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 Table of Contents  
CASE SERIES
Year : 2020  |  Volume : 34  |  Issue : 2  |  Page : 128-130

“Abdominal pain” in COVID-19 patients: A conundrum for the pain physician


Department of Anaesthesiology and Pain Medicine, University College of Medical Sciences, University of Delhi and GTB Hospital, Delhi, India

Date of Submission11-May-2020
Date of Decision27-May-2019
Date of Acceptance30-May-2020
Date of Web Publication06-Aug-2020

Correspondence Address:
Prof. Ashok Kumar Saxena
Department of Anaesthesiology and Pain Medicine, University College of Medical Sciences and GTB Hospital, Dilshad Garden, Delhi - 110 095
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_63_20

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  Abstract 


In the current scenario of Corona-19 pandemic, absolute awareness among all health – care workers is necessary. History taking and analyzing the symptoms obviously remains the cornerstone for the detection of COVID-19. However,physician must suspect COVID-19 in patients presenting with the chief complaint of gastrointestinal symptoms such as abdominal pain,diarrhea, and vomiting with or without respiratory complaints. This case series conveys an important message about changing our approach in the initial assessment and management of patients with acute abdominal pain or acute on chronic abdominal pain.

Keywords: Abdominal pain, conundrum, COVID-19, pain physician


How to cite this article:
Saxena AK, Choudhary S, Gaur D. “Abdominal pain” in COVID-19 patients: A conundrum for the pain physician. Indian J Pain 2020;34:128-30

How to cite this URL:
Saxena AK, Choudhary S, Gaur D. “Abdominal pain” in COVID-19 patients: A conundrum for the pain physician. Indian J Pain [serial online] 2020 [cited 2020 Nov 26];34:128-30. Available from: https://www.indianjpain.org/text.asp?2020/34/2/128/291551




  Introduction Top


As the countries all around the globe grapple with the COVID-19 pandemic, in the current scenario, researchers globally race in finding cure to the solution and provide us basic understanding of the virus SARS-CoV-2. History taking and analyzing the symptoms obviously remains the cornerstone for the detection of COVID-19. However, with the limitation of time and resources and the rapid spread of disease, there still remains a great concern about the detection and tracing of contacts and their isolation and quarantine.

The very first case of COVID-19 was reported on December 31, 2019, from the Wuhan city of China.[1],[2] Subsequently, the WHO had declared it as a pandemic on March 11, 2020, and also declared it as a public health emergency of an international consequence and seriousness.

In our tertiary hospital setup, we have encountered a large number of patients suspicious of COVID 19 admitted in the emergency room with symptoms, other than dry cough, fever, breathlessness, and malaise, and this being generalized abdominal pain. Few of such COVID-19 patients presented with extrapulmonary symptoms such as stabbing headache, abdominal pain, diarrhea, and vomiting. Abdominal pain is commonly ignored in comparison to the respiratory symptoms.

In a recently published article, the American Journal of Gastroenterology, the authors observed digestive symptoms in 50.5% of COVID-19 patients. Pan et al.[3] studied 204 patient population of COVID-19 infection between January 18, 2020, and February 28, 2020. In this study, the main digestive symptoms were lack of appetite, diarrhea, vomiting, and abdominal pain. Further, they concluded that the digestive symptoms among larger group grew more severe as the severity of COVID-19 increased. Hence, they concluded that in these patients presenting with digestive symptoms, an index of suspicion is needed earlier than waiting for the respiratory symptoms to manifest.

In another interesting study published in December 2019, a new highly infectious illness was first detected in Wuhan, China. The virus was named SARS-CoV-2, and the disease it causes is COVID-19. This virus (SARS-CoV-2) is a large, positive, single-stranded RNA virus, which is only moderately related to other known coronaviruses.[4] The Centers for Disease Control and Prevention, explains the modes of transmission through close contact with one another (within about 6 feet). When an infected person coughs or sneezes, respiratory droplets are produced, which can land in the mouths or noses of people who are nearby, or possibly be inhaled into the lungs. Thus, the virus can spread from contact with contaminated surfaces.[5]

According to the latest WHO guidelines, the most common symptoms of COVID-19 infection include fever, dry cough, malaise, and breathlessness. Other minimal early symptoms such as nasal congestion and sore throat or no symptom at all have also been described in asymptomatic transmission.[6]


