Digestive symptoms may be more common in coronavirus infections than previously thought, with a small study released Wednesday finding that symptoms such as diarrhea and a loss of appetite were the “chief complaint” in nearly half of more than 200 confirmed COVID-19 cases.

The research suggests that, during the coronavirus pandemic, clinicians may need to look beyond the major Covid-19 symptoms identified by US health officials: fever, cough and shortness of breath.

That’s because many patients infected with coronavirus, according to the study, may initially present to the hospital with diarrhea, anorexia and vomiting – not necessarily with respiratory symptoms.

Even when researchers excluded anorexia – a loss of appetite or aversion to food – they found that 1 in 5 coronavirus patients still came to the hospital with diarrhea, vomiting or abdominal pain.

In more severe coronavirus cases, digestive symptoms also became more pronounced, and patients with digestive problems were less likely to be discharged, according to the study.

The research, published in the American Journal of Gastroenterology, looked at 204 confirmed coronavirus cases in Hubei province, China. A small number of those patients – seven people – had digestive problems, but no respiratory symptoms at all.

While the researchers cautioned that larger studies would be needed to confirm their findings, they warned that “if clinicians solely monitor for respiratory symptoms to establish case definitions for COVID-19, they may miss cases initially presenting with extra-pulmonary symptoms, or the disease may not be diagnosed later until respiratory symptoms emerge.”

That might explain why many health care workers in China were infected in the early days of the coronavirus outbreak, the researchers said.

“Although this was related to improper protection of medical personnel early on,” they wrote, “it may also have resulted from failing to consider COVID-19 in the face of atypical extra-pulmonary symptoms, especially those with digestive symptoms at the beginning of the outbreak.”