key: cord-0863688-vozu14wg authors: O’Brien, Ciara M.; Jung, Katherine; Dang, Wilfred; Jang, Hyun-Jung; Kielar, Ania Z. title: Collateral damage: the impact of the COVID-19 pandemic on acute abdominal emergency presentations date: 2020-08-20 journal: J Am Coll Radiol DOI: 10.1016/j.jacr.2020.08.010 sha: 81cec3c4dad2e3c56e411ef3f0ac2f7fa609d04e doc_id: 863688 cord_uid: vozu14wg Abstract Introduction In March 2020 the World Health Organization declared a pandemic caused by a novel coronavirus. Public information created awareness as well as concern in the general population. There has been a reported decrease in the number of patients attending Emergency departments (ED) during the pandemic in previously published study. This is the first study to determine differences in the types of presenting illnesses, severity and rate of resultant surgical intervention during the pandemic. Methods and Materials We carried out a retrospective, observational cohort study comparing two groups of patients attending the ED at our tertiary-care academic hospital. A historical comparison cohort was obtained by reviewing the number of patients referred by the ED for abdominal CT between March 15th - April 15th, 2020 compared to March 15th - April 15th, 2019. CT reports were reviewed; primary pathologies, complications and subsequent surgical intervention was documented and compared between the two groups. Results 733 patients were included in the 2019 cohort and 422 patients were included in the 2020 cohort. In 2019 32.7% had positive CT findings increasing to 50.5% in 2020. The number of complications increased from 7.9% to 19.7%. The rate requiring surgical intervention increased from 26.3% to 47.6% in 2020. Conclusion To date, there is little published data regarding the presentation and severity of illnesses during COVID-19. This information has important public-health implications, highlighting the need to educate patients to continue to present to hospital services during such crises, including if a purported second wave of COVID-19 arises. reported as the virus has been isolated from blood and fecal swabs 3 . The public information and various forms of media coverage of COVID-19 created awareness as well as concern in the general population. On March 17 th 2020 the Government of Ontario declared a provincial state of emergency and issued a public statement saying 'stay home, stay informed, stay healthy and stay calm' 4 . During the COVID-19 pandemic, a decrease in the number of acute non-COVID related emergency hospital presentations was noted in various publications and news outlets 5, 6 . K. Søreide et al hypothesized that a decrease in trauma admissions to the emergency departments was a result of social distancing and overall reduced activity during the pandemic. They also discuss that patients may prefer to defer non-essential elective surgery owing to fear of contracting COVID-19 while in hospital; this fear is also likely to prevent patients from seeking timely care for conditions that would otherwise be correctable or curable by presenting at an earlier stage 5 . Dreifuss et al also described delays in patient consultation during the pandemic which resulted in worse postoperative outcomes in cases of appendicitis 6 . They hypothesize that the 'stay home' policy and population fear of the Hospital environment contributed to the severity of the presenting disease 6 . In this observational study, we first wished to quantify changes in the overall volume of CT scans performed for all causes of acute abdominal presentations from the emergency department (ED), following the pandemic announcement. To date, there has been a relative paucity of literature regarding the impact of the pandemic on morbidity and mortality, with some data looking at appendicitis outcomes alone 6, 7 . We wished to provide a broader view, looking at not just appendicitis but all acute abdominal J o u r n a l P r e -p r o o f presentations to our center. We sought to determine differences in the types of presenting illnesses, the severity of illness, and in the rate of resultant surgical intervention during the pandemic to better understand patterns of care seeking under COVID. We carried out a retrospective, observational cohort study comparing two groups of patients attending the ED at our tertiary-care academic hospital, during two equivalent time intervals, 1 year apart (Table 1) The reports were initially categorized as either "no abnormality found" or as having a cause identified for their presenting symptoms. The abdominal abnormalities identified on CT were categorized into 10 groups which included gastrointestinal (GI), genitourinary (GU), hepatobiliary and pancreas (HPB), peritoneal, malignancy (categorized as GI and GU encompassing all intra-abdominal pathologies including Hepatobiliary (HPB) and other ( Table 2 ). The GI group was further subdivided according to common pathologies including; inflammation (e.g. colitis, enteritis, esophagitis), ischemia, bowel