  Case Series Top


In this case series, we provide information of COVID-19 patients admitted in the isolation ward of our hospital. On detailed history and observation, we detected that a specific percentage of patients (age: 28–68 years, mean age: 52.9 years; 66 males and 34 females) on admission, had only gastrointestinal symptoms with generalized abdominal pain. In these patients, about 18% had pain which was nonradiating and moderate in intensity, and associated with diarrhea in 12%, anorexia in 42%, vomiting in 8%, and nausea in 5% of patients. Around 25% of these patients presenting with gastrointestinal symptoms only, had a mean body mass index of 32.5 kg/m2. Moreover, 36% of patients had both respiratory and gastrointestinal symptoms [Table 1] and [Figure 1]. In around 35% of COVID-19 patients, the presentation was pain in the flanks and epigastric area. Their average rate of hospital admission was 10.1 days from the initial onset of symptoms. Hence, it is imperative that the treating pain physician should be aware of the fact that few COVID-19 patients may present with gastrointestinal symptoms such as abdominal pain and diarrhea, only in the initial stage, or they may be associated with respiratory complaints also, which subsequently using rt-PCR, confirmed the diagnosis.
Table 1: Varied percentage presentation of individual gastrointestinal symptoms among 64% of COVID-19 patients presenting only with gastrointestinal complaints

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Figure 1: Pie diagram representation of varied percentage presentation of individual gastrointestinal symptoms among 64% of COVID-19 patients presenting only with gastrointestinal complaints

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To further substantiate our observation, in another recent study by Holshue et al., it was reported that the first US patient admitted to a hospital with COVID-19 positivity had a loose bowel movement on hospital admission day 2, and further, it was confirmed that laboratories in China were able to isolate the live coronavirus from the stool of such patients.[7] This leads Holshue et al. to think and suggest that the treating physician should identify patients with gastrointestinal symptoms also and carefully monitor such patients.[7]

Another interesting study by Xiao et al. from Guangdong Province in China, in support of our gastrointestinal observation in COVID-19 patients, confirmed the presence of viral RNA in the feces obtained from 71 such patients with confirmed COVID-19 during their hospitalization between February 1 and 14, 2020.[8] They collected serum, nasopharyngeal and oropharyngeal swabs, urine, stool, and tissues (from endoscopy) from these patients. The duration of positive stool tests ranged from 1 to 12 days, and they added that patients remained positive through stool tests even after showing negative report in nasal and oropharyngeal samples. Although the previous study by Holshue et al. suggests that the infectious virions can be released into the gastrointestinal tract, Xiao et al. suggest that fecal–oral transmission could be a possible pathway for viral spread in COVID-19 patients.

Recently, Siegel et al. observed that in their COVID-19 patient series presenting with abdominal pain, there were alarming computed tomography (CT) findings in the lung bases, which showed typical peripheral and subpleural “ground-glass opacities,” often bilateral, with nodular configuration.[9] Diagnosis as confirmed using rt-pcr, SARS-CoV-2.

In another very recent review article by Tian et al., it was concluded that SARS-CoV-2 gains entry into the gastrointestinal epithelial cells, and the stools of COVID-19 patients are potentially infectious. Tian et al. detected angiotensin-converting enzyme 2 (ACE 2) and virus nucleocapsid protein in the gastrointestinal epithelial cells, and infectious virus particles in the feces.[10]

Sometimes, basal pneumonia with pleural effusion can explain discomfort and abdominal pain. One can always argue that basal pneumonia should not cause lower abdominal pain and associated symptoms such as nausea and vomiting. On a similar pattern of SARS-CoV, SARS-CoV-2 has also been proved to have proteins which quickly adhere to the cell receptor ACE 2. In the opinion of Selleval et al., it is interesting to note that a large percentage of ACE 2 receptors have been seen in the ileum, esophagus, heart, kidney, and bladder. Moreover, epithelial cells in the ileum have large number of ACE 2 receptors.[11]

Whatever may be the mode of spread, variety of symptoms, progression, or severity of disease, the treatment lies in the prevention of spread. In the current scenario where vaccine for COVID-19 is in the developmental stage, preventive measures should be strictly followed. Obviously, this includes the controversial role of hydroxychloroquine in the prevention of infection with SARS-CoV-2 virus, in addition to the established role of 70% isopropyl alcohol or washing hand with soap and water for at least 20 s, social distancing, N95 mask, face shield, gloves, and leggings and avoiding touch of object, surfaces, eye, nose, and mouth, and use of personal protective equipment, which are obviously always in short supply, due to excessive demand, especially in a developing country like India.

