Respiratory symptoms are still the top complaint, but don't ignore a case of diarrhea right now.

You've likely heard the most common symptoms of COVID-19 by now: dry cough, fever, shortness of breath. But now, researchers are warning that another less-common symptom may be more prominent than doctors once thought: diarrhea.

A new study published Wednesday in The American Journal of Gastroenterology claims that digestive issues—like diarrhea, vomiting, and abdominal pain—may be more common in those with COVID-19 than was once thought, with up to half of patients diagnosed with the disease in the study issuing complaints of those issues. Also important: Compared to study patients without gastrointestinal issues, those who had GI complaints had a higher risk of mortality. 

The research, a cross-sectional multicenter study from China by investigators from the Wuhan Medical Treatment Expert Group for COVID-19, examined 204 early cases of novel coronavirus in Wuhan, China from three separate hospitals. The average age of the patients was 54.9 years, and included 107 men and 97 women.

The study authors noted that while respiratory issues remain the most common symptom of novel coronavirus, many patients—99 of the 204, or 48.5%—experienced digestive symptoms as their chief complaint that generally worsened with time. Some patients also never presented with respiratory symptoms at all. “Clinicians must bear in mind that digestive symptoms, such as diarrhea, may be a presenting feature of COVID-19, and that the index of suspicion may need to be raised earlier in these cases rather than waiting for respiratory symptoms to emerge,” write the authors.

Those with digestive symptoms—which included anorexia or loss of appetite (83.8% cases), diarrhea (29.3%), vomiting (0.8%), and abdominal pain (0.4%)—also had “a worse clinical outcome and higher risk of mortality compared to those without digestive symptoms,” Brennan M.R. Spiegel, MD, MSHS, FACG, Co-Editor-in-Chief of The American Journal of Gastroenterology, explained in a press release. And, due to the fact that patients without digestive symptoms were more likely to be cured and discharged than patients with digestive symptoms, (60% of those without digestive symptoms were discharged, versus only 34.3% of patients with digestive symptoms), Dr. Spiegel emphasized “the importance of including symptoms like diarrhea to suspect COVID-19 early in the disease course before respiratory symptoms develop.” That in itself could lead to an earlier diagnosis of COVID-19, "which can lead to earlier treatment and more expeditious quarantine to minimize transmission," he said. 

It should also be noted that those with digestive symptoms took much longer seek medical care. While the average time from symptom onset to hospital admission for those without digestive symptoms was 7.3 days, those with them took 9 days to be admitted. Researchers believe this may be an indicator that those with digestive symptoms sought care later because they did not yet suspect they were infected with the virus since they weren’t experiencing the most commonly discussed respiratory symptoms like cough or shortness of breath.

Niket Sonpal, MD, Board Certified NYC Internist and Gastroenterologist, who was not involved with the study, explains to Health that this is a “significant” finding, due to the fact that, “in the earlier stages of the outbreaks in China, Iran, and later Italy, we mostly saw the lower respiratory symptoms—dry cough, fatigue, accompanied by fevers.”  Diarrhea was seen in some cases, “but not an overwhelming amount in the reported cases, as we see with the dry cough and the fever,” he explains. The significance here “has more to do with testing and hospital admission, as reports out of China state that many patients who presented, first, with digestive symptoms were made to wait longer until they had the respiratory issues as well before they could get tested or receive medical attention,” says Dr. Sonpal. According to the study, these people too should have been a priority. 

At the community level, these findings should be used to promote social distancing and isolation to flatten the curve, says Dr. Sonpal. "There is so much we do not know about this virus, and while we are moving as fast as possible, it is up to the community to stay home to control the spread," he says. He also urges that if you do experience diarrhea during the coronavirus pandemic, you should exert extra caution to protect those around you. 

“With many viruses, the fecal matter needs to be taken into consideration,” he explains. “This is part of the reason why, when possible, a sick person should be using a different bathroom from others inside their home. If this is not possible, while it may be tedious, the CDC says it is in everyone’s best interest for the sick person to disinfect the bathroom after using it to avoid other members of the family becoming infected through bodily fluids.” That's, of course, in conjunction with the other preventive tips from the CDC, which include washing your hands frequently, avoiding large crowds or groups of over 10 people, keeping a safe distance from those who are sick, and disinfecting commonly touched surfaces. 

The information in this story is accurate as of press time. However, as the situation surrounding COVID-19 continues to evolve, it's possible that some data have changed since publication. While Health is trying to keep our stories as up-to-date as possible, we also encourage readers to stay informed on news and recommendations for their own communities by using the CDCWHO, and their local public health department as resources.

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