obstruction, diverticulitis and appendicitis. The category 'other' included a broad range of less common pathologies such as pelvic inflammatory disease, epiploic appendagitis, hernias and pneumonia ( Table 2 ). The CT reports were then evaluated for complications arising from the primary pathology. Two abdominal radiologists agreed in consensus what constituted a complication as a result of the primary pathologies outlined in Table 3 . The complications included perforation (e.g. in the case of bowel obstruction, diverticulitis or ischemic bowel), abscess formation (e.g. in case of appendicitis, diverticulitis), ischemia (e.g. in case of bowel obstruction), reactive inflammation of adjacent structures (including pelvic inflammatory disease (PID) causing inflammation of adjacent bowel, appendicitis causing small bowel inflammation, etc.), aspiration, cardiac arrest and first time diagnosis of invasive cancer with extension or growth into adjacent organs (Table 3 ). These complications were assigned a numerical identity from 1-8 for the purpose of data collection. The electronic patient record (EPR) was reviewed to investigate if patients had subsequent surgical intervention. COVID-19 status was documented, where available for the 2020 cohort. Statistical analysis was performed with SPSS (Version 25.0. IBM Corp, Armonk, NY). A Fisher exact test was performed for analysis of the unpaired groups, investigating complication rates and surgical intervention, particularly when the number of cases was small. A Chi-squared test was used for analysis of the primary pathologies and a student t test for continuous variables. A Fisher Exact Test was performed to investigate the differences in sex makeup, complication rates and surgical intervention frequency between 2019 and 2020. A single chi-squared test was used to analyze the distribution of the types of pathologies and the types of complications. Average age was analyzed using a student t test for continuous variables. A p value of < 0.05 was considered to be statistically significant. A total of 1,155 patients were identified for this study. The mean age was 58.9 years and 49.3 % of patients were female. 733 patients were included in the 2019 cohort (mean age 59.4 years, 50.3% female) and 422 patients were included in the 2020 cohort (mean age 57.9 years, 47.4% female). Overall findings are summarized in Table 1 . There were no statistically significant differences in the recorded patient demographics (age and sex). In terms of total emergency room visits for the two cohorts, there were 5942 visits recorded in 2020 during the study period and 11119 in the 2019 time frame. There was a 46.7% decrease in net number of ED visits in that time (p<0.005). This 2019, approximately 6.6% of all patients in the ED underwent a CT scan of the abdomen: In 2020, 7.1% of all-comers to the ED underwent CT, which was not statistically different. In 2019, 240 patients (32.7%) had positive findings on CT abdomen compared to 213 patients (50.5%) in 2020, a statistically significant increase in the percentages of pathological cases (p < 0.0001). However, the distribution of the pathologies did not significantly differ between 2019 and 2020 (p = 0.192) ( Table 2 ). The percent of scans with complications also increased significantly, from 7.9% in 2019 to 19.7% in 2020 (p = 0.0003) ( Table 4 ). Nevertheless, the distribution of the types of complications outlined in Table 3 did not significantly differ between the two years (p = 0.4999). 10 . This delay in diagnosis and treatment may lead to medical and surgical emergencies proving more costly in terms of surgery and/or chemotherapy 10 . Our 6% reduction in GI/GU malignancy cases over a 4 week period is limited to patients in the emergency department and is a small number overall. However, it raises concerns for the short-term future of cancer diagnosis and treatment as restrictions related to COVID-19 are relaxed and eventually removed. This is an area where further research is warranted to fully investigate the impact of COVID-19 on cancer diagnosis and outcomes. COVID-19 is associated with abdominal manifestations involving the bowel and liver. COVID-19 positive patients frequently have elevated liver enzymes of uncertain etiology; a recent study reported that greater than 50% of these patients had cholestasis on ultrasound 11 . Bowel manifestations include bowel wall thickening, pneumatosis and portal venous gas possibly related to direct viral infection, small vessel thrombosis or non-occlusive mesenteric ischemia 11 . In our 2020 patient cohort, 10 patients tested positive for COVID-19. Of these patients, only 1 had abdominal pathology which was a new diagnosis of pancreatic malignancy and liver metastasis. None of the 10 COVIDpositive patients in our study had bowel or biliary pathology reported at the time of their abdominal imaging. Our study has limitations, mainly pertaining to its retrospective single-center