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. doi: 10.1053/j.gastro.2020.03.065. Epub 2020 Apr 3.


Background & aims: Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19), which has been characterized by fever, respiratory, and gastrointestinal symptoms as well as shedding of virus RNA into feces. We performed a systematic review and meta-analysis of published gastrointestinal symptoms and detection of virus in stool and also summarized data from a cohort of patients with COVID-19 in Hong Kong.

Methods: We collected data from the cohort of patients with COVID-19 in Hong Kong (N = 59; diagnosis from February 2 through February 29, 2020),and searched PubMed, Embase, Cochrane, and 3 Chinese databases through March 11, 2020, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We analyzed pooled data on the prevalence of overall and individual gastrointestinal symptoms (loss of appetite, nausea, vomiting, diarrhea, and abdominal pain or discomfort) using a random effects model.

Results: Among the 59 patients with COVID-19 in Hong Kong, 15 patients (25.4%) had gastrointestinal symptoms, and 9 patients (15.3%) had stool that tested positive for virus RNA. Stool viral RNA was detected in 38.5% and 8.7% among those with and without diarrhea, respectively (P = .02). The median fecal viral load was 5.1 log10 copies per milliliter in patients with diarrhea vs 3.9 log10 copies per milliliter in patients without diarrhea (P = .06). In a meta-analysis of 60 studies comprising 4243 patients, the pooled prevalence of all gastrointestinal symptoms was 17.6% (95% confidence interval [CI], 12.3-24.5); 11.8% of patients with nonsevere COVID-19 had gastrointestinal symptoms (95% CI, 4.1-29.1), and 17.1% of patients with severe COVID-19 had gastrointestinal symptoms (95% CI, 6.9-36.7). In the meta-analysis, the pooled prevalence of stool samples that were positive for virus RNA was 48.1% (95% CI, 38.3-57.9); of these samples, 70.3% of those collected after loss of virus from respiratory specimens tested positive for the virus (95% CI, 49.6-85.1).

Conclusions: In an analysis of data from the Hong Kong cohort of patients with COVID-19 and a meta-analysis of findings from publications, we found that 17.6% of patients with COVID-19 had gastrointestinal symptoms. Virus RNA was detected in stool samples from 48.1% patients, even in stool collected after respiratory samples had negative test results. Health care workers should therefore exercise caution in collecting fecal samples or performing endoscopic procedures in patients with COVID-19, even during patient recovery.

Keywords: Fecal-to-Oral Transmission; PRISMA; SARS; Viral Persistence.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Betacoronavirus / genetics
  • Betacoronavirus / isolation & purification*
  • Betacoronavirus / pathogenicity
  • COVID-19
  • COVID-19 Testing
  • Clinical Laboratory Techniques
  • Coronavirus Infections / diagnosis
  • Coronavirus Infections / epidemiology
  • Coronavirus Infections / prevention & control*
  • Coronavirus Infections / transmission
  • Diarrhea / diagnosis
  • Diarrhea / epidemiology
  • Diarrhea / virology*
  • Endoscopy, Gastrointestinal / standards
  • Feces / virology*
  • Gastrointestinal Tract / diagnostic imaging
  • Gastrointestinal Tract / virology
  • Hong Kong / epidemiology
  • Humans
  • Infection Control / standards
  • Infectious Disease Transmission, Patient-to-Professional / prevention & control
  • Pandemics / prevention & control*
  • Pneumonia, Viral / diagnosis
  • Pneumonia, Viral / epidemiology
  • Pneumonia, Viral / prevention & control*
  • Pneumonia, Viral / transmission
  • Prevalence
  • RNA, Viral / isolation & purification
  • SARS-CoV-2
  • Viral Load*


  • RNA, Viral