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CME / ABIM MOC / CE

Are Gastrointestinal Symptoms With COVID-19 Indicative of Worse In-Hospital Complications?

  • Authors: News Author: Carolyn Crist; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 10/21/2022
  • Valid for credit through: 10/21/2023, 11:59 PM EST
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

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Target Audience and Goal Statement

This activity is intended for primary care physicians, infectious disease specialists, gastroenterologists, nurses, pharmacists, physician assistants, and other members of the healthcare team who treat and manage patients at risk for COVID-19.

The goal of this activity is for learners to be better able to analyze how the presence of gastrointestinal symptoms affects the prognosis of COVID-19.

Upon completion of this activity, participants will:

  • Distinguish the most common gastrointestinal symptom associated with COVID-19 infection
  • Analyze how the presence of gastrointestinal symptoms affects the prognosis of COVID-19
  • Outline implications for the healthcare team


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News Author

  • Carolyn Crist

    Freelance writer, Medscape

    Disclosures

    Carolyn Crist has no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine

    Disclosures

    Charles P. Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

Editor/Nurse Planner

  • Leigh Schmidt, MSN, RN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Leigh Schmidt, MSN, RN, CNE, CHCP, has no relevant financial relationships.

Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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CME / ABIM MOC / CE

Are Gastrointestinal Symptoms With COVID-19 Indicative of Worse In-Hospital Complications?

Authors: News Author: Carolyn Crist; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 10/21/2022

Valid for credit through: 10/21/2023, 11:59 PM EST

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Note: The information on the coronavirus outbreak is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available. It is the policy of Medscape Education to avoid the mention of brand names or specific manufacturers in accredited educational activities. However, manufacturer names related to the approved COVID-19 vaccines are provided in this activity in an effort to promote clarity. The use of manufacturer names should not be viewed as an endorsement by Medscape of any specific product or manufacturer.

Clinical Context

Gastrointestinal (GI) symptoms have not been a hallmark of COVID-19, but a study by Marasco and colleagues suggests that GI symptoms might be more frequent in COVID-19 than previously thought. They prospectively evaluated 871 hospitalized patients with and without COVID-19 in their analysis, the results of which were published in the January 2022 issue of the American Journal of Gastroenterology.[1]

A total of 59.7% of patients with COVID-19 had GI symptoms compared with 43.2% in the control group without COVID-19. Symptoms particularly associated with COVID-19 included nausea and loose stools with urgency. At 1 month after hospital admission, GI symptoms had generally subsided in the COVID-19 cohort, but nausea remained more prevalent compared with the control group. Variables associated with a higher rate of nausea at 30 days included female sex, high body mass index, the presence of dyspnea, and elevated C-reactive protein.

This study found that GI symptoms were common in COVID-19, but do they affect prognosis of the infection? The current study analyzes this possibility.

Study Synopsis and Perspective

Patients with COVID-19 who experience GI symptoms have overall worse in-hospital complications but less cardiomyopathy and mortality, according to a new study.

About 20% of COVID-19 patients experience GI symptoms, such as abdominal pain, diarrhea, nausea, and vomiting, which clinicians should consider when treating their hospitalized patients, write researchers led by Nikita Patil, MD, a hospitalist at Nash General Hospital–UNC Nash Healthcare in Rocky Mount, North Carolina, in Gastro Hep Advances.[2]

"It's important to know that certain complications are higher in people with GI symptoms," she said in an interview. "Even without an increased risk of death, there are many problems that affect quality of life and lead to people not being able to do the things they were able to do before."

Dr Patil and colleagues analyzed the association of GI symptoms with adverse outcomes in 100,902 patients from the Cerner Real-World Data COVID-19 Database, which included hospital encounters and emergency department visits for COVID-19 between December 2019 and November 2020; the data were taken from electronic medical records at centers with which Cerner has a data use agreement. The researchers also looked at factors associated with poor outcomes, such as acute respiratory distress syndrome, sepsis, and ventilator requirement or oxygen dependence.

The average age of the patients was 52 years, and a higher proportion of patients with GI symptoms were aged 50 years and older. Of those with GI symptoms, 54.5% were women. Overall, patients with GI symptoms were more likely to have higher Charlson Comorbidity Index scores and have comorbidities such as acute liver failure, gastroesophageal reflux disease, GI malignancy, and inflammatory bowel disease.

The research team found that patients with COVID-19 with GI symptoms were more likely to have acute respiratory distress syndrome (odds ratio, 1.20; 95% CI, 1.11-1.29), sepsis (OR, 1.19; 95% CI, 1.14-1.24), acute kidney injury (OR, 1.30; 95% CI, 1.24-1.36), venous thromboembolism (OR, 1.36; 95% CI, 1.22-1.52), and GI bleeding (OR 1.62; 95% CI, 1.47-1.79) compared with patients with COVID-19 without GI symptoms (P<.0001 for all comparisons). At the same time, those with GI symptoms were less likely to experience cardiomyopathy (OR, 0.87; 95% CI, 0.77-0.99; P=.027), respiratory failure (OR, 1.20; 95% CI, 1.11-1.29; P<.0001), or death (OR, 0.71; 95% CI, 0.67-0.75; P<.0001).

