Lessons Learned on Gastroenterology Future During COVID-19 Pandemic

Fernando Magro, MD

The COVID-19 pandemic has caused a disruption to services and care in all medical fields, including gastroenterology.

A team, led by Fernando Magro, MD, Department of Biomedicine, Unit of Pharmacology and Therapeutics, University of Porto, evaluated how the COVID-19 pandemic impacted the quality of health care services for gastroenterology patients.

While controlling and curbing the spread of the virus was paramount, some of the unintended consequences include missed medical appointments, a delay in disease screenings, and the forced introduction of telemedicine to replace in-person care in many scenarios.

“On this setting, the susceptibility, monitoring, diagnosis, and treatment of patients with chronic gastrointestinal (GI) diseases are major concerns,” the authors wrote. “Regarding diagnosis, endoscopy is one of the most affected procedures and the impact of the decrease of procedures is yet to be determined.”

Another byproduct of the pandemic has been an increase in burnout and mental health concerns for gastroenterologists.

The Analysis

The researchers performed a literature review to summarize the main aspects to consider in gastroenterology. This included a deep discussion on the main changes affecting this patient population, as well as healthcare systems.

The review also anticipates the pandemic recovery with future practices and policies.

Gastrointestinal Symptoms

In the early stages of the COVID-19 pandemic, many researchers thought the virus would increase gastrointestinal symptom presentation as initial analysis showed an increase in diarrhea from infected patients, even without the more common respiratory symptoms.

Some studies have showed 0.9-10.5% of patients suffering from post-acute COVID-19 also have symptoms of subacute or chronic diarrhea, leading to more studies looking at the subacute and long-term consequences of the virus on the gastrointestinal symptoms, including post-infectious irritable bowel syndrome (IBS).

In a population-based survey, investigators found IBS patients reported significantly worse emotional, social, and psychological well-being, compared to non-IBS respondents.

The researchers found gastrointestinal symptoms can be caused by some of the socio-cultural changes implemented during the pandemic, including lockdowns and social distancing requirements. These behavior modifying policies may have directly led to an increase in unhealthy eating habits, a decrease in physical exercise, and a decrease in patient interactions with medical services.

The mitigation measures may have also caused an increase in anxiety and alcohol consumption.

“Overall, the pandemic is affecting general Gastroenterology services with impact on patients, HCPs, and policy makers,” the authors wrote. “Outpatient care has evolved, and patients have seen their appointments delayed and their visiting rights restricted.”

Inflammatory Bowel Disease

It was also thought in the beginning of the pandemic that inflammatory bowel disease (IBD) patients might be more susceptible to COVID-19 infections because of the use of immunosuppressant treatments.

However, these patients do not appear to be at an increased risk of infection in comparison to the general population, but there are some circumstances that do warrant further research.

“It has been demonstrated, across different cohorts, that steroids increase the risk of infection and that active disease should be considered as a risk factor,” the authors wrote. “In addition, thiopurines have been identified as the major responsible for the increased risk of viral infections in IBD patients.”

Liver Disease

For liver injuries associated with COVID-19, they have generally remained hepatocellular in nature with transaminitis. Some of the possible causative mechanisms being examined include direct hepatocytopathic effect of SARS-CoV-2, liver engorgement from increased pulmonary pressure, drug-induced liver injury, or ischemic hepatitis.

In recent meta-analyses, researchers found the prevalence of COVID-19 acute liver injuries in hospitalized patients was between 24-27%, with 2% of patients developing chronic liver disease.

In addition, acute liver injury was found in 45% of patients with severe COVID-19 and 20% of non-severe COVID-19 patients.

Elective Procedures and Telemedicine

A few months of elective procedure cancellations could have a big impact moving forward.

“After the first wave, endoscopy departments faced the challenges of reconfiguring services to adapt, revert to pre-pandemic levels of activity, and address waiting list backlogs,” the authors wrote. “The impact of these tendencies is predictable if we acknowledge that even a slight 3-month delay in cancer diagnosis (especially T2-T3) may have significant impact on survival.”

It was clear that telemedicine should not be the only option for care when in-person visits are a possibility.

“We predict that, considering its recent developments and indicators, such as reduction of costs and administrative burdens, telemedicine can remain a valid strategy for IBD patients, in combination with conventional visits, both for continuous care and procedure's monitoring,” the authors wrote. “However, it is mandatory to observe how telemedicine will evolve and impact the whole management, while guaranteeing individual accessibility.”

The study, “COVID-19 in gastroenterology: Where are we now? Current evidence on the impact of COVID-19 in gastroenterology,” was published online in United European Gastroenterology.