Sandbox: ifrah
- Diarrhea is an uncommon gastrointestinal symptom in patients with COVID-19, but in may be the presenting symptom in few patients. The frequency of occurrence of diarrhea varies between 1%-35%. It varies widely between different studies probably due to the different criteria used to define diarrhea.
- Greater percentage of occurrence was noted in patients with severe COVID-19 when compared to non-severe disease. Likewise, patients with gastrointenstinal symptoms were more likely to have severe respiratory disease with ARDS requiring ventilatory support.  

# Pathophysiology
- SARS-CoV-2 uses the Angiotensin-converting enzyme 2 (ACE2) and the serine protease TMPRSS2 receptors for cell entry. These receptors are presently abundantly not only in the lungs but also in the enterocytes of the small intestinal. Other sites of expression of the receptors in the gastrointestinal tract are-the upper esophagus, liver, and colon. 
- Entry of the virus causes disruption of the enterocytes and may lead to inflammation and alteration of intestinal permeability.
- COVID- 19 is being treated by atrial of many different antivirals and antibiotics. Diarrhea could also be a result of an alteration of the gut microbiota due to any of these. 

# Clinical Features of Diarrhea caused by SARS-CoV-2
- According to Jin et al, the definition of diarrhea was the passing of loose stools >3 times per day.
- According to this study, 8.1% had diarrhea at onset and the symptoms lasted for approximately 4 days.
- The duration of diarrhea ranged from 2-4 days with 3-8 bowel movements per day, according to various studies. 

# Treatment
- Supportive management is the mainstay of treatment.
- Rehydration, fluid repletion, and potassium monitoring are essential.
- Use of probiotics may have a role if the diarrhea is being caused by alteration of the gut microbiome. This could also be potentially useful in preventing secondary bacterial infections by restoring the gut microbiota. 
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-  Jump up to: 2.0 2.1 Jin X, Lian JS, Hu JH, Gao J, Zheng L, Zhang YM;  et al. (2020). "Epidemiological, clinical and virological characteristics of 74 cases of coronavirus-infected disease 2019 (COVID-19) with gastrointestinal symptoms". Gut. 69 (6): 10021009. doi:10.1136/gutjnl-2020-320926. PMC 7133387 Check |pmc= value (help). PMID 32213556 Check |pmid= value (help).CS1 maint: Multiple names: authors list (link)
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-  Jump up to: 6.0 6.1 Gao QY, Chen YX, Fang JY (2020). "2019 Novel coronavirus infection and gastrointestinal tract". J Dig Dis. 21 (3): 125126. doi:10.1111/1751-2980.12851. PMC 7162053 Check |pmc= value (help). PMID 32096611 Check |pmid= value (help).CS1 maint: Multiple names: authors list (link)
-  Song Y, Liu P, Shi XL, Chu YL, Zhang J, Xia J;  et al. (2020). "SARS-CoV-2 induced diarrhoea as onset symptom in patient with COVID-19". Gut. 69 (6): 11431144. doi:10.1136/gutjnl-2020-320891. PMID 32139552 Check |pmid= value (help).CS1 maint: Multiple names: authors list (link)
-  Chan JF, Yuan S, Kok KH, To KK, Chu H, Yang J;  et al. (2020). "A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster". Lancet. 395 (10223): 514523. doi:10.1016/S0140-6736(20)30154-9. PMC 7159286 Check |pmc= value (help). PMID 31986261.CS1 maint: Multiple names: authors list (link)