key: cord-0878552-lwb9c5qn authors: Gubatan, John; Zikos, Thomas; Spear Bishop, Estelle; Wu, John; Gottfried, Andrés; Becker, Laren; Habtezion, Aida; Neshatian, Leila title: Gastrointestinal symptoms and healthcare utilization have increased among patients with functional gastrointestinal and motility disorders during the COVID‐19 pandemic date: 2021-08-11 journal: Neurogastroenterol Motil DOI: 10.1111/nmo.14243 sha: 072b2164dc3519b4e0ed49a0ed27f8fe5b361ae6 doc_id: 878552 cord_uid: lwb9c5qn BACKGROUND: The coronavirus disease 2019 (COVID‐19) pandemic has led to unprecedented disruptions in healthcare. Functional gastrointestinal and motility disorders (FGIMD) are associated with significant healthcare utilization. The clinical implications of these healthcare disruptions due to the COVID‐19 pandemic on clinical outcomes in patients with FGIMD are unclear. METHODS: We performed a retrospective study of patients with three common FGIMD (irritable bowel syndrome [IBS], gastroparesis, functional dyspepsia [FD]) tested for SARS‐CoV‐2 to describe alterations in gastrointestinal symptoms, medication use, and healthcare utilization during and before the pandemic and factors associated with COVID‐19. KEY RESULTS: The prevalence of COVID‐19 during the pandemic (03/2020–09/2020) was 3.20% (83/2592) among patients with FGIMD, 3.62% in IBS (57/1574), 3.07% in gastroparesis (23/749), and 2.44% in FD (29/1187) at our institution. Patients with FGIMD had increased abdominal pain, nausea/vomiting, diarrhea, constipation, and weight loss (p < 0.001) along with increased proton pump inhibitor, H2 blocker, and opioid use (p < 0.0001). Both inpatient hospitalizations and outpatient visits (p < 0.0001) and number of diagnostic tests including cross‐sectional imaging (p = 0.002), and upper and lower endoscopies (p < 0.0001) were significantly higher during the pandemic as compared to 6 months prior. Diarrhea‐predominant IBS was positively (OR 2.37, 95% CI 1.34–4.19, p = 0.003) associated with COVID‐19, whereas functional dyspepsia was negatively (OR 0.46, 95% CI 0.27–0.79, p = 0.004) associated. CONCLUSIONS & INFERENCES: Patients with common functional gastrointestinal and motility disorders have reported more gastrointestinal symptoms during the COVID‐19 pandemic with concurrent increased medication use and healthcare utilization. Functional gastrointestinal and motility disorders (FGIMD) or disorders of gut-brain interactions and motility disorders are highly prevalent with more than 40% of persons estimated to be affected worldwide. 1 The management of FGIMD represents a major social and economic burden accounting for significant healthcare utilization and costs. 2 The coronavirus disease 2019 (COVID- 19) pandemic has led to an unprecedented disruption in healthcare including reduced 3, 4 and delayed access and availability 5 to non-COVID-19 services. The clinical ramifications of these healthcare disruptions due to the COVID-19 pandemic on clinical outcomes in patients with FGIMD are unclear. There has been great interest in understanding the epidemiology of COVID-19 in patients with gastrointestinal diseases as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is known to infect the gastrointestinal (GI) tract 6 and GI symptoms are common among patients with COVID-19. 7, 8 Prior studies have focused on the epidemiology and clinical outcomes of COVID-19 in patients with inflammatory bowel disease, 9, 10 cirrhosis, 11 and pancreatic diseases. 12 Although FGIMD are prevalent, there are currently limited epidemiological studies exploring the clinical outcomes of COVID-19 in patients with FGIMD as well as the impact of the pandemic on these patients. This is especially important and clinically relevant as there have been some reports of COVID-19 exacerbating FGIMD or gastrointestinal motility. For example, a recent case report detailed COVID-19 presenting as a severe diabetic gastroparesis flare. 13 In a case series of 141 patients with COVID-19 admitted to the intensive care unit, about 55.8% of patients developed an ileus, whereas 2.9% developed Ogilvie's syndrome. 14 The primary aim of this study was to describe changes in gastrointestinal symptoms, medication use, and healthcare utilization in patients with three common FGIMD (irritable bowel syndrome [IBS] , gastroparesis, functional dyspepsia [FD] ) during and before the COVID-19 pandemic. Our secondary aims were to determine the prevalence and clinical factors associated with COVID-19 in patients with these FGIMD. We performed a retrospective analysis of data collected from consecutive patients whose SARS-CoV-2 testing was performed by a laboratory at Stanford University between March 15, 2020, and September 30, 2020, and received emergency department, outpatient, or inpatient care at any Stanford Healthcare facility. We included all SARS-CoV-2 tests including those performed in the outpatient setting. Our institution initially reserved testing for symptomatic patients, however, later expanded testing for asymptomatic individuals who required testing prior to procedures or for employment. Our cohort included both symptomatic and asymptomatic individuals. We evaluated the association of the COVID-19 pandemic on rates of GI symptoms, medication use, and healthcare utilization, prevalence, and prevalence and clinical predictors of COVID-19 among patients with three common FGIMD (IBS, gastroparesis, FD). All SARS-CoV-2 RNA testing was performed using samples from a nasopharyngeal swab. The clinical sensitivity of the COVID-19 test at our institution is 96% and clinical specificity approaches 100%. For all included patients, we obtained data regarding medication use (proton pump inhibitors (PPI), H2 blockers, steroids, buspirone, dicyclomine, loperamide, mirtazapine, opioids, selective serotonin reuptake inhibitors (SSRI), serotonin-norepinephrine reuptake inhibitor (SNRI), tricyclic antidepressants (TCA), aspirin, antiplatelets, anticoagulants, and non-steroid anti-inflammatory drugs (NSAID). Medication use was determined by inpatient provider orders or outpatient prescriptions by healthcare providers. We were unable to capture over-the-counter medication use as this was not coded in our electronic medical record. We also assessed