Gastrointestinal Manifestations and Neutrophil-to-Lymphocyte Ratio as Marker of Occult Bleeding in COVID -19

Desi Maghfirah, Fauzi Yusuf, Marisa Marisa, Muhammad Ridho Akbar Eljatin

Abstract


Background: Coronavirus disease 2019 (COVID-19) was initially recognized as a respiratory illness; however, it has been gradually recognized as a disease that affects multiple organ systems, including the gastrointestinal (GI) tract. GI involvement ranges from mild symptoms, such as nausea and diarrhea, to complications like gastrointestinal bleeding. The neutrophil-to-lymphocyte ratio (NLR) has been proposed as a simple biomarker of inflammation and disease severity in COVID-19.

Objective: To describe gastrointestinal manifestations of COVID-19 and examine the association between NLR levels and occult gastrointestinal bleeding.

Methods: This cross-sectional study was conducted in 2021 at the New-Emerging and Re-Emerging Infectious Diseases inpatient unit of Dr. Zainoel Abidin General Hospital, Banda Aceh, Indonesia. COVID-19-positive patients aged ≥18 years with gastrointestinal symptoms were included, excluding those who were pregnant or had pre-existing GI disorders. Data were collected from medical records and patient interviews. Statistical analysis was performed using the Mann–Whitney U test, with p < 0.05 considered significant

Results: The most frequent symptoms were appetite loss and nausea (93%), bloating and vomiting (87%), and diarrhea (57%). Occult GI bleeding occurred in seven patients (23.3%) who had significantly higher NLR values than those without bleeding (p = 0.041).

Conclusion: The most frequent GI manifestations of COVID-19 are loss of appetite, nausea, bloating, vomiting, and diarrhea, while occult gastrointestinal bleeding occurs in about one-fourth of cases. Elevated NLR levels are associated with occult bleeding, suggesting its potential role as a simple and accessible biomarker of intestinal inflammation and disease severity.


Keywords


COVID-19; gastrointestinal manifestation; occult bleeding; the neutrophil-to-lymphocyte ratio