Using protective gears is mandatory in dealing with COVID-19 patients and is akin to Marie Curie's case, where her exposure to radioactivity did not just affect her (leading to aplastic anemia and death), but it also affected her belongings, clothes, books, etc.

In conclusion, the pain physician must be aware of the fact that an unexplained abdominal pain should be kept in mind as a criterion in the pretriage assessment. Hence, in this manner, the pain physician can do an excellent job by potentially minimizing the risk to other patients and health care workers. The other important aspect is that pain physician can always ask for CT thorax along with CT abdomen at the time of admission for early diagnosis. This will avoid wastage of time and help in early diagnosis.

At the moment, it seems – it is all Pain – no gain. It certainly calls for absolute awareness among all health-care personnel working as frontline warriors, about the ground reality that COVID-19 patients may present with the chief complaint of gastrointestinal symptoms such as abdominal pain with or without respiratory complaints. This case series conveys an important message about changing our approach in the initial assessment and management of patients with acute abdominal pain or acute-on chronic abdominal pain. This monumental challenge has pulled of what mighty leaders across the globe has have to put off. We all could ask this invisible virus, ask “Hu Yu”? China juggernaut juddered to a standstill. With every day substantial rise of confirmed cases of COVID-19 and confirmed cases of deaths of COVID-19 patients, the frontline warriors (doctors, nurses, and other medical staff) in their battle against COVID-19 have already started writing up their wills being aware of the intense risk they face in the COVID-19 isolation wards and COVID-19 intensive care units. Let us all bow down and say “NAMASTE” to COVID-19 times a day, which should be termed as “Carona-namaha.”

Acknowledgments

We would like to express our heartfelt thanks to our families for their unlimited support and our deep gratitude to all the frontline warriors of the CORONA pandemic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflict of interest.



 
  References Top

1.
Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel corona virus from patients with pneumonia in China. N Eng J Med 2020;382:727-33.  Back to cited text no. 1
    
2.
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalised patients with 2019 novel coronavirus infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.  Back to cited text no. 2
    
3.
Pan L, Mu M, Yang P, Sun Y, Wang R, Yan J, et al. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: A descriptive, cross-sectional, multicenter study. Am J Gastroenterology 2020;115:766-73.  Back to cited text no. 3
    
4.
Gu J, Korteweg C. Pathology and pathogenesis of severe acute respiratory syndrome. Am J Pathol 2007;170:1136-47.  Back to cited text no. 4
    
5.
Available from: https://www.cdc.gov/coronavirus/2019-ncov/prepare/transmission.html. [Last accessed on 2020 Mar 30].  Back to cited text no. 5
    
6.
Sohrabi C, Alsafi Z, O'Neill N, Khan M, Kerwan A, Al-Jabir A, et al. World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19). Int J Surg 2020;76:71-6.  Back to cited text no. 6
    
7.
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 2020;382:929-36.  Back to cited text no. 7
    
8.
Xiao F, Tang M, Zheng X, Liu Y, Li X, Shan H. Evidence for gastrointestinal infection of SARS-CoV-2. Gastroenterology 2020;158:1831-3000.  Back to cited text no. 8
    
9.
Siegel A, Chang PJ, Jarou ZJ, Paushter DM, Harmath CB, Arevalo JB, et al. Lung base findings of coronavirus disease (COVID-19) on abdominal ct in patients with predominant gastrointestinal symptoms. [Published online ahead of print, 2020 april 17] AJR Am J Roentgenol 2020;1-3.   Back to cited text no. 9
    
10.
Tian Y, Rong L, Nian W, He Y. Review article: Gastrointestinal features in COVID-19 and the possibility of faecal transmission. Aliment Pharmacol Ther 2020;51:843-51.  Back to cited text no. 10
    
11.
Sellevoll HB, Saeed U, Young VS, Sandbæk G, Gundersen K, Mala T. Acute abdomen as an early symptom of COVID-19. Covid-19 med akutte magesmerter som debutsymptom. Tidsskr Nor Laegeforen 2020;140:10.  Back to cited text no. 11
    


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