GI bleed was the most common GI complication, found among 2% of all patients, and was more likely in patients with GI symptoms than in those without (3.5% vs. 1.6%). Intestinal ischemia, pancreatitis, acute liver injury, and intestinal pseudo-obstruction were not associated with GI symptoms.

Among the 19,915 patients with GI symptoms, older age, higher Charlson Comorbidity Index scores, use of proton pump inhibitors, and use of H2 receptor antagonists were associated with higher mortality, acute respiratory distress syndrome, sepsis, and ventilator or oxygen requirement. Men with GI symptoms also had a higher risk for mortality, acute respiratory distress syndrome, and sepsis.

In particular, proton pump inhibitor use was associated with more than twice the risk for acute respiratory distress syndrome (OR, 2.19; 95% CI, 1.91-2.50; P<.0001). Similarly, H2 receptor antagonist use was associated with higher likelihood of death (OR, 1.78; 95% CI, 1.57-2.02), as well as more than 3 times the risk for acute respiratory distress syndrome (OR, 3.75; 95% CI, 3.29-4.28), more than twice the risk for sepsis (OR, 2.50; 95% CI, 2.28-2.73), and nearly twice the risk for ventilator or oxygen dependence (OR, 1.97; 95% CI, 1.68-2.30) (P<.0001 for all).

The findings could guide risk stratification, prognosis, and treatment decisions in patients with COVID-19 with GI symptoms, as well as inform future research focused on risk mitigation and improvement of COVID-19 outcomes, Dr Patil said.

"The protocols for COVID-19 treatment have changed over the past 2 years with blood thinners and steroids," she said. "Although we likely can't avoid antireflux medicines entirely, it's something we need to be cognizant of and look out for in our hospitalized patients."

One study limitation was its inclusion of only inpatient or ED encounters and, therefore, omission of those treated at home; this confers bias toward those with more aggressive disease, according to the authors.

The authors reported no grant support or funding sources for this study. One author declared grant support and consultant fees from several companies, including some medical and pharmaceutical companies, which were unrelated to this research. Dr Patil has disclosed no relevant financial relationships.

Gastro Hep Adv. Published online August 26, 2022.

Study Highlights

  • Study data were drawn from the Cerner Real-World COVID-19 database, which collects data on patient demographic and clinical data in hospitals with a data use agreement with Cerner.
  • The current study focused on patients admitted to the hospital after December 1, 2019, with COVID-19 infection.
  • Study outcomes included acute respiratory distress syndrome, sepsis, acute kidney injury, venous thromboembolism, cardiomyopathy, the use of mechanical ventilation, and mortality. Researchers also followed rates of GI complications.
  • The principal study variable was GI symptoms. Results of the analysis were adjusted to account for demographic, hospital, and disease variables, as well as the use of acid suppressive therapy.
  • 100,902 patients were included in the study sample. The mean age of patients was 52 years. Half of the cohort were women, and 18.4% of the cohort was Black.
  • 20% of patients had GI symptoms at presentation. Variables associated with a higher rate of GI symptoms included being a woman and being hospitalized in the southern United States.
  • Patients with GI symptoms had more chronic illnesses and were more likely to use acid suppressive therapy before admission.
  • The ORs for study outcomes associated with GI symptoms at admission are as follows:

    Event

    ORs With 95% CI

    Acute respiratory distress syndrome 1.20; 1.11-1.29
    Sepsis 1.19; 1.14-1.24
    Acute kidney injury 1.30; 1.24-1.36
    Venous thromboembolism 1.36; 1.22-1.52
    Cardiomyopathy 0.87; 0.77-0.99
    Mortality 0.71; 0.67-0.75
  • The most common GI complication was bleeding (2% of cohort); this complication was more likely among patients with GI symptoms.
  • Complications such as intestinal ischemia and pancreatitis occurred in less than 1% of patients and were unrelated to the presence of GI symptoms.
  • GI symptoms appeared to promote a particularly worse prognosis among men, and larger hospital size was also associated with a higher risk for death among patients with GI symptoms.
  • The use of proton pump inhibitors was associated with an OR of 1.48 for mortality (95% CI, 1.32-1.66), and it was also associated with higher risks for acute respiratory distress syndrome and mechanical ventilation. Histamine-2 receptor antagonists were associated with an OR for mortality of 1.78 (95% CI, 1.57-2.02), and they were associated with higher risks for acute respiratory distress syndrome, mechanical ventilation, and sepsis as well.

Clinical Implications

  • In a previous study, 59.7% of hospitalized patients with COVID-19 had GI symptoms compared with 43.2% in the control group without COVID-19. The most salient GI symptom at admission and 1 month later was nausea.
  • The current study finds that GI symptoms among patients hospitalized for COVID-19 are associated with multiple complications, such as acute respiratory distress syndrome and sepsis, but they were not associated with a higher risk for mortality.

Implications for the Healthcare Team

The healthcare team should be aware of gastrointestinal symptoms in COVID-19 as potential risk factors for complicated illness.

 

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