References


  1. Groff A, Kavanaugh M, Ramgobin D, McClafferty B, Aggarwal CS, Golamari R, et al. Gastrointestinal manifestations of COVID-19: a review of what we know. Ochsner J. 2021;21(2):177–80. doi:10.31486/toj.20.0086
  2. Tenda ED, Asaf MM, Pradipta A, Kumaheri MA, Susanto AP. The COVID-19 surge in Indonesia: what we learned and what to expect. Breathe (Sheff). 2021;17(4):210146. doi:10.1183/20734735.0146-2021
  3. Oktari RS, Detiro MD, Rahman S. How is COVID-19 perceived by medical students? A survey in Aceh province, Indonesia. Jamba J Disaster Risk Stud. 2021;13(1):1–8. doi: 10.4102/jamba.v13i1.1146
  4. Trindade AJ, Izard S, Coppa K, Hirsch JS, Lee C, Satapathy SK, et al. Gastrointestinal bleeding in hospitalized COVID-19 patients: a propensity score matched cohort study. J Intern Med. 2021;289(6):887–94. doi:10.1111/joim.13232
  5. Zhao X, Tao M, Chen C, Zhang Y, Fu Y. Clinical features and factors associated with occult gastrointestinal bleeding in COVID-19 patients. Infect Drug Resist. 2021;14:4217–26. doi:10.2147/IDR.S335868
  6. Seretis K, Sfaelos K, Boptsi E, Gaitanis G, Bassukas ID. The neutrophil-to-lymphocyte ratio as a biomarker in cutaneous oncology: a systematic review of evidence beyond malignant melanoma. Cancers (Basel). 2024;16(5)1044. doi:10.3390/cancers16051044
  7. Buonacera A, Stancanelli B, Colaci M, Malatino L. Neutrophil to lymphocyte ratio: an emerging marker of the relationships between the immune system and diseases. Int J Mol Sci. 2022;23(7):3636 doi:10.3390/ijms23073636.
  8. Vanella G, Capurso G, Burti C, Fanti L, Ricciardiello L, Souza Lino A, et al. Gastrointestinal mucosal damage in patients with COVID-19 undergoing endoscopy: an international multicentre study. BMJ Open Gastroenterol. 2021;8(1) :e000578. doi:10.1136/bmjgast-2020-000578.
  9. Hunt RH, East JE, Lanas A, Malfertheiner P, Satsangi J, Scarpignato C, et al. COVID-19 and gastrointestinal disease: implications for the gastroenterologist. Dig Dis. 2021;39(2):119–39. doi:10.1159/000512152
  10. Wei XS, Wang X, Niu YR, Ye LL, Peng WB, Wang ZH, et al. Diarrhea is associated with prolonged symptoms and viral carriage in coronavirus disease 2019. Clin Gastroenterol Hepatol. 2020;18(8):1753–59.e2. doi:10.1016/j.cgh.2020.04.030
  11. Yusuf F, Abubakar A, Maghfirah D, Muhsin M, Fahriani MI. Alterations of gut microbiota composition in severe acute respiratory syndrome coronavirus 2 infection: a brief review. Ann Rom Soc Cell Biol. 2021;25(6):13136–43.
  12. Juthi RT, Sazed SA, Sarmin M, Haque R, Alam MS. COVID-19 and diarrhea: putative mechanisms and management. Int J Infect Dis. 2023;126:125-31. doi:10.1016/j.ijid.2022.11.018
  13. Zhang H, Kang Z, Gong H, Xu D, Wang J, Li Z, et al. Digestive system is a potential route of COVID-19: an analysis of single-cell coexpression pattern of key proteins in viral entry process. Gut. 2020;69(6):1010–8. doi:10.1136/gutjnl-2020-320953
  14. Baldi S, Fabbrizzi A, Di L, Marco G, Giulia P, Mario N, et al. First exploration of the altered microbial gut-lung axis in the pathogenesis of human refractory chronic cough. Lung. 2024;202(2):107–18. doi:10.1007/s00408-024-00681-7
  15. D’Amico F, Baumgart DC, Danese S, Peyrin-Biroulet L. Diarrhea during COVID-19 infection: pathogenesis, epidemiology, prevention, and management. Clin Gastroenterol Hepatol. 2020;18(8):1663–72. doi:10.1016/j.cgh.2020.04.001
  16. Gu J, Han B, Wang J. COVID-19: gastrointestinal manifestations and potential faecal–oral transmission. Gastroenterology. 2020;158(1):1518–9. doi:10.1053/j.gastro.2020.02.054
  17. Andrews PLR, Cai W, Rudd JA, Sanger GJ. COVID-19, nausea, and vomiting. J Gastroenterol Hepatol. 2021;36(3):646–56. doi:10.1111/jgh.15261
  18. Yu Z, Yang Z, Wang Y, Zhou F, Li S, Li C, et al. Recent advance of ACE2 and microbiota dysfunction in COVID-19 pathogenesis. Heliyon. 2021;7:e07548. doi:10.1016/j.heliyon.2021.e07548
  19. Zerbato V, Di Bella S, Giuffrè M, Jaracz AW, Gobbo Y, Luppino D, et al. High fecal calprotectin levels are associated with SARS-CoV-2 intestinal shedding in COVID-19 patients: a proof-of-concept study. World J Gastroenterol. 2021;27(22):3130–7. doi:10.3748/wjg.v27.i22.3130
  20. Redd WD, Zhou JC, Hathorn KE, McCarty TR, Bazarbashi AN, Thompson CC, et al. 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. 2020;159(2):765–767.e2. doi:10.1053/j.gastro.2020.04.045
  21. Villapol S. Gastrointestinal symptoms associated with COVID-19: impact on the gut microbiome. Transl Res. 2020;226:57–69. doi:10.1016/j.trsl.2020.08.004
  22. Andring JT, McKenna R. Amino acid transporter B0AT1 influence on ADAM17 interactions with SARS-CoV-2 receptor ACE2 putatively expressed in intestine, kidney, and cardiomyocytes. bioRxiv. 2020. doi: https://doi.org/10.1101/2020.10.30.361873
  23. Li X, Liu C, Mao Z, Xiao M, Wang L, Qi S, et al. Predictive values of neutrophil-to-lymphocyte ratio on disease severity and mortality in COVID-19 patients: a systematic review and meta-analysis. Crit Care. 2020;24(1):1–10. doi:10.1186/s13054-020-03374-8
  24. Ye Q, Wang B, Zhang T, Xu J, Shang S. The mechanism and treatment of gastrointestinal symptoms in patients with COVID-19. Am J Physiol Gastrointest Liver Physiol. 2020;319(2):G245-G52. doi:10.1152/ajpgi.00148.2020.
  25. Yusuf F, Fahriani M, Mamada SS, Frediansyah A, Abubakar A, Maghfirah D, et al. Global prevalence of prolonged gastrointestinal symptoms in COVID-19 survivors and potential pathogenesis: A systematic review and meta-analysis. F1000Res. 2021;10:301. doi:10.12688/f1000research.52216.1
  26. Mutiawati E, Fahriani M, Mamada SS, Fajar JK, Frediansyah A, Maliga HA, et al. Anosmia and dysgeusia in SARS-CoV-2 infection: incidence and effects on COVID-19 severity and mortality, and the possible pathobiology mechanisms - a systematic review and meta-analysis. F1000Res. 2021;10:40. doi:10.12688/f1000research.28393.1.
  27. Hashem MK, Hussein AARM, Amin MT, Mahmoud A, Shaddad AM. The burden of COVID-19 pandemic on tuberculosis detection: a single-center study. Egypt J Bronchol. 2022;16(1). https://doi.org/10.1186/s43168-022-00117-x
  28. Man MA, Rajnoveanu R, Stefania N, Id M, Bondor CI, Chis AF, et al. Neutrophil-to-lymphocyte ratio, platelets-to-lymphocyte ratio, and eosinophils correlation with high-resolution computer tomography severity score in COVID-19 patients. PLoS One. 2021;16(6):e0252599. doi:10.1371/journal.pone.0252599




DOI: https://doi.org/10.15850/ijihs.v13n2.4210

Article Metrics

Abstract view : 0 times



 

This Journal indexed by

                   

 


Creative Commons License
IJIHS is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License



View My Stats