nature. Although we have data to show a reduction in net number of patient visits and increased J o u r n a l P r e -p r o o f rates of positive findings, complications and need for surgery, we can only hypothesize that patients chose to avoid the ED, and acknowledge that other factors may have come into play during this pandemic. We also acknowledge that it is possible that the Emergency physicians requested less CT studies in an effort to reduce patient time in hospital and COVID-19 exposure. Finally we acknowledge that the drop in the number of hospital visits and CT scans performed is also partly due to the fact that people who did not really need an ER visit, were less likely to come. However, the number of complications outlined in our results does suggest that there is still a need for people to be encouraged to come when they are ill. In conclusion, we have documented a significant reduction in the overall number of ER visits as well as the number of abdominal CT scans performed during the first month after the COVID pandemic was announced in our area. There was a concomitant increase in "positive" findings, as well as an increase in complications related to the findings and need for surgical intervention during the COVID-19 pandemic. To date, there is little published regarding the severity of illness or patient morbidity when they do present to the ED. This information has important public-health implications, and highlights the need to educate patients to continue to present to hospital services during such crises, or indeed if a purported second wave arises. • Although there has been a decline in the number of CT studies being performed from the ED (7.1% to 6.6%), the proportion of acute abdominal pathologies has increased from 32.7% to 50.5%. We have demonstrated an increase in the severity of these pathologies (7.9% to 19.7%) and an associated trend for increased need for surgical intervention (26.3% to 47.6%). • In the event of a second wave of COVID-19 patients need to be educated on when to present to the emergency departments for assessment. They should be informed of the measures in place throughout health care institutions to keep them safe from the spread of the virus. • The onus is on the government, media and healthcare institutions to publicize the measures undertaken to ensure patient safety during the pandemic and reduce anxiety associated with presenting to hospital when in need of any type of medical attention. Axial, coronal and sagittal contrast enhanced abdominal CT images from a 43 year old female who presented to the ED with a 5 day history of lower abdominal pain. The images show a perforated appendicitis with a >1cm appendicolith in the right lower pelvis. The abscess involves the right adnexa and fallopian tube. Axial, coronal and sagittal contrast enhanced abdominal CT images from a 73 year old female presenting to ED with a 5 day history of lower abdominal pain and constipation. The images demonstrate severe sigmoid diverticulitis with a perforation and large air and fluid collection in the left lower quadrant. Axial and coronal contrast enhanced abdominal CT images from a 56 year old male presenting with a 6 day history of increasing abdominal girth, no bowel motion or flatus. The images show an obstructing apple core mass in the sigmoid colon with an J o u r n a l P r e -p r o o f associated large bowel obstruction and free fluid. The gas pattern of the caecum is suspicious for ischemia. 4 (a-c) Axial, coronal and sagittal contrast enhanced abdominal CT images from a 73 year old male presenting with a 3 day history of vomiting and no bowel motions. The image demonstrate a proximal small bowel obstruction and associated perforation. There is an organizing air and fluid collection in the Coronavirus Disease (COVID-19): A primer for emergency physicians Lianyang Zhang Emergency trauma care during the outbreak of corona virus disease 2019 (COVID-19) in China The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak -an update on the status Stay home, stay informed": Ontario reports 1sr COVID-19-related death as province declares state of emergency cbc news Immediate and long-term impact of the COVID-19 pandemic on delivery of surgical services Acute appendicitis does not quarantine: surgical outcomes of laparoscopic appendectomy in COVID-19 times The management of adult appendicitis during the COVID-19 pandemic: an interim analysis of a UK cohort study Impact of the COVID-19 Pandemic on Imaging Case Volumes Variables Influencing Radiology Volume Recovery During the Next Phase of the Coronavirus Disease 2019 (COVID-19) Pandemic Collateral damage: the impact on outcomes from cancer surgery of the COVID-19 pandemic Abdominal Imaging Findings in COVID-19: Preliminary Observations J o u r n a l P r e -p r o o f Tables: Table 1 . Table 3 . Outlines the number assigned to each complication documented and the number (n) of patients in 2019 and 2020 that presented with each.