There is increasing evidence of GI tract epithelial cells serving as replication medium for COVID-19. Data from GI suites in Europe have shed light on this issue where the virus can be spread through fecal transmission long after respiratory symptoms have subsided.
1- Is there benefit of routinely screening stool for COVID-19 PCR prior to elective Colonoscopic procedures?
2- What are any hurdles in implementing this practice across United States?
There is data suggesting viral shedding in feces up to 45 days. An italian health care workers study did show transmission with GI procedures including Colonoscopy. Currently no acurate stool testing available. But this definitely will be an important issue to look at.
Biggest hinderance is practical aspect ofchecking stool test prior to porcedure and payment for test.
There are evidence that viral particles were present in stool sampless even after the respiratory tract is cleared from the virus. However, whether the virus present in stool is infective is not clear. This virus get infected through ACE receptors in the respiratory tract and as ACE receptors are available in GI tract as well it is a possibility that the live virus can be there. It is said that when the viral load respiratory tract is very high the alveoli can get disrupted and virus can enter blood and travel to the other parts of the body and get infecetd through ACE receptors. However, solid evidence is not available whether the virus passes through the GI tract is infective.
A paper awaiting publication in Gastroenterology suggests the virus could be spread via fecal-oral transmission in addition to the most common spread in droplets expelled during coughing or sneezing.
In a recent case study of stool samples of 73 COVID-19 patients in China, 39 samples tested positive for the SARS-CoV-2 protein, indicating a presence of the disease in the patients’ GI tracts. In addition, 17 of those patients continued to have positive stool samples even after respiratory samples had come back clear of the virus. However their infectivity is unclear. I am attaching this study.
CDC also included nausea and diarrhea as symptoms suspicious for COVID-19.
So there is increasing concern for virus being shed in stool to potentially be infective.
Thanks a lot. The infectivity piece is key and is still unclear. Eranga Harshani Silva
Another paper from Italian group saw low but possible infectivity after GI procedures in Italy (attached). Arslan Kahloon
GI societies like ASGE do not think there is enough evidence of viable virus in stool and hence don't recommend anything more than regular disinfection procedures (attached).
See attached information.
Reza Fotohi : Wondering if positive stool PCR has been shown to be linked to new infections and further transmission.
Large case series are needed as otherwise fecal-oral spread can lead to new infections Reza Fotohi Arslan Kahloon
Can anyone share any available data about infectivity of fecal Sars-Cov-2 ? Eranga Harshani Silva
I think there is no benefit from the aforementioned examination only. The examination is by taking a swab from the pharynx and the trachea
Fawzi Hassan Nasal swab is currently in wide spread practice to detect active infection, however fecal test can be done prior to procedures or surgeries involving abdominal or intestinal tract to prevent unintentional spread from asymptomatic carriers or even after when nasal swab PCR is negative after a known infection.
I feel this is important public health issue to prevent community spread.
Eranga Harshani Silva Good points about ACE receptors in lungs and GI tract.
Hina Akbar following link provides a good commentary on this issue.
https://www.tctmd.com/news/ace-inhibitors-arbs-and-covid-19-new-insights-advice
Preprint The digestive system is a potential route of 2019-nCov infec...
check this out Hina Akbar
Eranga Harshani Silva Thanks for sharing. ACE2- in GI tract is well known. Issue is if the viral being shed in stool a viable virus with infectious potential or non-infectious particles with no risk of new infection.
There is no such data that I have encountered so far.
I also feel that after protein and lipid enzyme degradation processes in stomach and small intestine, it maybe distorted virus with no risk for infectivity. But this concept is refuted by other GI tract infections with Adenovirus/Norvovirus/Rotavirus etc Arslan Kahloon
Yes that is unanswered question. Mounting evidence of fecal shedding from Quarantine facilities in China but no reported evidence of it causing new infections.
Hina Akbar : We anticipate more data coming out as states open up in United States and elective GI procedures start.
Also most places starting procedure are testing for COVID-19 before procedures. It will be interesting to compare rates of infection/transmission between facilities testing and not testing.
Thank you Arslan Kahloon
Attached article by American College of Surgery provides guidelines how to safely approach phased opening. I feel same principles will be followed in GI Endoscopy
Please share any further information on this topic as I foresee it to be an important public health issues in coming days.
Hina Akbar we are routinely trying to pre-test patients for COVID-19 before elective left heart caths and trans esophageal echocardiograms when possible.
Obviously pre-testing is not a priority in Acute Coronary syndrome presentations.
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