healthcare utilization by measuring the number of (emergency department) ED visits, inpa- We compared rates of gastrointestinal complaints, medication use, with medication use and healthcare utilization in patients with FGIMD 6 months before and during COVID-19 pandemic Table 2 Again, similar trends were seen, with higher gastrointestinal symptom burden, medication prescription, and health care utilization during the pandemic as compared to before the pandemic. In this retrospective study of over 2500 patients with common FGIMD (IBS, gastroparesis, and FD), we report for the first time that the COVID-19 pandemic has led to increased gastrointestinal complaints, medication use, and healthcare utilization overall. We demonstrate that the prevalence of COVID-19 in patients with FGIMD is 3.20% (IBS 3.62%, gastroparesis 3.07%, FD 2.44%). Finally, we show that active smoking and IBS-D were independent risk factors for COVID-19 in this cohort of patients with FGIMD, and symptoms of cough, dyspnea, and pneumonia were predictive of COVID-19. Our study revealed patients with FGIMD developed increased gastrointestinal symptoms, medication use, and healthcare utilization during the pandemic. We found that this was independent of COVID-19 infection, as diarrhea was the only symptom that had increased with COVID-19. Our data suggest that patients with Given that a diagnosis of gastroparesis did not confer increased or decreased risk to COVID-19, gastric-specific factors may be less related to COVID-19 risks. We also highlight several interesting findings in our study. First, our study revealed that current smoker status was independently associated with increased risk of COVID-19 in our cohort of patients with FGIMD. This finding is consistent with prior studies in the general population showing an increased risk of symptomatic COVID-19 28 and COVID-19 severity and death 29 in smokers. The mechanism of this association is unclear but is speculated to be related to increased ACE2 expression in the lung mucosa of smokers. 29 Second, we showed that opioid use significantly increased were based on ICD codes. We thus cannot exclude the possibility of misclassification and selection bias using these codes. In conclusion, we demonstrate that the COVID-19 pandemic has led to increased gastrointestinal complaints, medication use, and healthcare utilization in patients with three common FGIMD. We demonstrate that the prevalence of COVID-19 in FGIMD is comparable to patients without risk factors for COVID-19 and identify IBS-D as positively associated with COVID-19 whereas FD is Scientist Scholar Award and an NIH NIDDK LRP Award. Authors have no conflicts of interests or financial disclosures relevant to this manuscript. JG and LN planned and designed the study; JG, TZ, and JW ex- Worldwide prevalence and burden of functional gastrointestinal disorders, results of Rome foundation global study Epidemiologic burden and treatment of chronic symptomatic functional bowel disorders in the United States: a nationwide analysis Reduction in healthcare services during the COVID-19 pandemic in China Effects of State COVID-19 Closure Policy on Non-COVID-19 Health Care Utilization (No. w27621) Changes in healthcare utilization, spending, and perceived health during COVID-19: A longitudinal study from Singapore. Spending, and Perceived Health during COVID-19: A Longitudinal Study from Singapore Evidence for gastrointestinal infection of SARS-CoV-2 Gastrointestinal symptoms of 95 cases with SARS-CoV-2 infection High prevalence of concurrent gastrointestinal manifestations in patients with SARS-CoV-2: early experience from California SARS-CoV-2 testing, prevalence, and predictors of COVID-19 in patients with inflammatory bowel disease in Northern California Risk and outcomes of coronavirus disease (COVID-19) in patients with inflammatory bowel disease: a systematic review and meta-analysis. United Outcomes following SARS-CoV-2 infection in patients with chronic liver disease: an international registry study Prevalence, risk factors and clinical outcomes of COVID-19 in patients with a history of pancreatitis in Northern California COVID-19 infection manifesting as a severe gastroparesis flare: A case report Gastrointestinal complications in critically ill patients with COVID-19 Impacts of the COVID2019 pandemic on functional dyspepsia and irritable bowel syndrome: a population-based survey The impact of COVID-19 pandemic on neurogastroenterologists in Latin America: results of an online survey Psychological co-morbidity in functional gastrointestinal disorders: epidemiology, mechanisms and management Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: a systematic review and meta-analysis Problems for gastrointestinal patients with diarrheal disorders: limited access to public bathrooms because previously open public bathrooms have closed due to COVID-19 pandemic and inadequate number of bathrooms in some endoscopy suites A survey on the impact of the COVID-19 pandemic on motility and functional investigations in Europe and considerations for recommencing activities in the early recovery phase Managing the inevitable surge of post-COVID-19 functional gastrointestinal disorders Increased risk of COVID-19 among users of proton pump inhibitors Are proton pump inhibitors contributing to SARS-COV-2 infection? Irritable bowel syndrome: methods, mechanisms, and pathophysiology. The confluence of increased permeability, inflammation, and pain in irritable bowel syndrome Severe COVID-19 Is fueled by disrupted gut barrier integrity. medRxiv Almost all irritable bowel syndromes are post-infectious and respond to probiotics: consensus issues Longitudinal analysis indicates symptom severity influences immune profile in irritable bowel syndrome Current smoking and COVID-19 risk: results from a population symptom app in over 2.4 million people Smoking and risk of negative outcomes among COVID-19 patients: a systematic review and meta-analysis Notes from the field: opioid overdose deaths before, during, and after an 11-week COVID-19 stay-at-home order-Cook County An epidemic in the midst of a pandemic: opioid use disorder and COVID-19 Incidence of thrombotic complications in critically ill ICU patients with COVID-19