Be prepared for Long Covid IBS

Gastroenterologists should be aware that SARS-CoV-2 infection can result in the development of chronic disorders of gut-brain interaction such as IBS, US experts say.

Up to 40% of patients with Covid report one or more troublesome gastrointestinal symptoms and many of these persist after acute infection to become part of the poorly-understood Long Covid syndrome, according to gastroenterologists Professor Walter Chan and Dr Madhusudan Grover of the Brigham and Women’s Hospital, Harvard Medical School, and the Mayo Clinic, Rochester.

In a paper published in Clinical Gastroenterology and Hepatology, the authors note the predominant GI symptoms seen in Covid such as nausea, diarrhoea and abdominal pain, overlap with those of IBS.

In one study of almost 750 patients with Covid, 29% developed new GI symptoms after the infection and of these around 40% met Rome IV criteria for irritable bowel syndrome (IBS).

Similarly, many of the pre-disposing factors for post-covid GI symptoms, such as psychiatric diagnoses (depression, anxiety), hospitalisation for acute illness and infectious gastroenteritis, are also established risk factor for development of disorders of gut-brain interaction (DGBI), and especially postinfection IBS.

The authors say that given Covid’s action on the ACE-2 receptor in the gut and its known links to inflammatory and neurological injury there are many plausible mechanisms that could explain why GI symptoms are part of a postacute COVID-19 syndrome (PACS).

“Invasion of SARS-CoV-2 in the intestinal epithelium may mediate immune dysregulation, barrier dysfunction, and neuromuscular plasticity. Additionally, changes in luminal milieu caused by altered microbiota or metabolites may mediate changes in sensory-motor function. Patients may develop central sensitisation because of the ongoing stress associated with the pandemic,” they write.

Another contributor to IBS-like GI symptoms may be the profound psychological impact of the pandemic on patients with disorders of gut-brain interaction.

Alterations in dietary habits and behaviours during the pandemic and lockdown, may also predispose to IBS, including increased sugar or carbohydrates consumption, decreased water intake, and reduced physical activity.

“These observations may foreshadow a continued rise in patients presenting to gastroenterologist offices with IBS or DGBI symptoms, both from de novo diagnosis and from increase/flare-up of existing symptoms,” the authors say.

However, since there are no biomarkers or evidence-based therapies for Covid-related GI symptoms, the management approach should be similar to that taken in IBS, the paper advises.

Investigations should be avoided unless alarm symptoms are present, and first-line treatments may include lifestyle and dietary modification such as adequate sleep and a high fibre/low FODMAPs diet. Symptom focused pharmacotherapies such as antispasmodics may help some patients, as well as neuromoudulation, psychological therapies (CBT) and microbiome-based approaches, the authors say.

“Future studies will likely provide more insight into mechanisms that can be systematically targeted for management of GI postacute COVID-19 syndrome,” they conclude.

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