Chen X, Yu L, Wu ZL et al (2020) Clinical characteristics and outcomes of COVID-19 patients with gastrointestinal symptoms admitted to Jianghan Fangcang shelter Hospital in Wuhan, China. J Med Virol 92(11):2735–2741 [cited 2022 Feb 13]. Available from:

    Article  CAS  Google Scholar 

  23. Chen J, Qi T, Liu L, Ling Y, Qian Z, Li T et al (2020) Clinical progression of patients with COVID-19 in Shanghai, China. J Infect 80(5):e1–e6 [cited 2022 Feb 13]. Available from:

    Article  CAS  Google Scholar 

  24. Shousha HI, Afify S, Maher R, Asem N, Fouad E, Mostafa EF et al (2021) Hepatic and gastrointestinal disturbances in Egyptian patients infected with coronavirus disease 2019: a multicentre cohort study. World J Gastroenterol 27(40):6951–6966 [cited 2022 Feb 13]. Available from:

    Article  CAS  Google Scholar 

  25. Teima AAA, Amer AA, Mohammed LI, Kasemy ZA, Aloshari SHA, Ahmed MM et al (2022) A cross-sectional study of gastrointestinal manifestations in COVID-19 Egyptian patients. Ann Med Surg 74:103234

    Article  Google Scholar 

  26. Wang H, Qiu P, Liu J, Wang F, Zhao Q (2020) The liver injury and gastrointestinal symptoms in patients with coronavirus disease 19: a systematic review and meta-analysis. Clin Res Hepatol Gastroenterol 44(5):653–661

    Article  CAS  Google Scholar 

  27. Zhang H, Kang Z, Gong H, Xu D, Wang J, Li Z et al (2020) The digestive system is a potential route of 2019-nCov infection: a bioinformatics analysis based on single-cell transcriptomes. bioRxiv. 2020.01.30.927806 Available from: [cited 2022 Feb 13]

  28. Perisetti A, Gajendran M, Goyal H (2020) Putative mechanisms of diarrhea in COVID-19. Clin Gastroenterol Hepatol 18(13):3054 [cited 2022 Feb 13]. Available from: /pmc/articles/PMC7289724/

    Article  CAS  Google Scholar 

  29. Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H et al (2020) Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. The lancet. Respir Med 8(5):475–481 [cited 2022 Feb 13]. Available from:

    CAS  Google Scholar 

  30. Henry BM, de Oliveira MHS, Benoit J, Lippi G (2020) Gastrointestinal symptoms associated with severity of coronavirus disease 2019 (COVID-19): a pooled analysis. Intern Emerg Med 15(5):857–859 [cited 2022 Feb 13]. Available from:

    Article  Google Scholar 

  31. Zhang H, Liao YS, Gong J, Liu J, Xia X, Zhang H (2020) Clinical characteristics of coronavirus disease (COVID-19) patients with gastrointestinal symptoms: a report of 164 cases. Digest Liver Dis 52(10):1076–1079 [cited 2022 Feb 13]. Available from:

    Article  Google Scholar 

  32. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z et al (2020) Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet (London, England) 395(10229):1054–1062 [cited 2022 Feb 13]. Available from:

    Article  CAS  Google Scholar 

  33. Wijarnpreecha K, Ungprasert P, Panjawatanan P, Harnois DM, Zaver HB, Ahmed A et al (2021) COVID-19 and liver injury: a meta-analysis. Eur J Gastroenterol Hepatol 990–5 [cited 2022 Feb 13]. Available from:

  34. Han C, Duan C, Zhang S, Spiegel B, Shi H, Wang W et al (2020) Digestive symptoms in COVID-19 patients with mild disease severity: clinical presentation, stool viral RNA testing, and outcomes. Am J Gastroenterol 115(6):916–923 [cited 2022 Feb 13]. Available from:

    Article  Google Scholar 

  35. An P, Chen H, Ren H, Su J, Ji M, Kang J et al (2021) Gastrointestinal symptoms onset in COVID-19 patients in Wuhan, China. Dig Dis Sci 66(10):3578–3587 [cited 2022 Feb 13]. Available from:

    Article  CAS  Google Scholar 

  36. Nobel YR, Phipps M, Zucker J, Lebwohl B, Wang TC, Sobieszczyk ME et al (2020) Gastrointestinal symptoms and coronavirus disease 2019: a case-control study from the United States. Gastroenterology. 159(1):373–375.e2 [cited 2022 Feb 13]. Available from:

    Article  CAS  Google Scholar 

Download references




Not applicable.

Author information

Authors and Affiliations



WH and AA designed the research and participated in the acquisition of data; WH, HA, and AA participated in the analysis and interpretation of the data; WH, DS, MI, and AA revised the article critically for important intellectual content; and WH wrote the manuscript. The authors have read and approved the manuscript.

Corresponding author

Correspondence to Walaa M. Hashem.

Ethics declarations

Ethics approval and consent to participate

All subjects involved in the study signed an informed consent to participate. The study was approved by the Ethical Review Board of Ain Shams University (Reference number: FMASU R 55/2020). The study protocol conforms to the ethical guidelines of Declaration of Helsinki as reflected in a priori approval by the institution’s human research committee.

Consent for publication

Participants provided a consent for the study findings to be published.

Competing interests

The authors declare they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Hashem, W.M., Abdelaziz, H., Sallam, D.E. et al. Impact of COVID-19 on digestive system: prevalence, clinical characteristics, outcome, and relation to the severity of COVID-19. Egypt J Intern Med 34, 45 (2022).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI:


  • COVID-19
  • Severe acute respiratory syndrome coronavirus 2
  • Gastrointestinal symptoms
  • Diarrhea
  • Outcome
  • Mortality