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Gastrointestinal (GI) symptoms may be the only evidence of COVID-19 coronavirus in a certain subgroup of cases, researchers found.

A subgroup of patients , with or without ever developing respiratory symptoms or even a fever, reported Xiaohua Hou, MD, PhD, of Huazhong University of Science and Technology in Wuhan, China, and colleagues.

Compared with patients with only respiratory symptoms, those with digestive symptoms were more likely to test positive for COVID-19 in their stool and have a longer delay until viral clearance, the authors wrote in a preprint appearing in the American Journal of Gastroenterology.

Moreover, they concluded that, when patients only present with new-onset GI symptoms and are a contact of a COVID-19 case, it may be reasonable to test them for the virus, even without any fever or respiratory symptoms.

"This study is vital because it represents the 80% or more of patients who do not have severe or critical disease. This is about the more common scenario of people in the community struggling to figure out if they might have COVID-19 because of new-onset diarrhea, nausea, or vomiting," Brennan M.R. Spiegel, MD, the journal's co-editor-in-chief, said in a statement.

GI symptoms have been associated with COVID-19 infection, as they were with SARS, though they appeared to be .

However, experts have been urging gastroenterologists to consider COVID-19 in a differential diagnosis when a patient presents with both respiratory and GI symptoms. This data seems to go beyond even that, saying COVID-19 should be suspected with GI symptoms in absence of respiratory symptoms.

"Because COVID-19 testing has largely focused on patients with respiratory symptoms -- not digestive symptoms -- it is possible there is a large cohort of undiagnosed patients with low severity illness but with digestive symptoms, such as diarrhea, who unknowingly spread the virus," Hou and colleagues wrote.

They examined data from 206 patients from a single hospital, including 48 who only presented with a digestive symptom (diarrhea, nausea, vomiting), 69 who presented with both digestive and respiratory symptoms, and 89 with respiratory symptoms alone. Patients were a mean age of 62, and 56% were women. Interestingly, the digestive and respiratory group was more likely to report shortness of breath, fatigue, and muscle soreness versus the respiratory-only group.

Among the group who had GI symptoms, 67 had diarrhea, with an average duration of over 5 days, and a frequency of around four bowel movements per day. They noted concurrent fever in 62% of patients with a digestive symptom, meaning almost 40% did not have fever.

Mean interval from symptom onset and viral clearance across groups was 38 days, with an average hospital stay of about 24 days. However, the total time between symptom onset and viral clearance was significantly longer in the digestive-only and digestive and respiratory symptom group versus the respiratory-only group (40.9 vs 42.0 vs 33.5 days, respectively, P<0.001).

Likewise, Hou and colleagues found patients with coronavirus RNA in their stool had a significantly longer time to viral clearance than patients who tested negative in stool (44.2 vs 33.7 days, P=0.003). Not surprisingly, those with digestive symptoms were more likely to have virus in their stool.

"The longer disease course in patients with digestive symptoms might reflect a higher viral burden in these patients in comparison to those with only respiratory symptoms," they wrote.

Limitations to the data include small sample size, inability to perform correlations between fecal virus RNA and severity of digestive symptoms, and the fact that the study does not confirm viral particles in stool are infectious and capable of disease transmission. Further research is needed to determine if COVID-19 can be spread through the fecal-oral route.

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