Spectrum of Gastrointestinal, Hepatobiliary, and Pancreatic Involvement in Hantavirus Infection: A Narrative Review

Hantavirus infection is a zoonotic, rodent-transmitted viral disease that presents with two distinct clinical syndromes: hemorrhagic fever with renal failure (HFRS) and hantavirus pulmonary syndrome (HPS). The 2026 cruise ship hantavirus outbreak has once again brought this infrequent disease into the limelight. Gastrointestinal (GI), hepatobiliary, and pancreatic manifestations, though frequent, have garnered less attention in patients with hantavirus infections. This narrative review summarizes the available literature on GI and hepatopancreatic involvement in hantavirus infection. A comprehensive review of the literature published between 2000 and May 2026 was conducted using PubMed. Eligible studies included observational studies, systematic reviews, meta-analyses, case series, and case reports describing GI, hepatic, biliary, or pancreatic manifestations in human hantavirus infection. The literature review identified GI symptoms among the earliest and most frequent prodromal manifestations of hantavirus disease. Nausea, vomiting, abdominal pain, and diarrhea often precede organ-specific complications by several days. GI bleeding develops as a component of hemorrhagic syndrome. Hepatic involvement most frequently manifests as transient elevations in aminotransferase levels and, less frequently, as hyperbilirubinemia. Gallbladder wall thickening, acalculous cholecystitis, instances of hantavirus-triggered autoimmune hepatitis, and acute pancreatitis have also been reported. Current management strategies are primarily supportive, including renal replacement therapy for severe renal injury and ventilatory support and extracorporeal membrane oxygenation for severe pulmonary disease. Antiviral therapies such as ribavirin and favipiravir have shown inconsistent or limited clinical benefits. Limited evidence links early and prominent GI symptoms and transaminitis with more severe disease and a worse prognosis. A high index of suspicion in patients with GI symptoms may facilitate earlier diagnosis and allow risk stratification. However, the current evidence is sparse, mostly derived from case reports, case series, and small retrospective studies, which limits our understanding of GI and hepatobiliary-pancreatic manifestations in patients with hantavirus infections. Large prospective studies are needed to clarify the mechanisms, incidence, and prognostic significance of these manifestations.