ABSTRACT
BACKGROUND: Post-infectious functional gastrointestinal disorders (PI-FGID) involve a broad group of well-recognized conditions such as Irritable Bowel Syndrome (IBS) and Functional Dyspepsia (FD) that follow an infectious illness involving the GI tract. Post-infectious IBS (PI-IBS) is the most well-known entity occurring in ~10% of patients following acute gastroenteritis due to bacteria or enteropathic viruses, and can last for several months. The SARS-CoV-2 (COVID-19) virus appears to infect the GI system as well as the respiratory tract. While respiratory signs and symptoms are generally the most prominent and life-threatening aspects of COVID-19 infection, nearly half of COVID-19 cases present with digestive symptoms such as diarrhea, anorexia, vomiting, nausea, and abdominal pain. COVID-19 infection has also been associated with autonomic dysregulation, manifesting as fatigue or dizziness. In addition, COVID-19 may infect the brain and lead to MRI changes which may alter emotions and somatic perception. The goal of this study was to determine the impact of COVID-19 on PI-FGID symptoms in children and adolescents. METHODS Recruitment: An electronic medical record (EMR) search was carried out to find all patients 8 years of age or older who were COVID-19 tested at the Ann and Robert H. Lurie Children's Hospital of Chicago between November 2020 and October 2021. Questionnaires: A COVID-19 Phenotype survey was administered to identify COVID-19 symptoms, severity, and duration in the 7 days prior to the COVID-19 test. The following questionnaires were distributed to the parent or guardian of the COVID-19 tested child with instructions to refer to the 3 months following the test (1) COMPASS-31 - assesses presence of symptoms of dysautonomia;(2) PEESS v2.0 - assesses frequency and severity of symptoms of esophageal dysfunction;(3) QPGSIV - assesses presence of functional nausea/vomiting, defecation, and pain disorders;(4) Nausea Profile (NP) - assesses severity of somatic, gastrointestinal and emotional symptoms associated with nausea;(5) Dyspepsia Symptom Survey (DSS) - novel survey to assess frequency and severity of symptoms related to gastric or duodenal dysfunction;(6) Nausea Severity Profile - assess severity of nausea (7) PedsQL General Well-Being Survey - assesses overall quality of life. An email was sent in July 2021 to patients tested November 2020-March 2021, and an email was sent in December 2021 to patients tested April-October 2021. Consent was obtained by patients agreeing to complete the surveys, and data were collected to a RedCAP database. Data analysis: A comparison of survey results was carried out for the following subgroups: COVID-19 positive, COVID-19 negative without symptoms at time of viral testing, and COVID-19 negative with symptoms at time of viral testing. Due to the small size of the COVID-19 positive group relative to the COVID-19 negative groups, a Mann-Whitney U was utilized to compare the COVID-19 positive group with the COVID-19 negative asymptomatic group and COVID-19 negative symptomatic group separately, along with the COVID-19 negative asymptomatic group versus the COVID-19 negative symptomatic group. Categorical data were compared via Fischer's Exact Test. RESULT(S): A total of 771 patients/parent(s)/guardian(s) completed the required questionnaires. The demographics for each of the comparative subpopulations were well-matched. The COVID-19 negative patients with symptoms present prior to the COVID test had significantly increased composite scores on all surveys compared to the COVID-19 negative asymptomatic group (p-values=0.014-0.0001). The COVID-19 positive group had no significant differences in composite scores compared to the COVID-19 negative symptomatic group with the exception of the NP somatic score (p-value=0.02). The COVID-19 positive group had significantly increased composite scores compared to the COVID-19 negative asymptomatic group on the DSS frequency composite and NP somatic, gastrointestinal, and emotional scores (p-value=0.03-0.0001). The COVID-19 negative symptomatic group had a significant increase in FGID prevalence detected by the QPGSIV (p-value <0.05) compared to the COVID-19 negative asymptomatic group, while the COVID-19 positive group showed no difference. CONCLUSION(S): We found an increased frequency of functional dyspepsia and nausea symptoms compared to a control population, although no differences were seen compared to a population with presumptive non-COVID-19 infection. Further, we found a significant increase in somatic and emotional symptoms in COVID-19 positive patients compared to a control population underscoring the need for a comprehensive biopsychosocial approach. Thus, Long-COVID GI disease likely exists in children. However, its manifestations do not appear worse than those following any other viral infection.
ABSTRACT
Introduction and Aims: Most children with functional constipation (FC) improve with conventional treatments. However, a proportion of children have poor treatment outcomes. Management of intractable FC may include botulinum toxin injections, transanal irrigation, antegrade enemas, colonic resections, and in some cases sacral nerve stimulation (SNS). SNS is surgically placed, not readily available and expensive. Posterior tibial nerve stimulation (PTNS) allows transmission of electronic impulses and retrograde stimulation to the sacral nerve plexus in a portable, simple and non-invasive fashion. Objectives: To assess the efficacy and safety of transcutaneous PTNS for the treatment of FC in children.Materials and Methods: Single-center, prospective interventional study. Children 4-14 years with Rome IV diagnosis of FC received ten daily PTNS (30 min/day) sessions. Electrodes placed over skin of ankle. Strength of stimulus was below pain threshold. Outcomes were assessed during treatment and 7 days after. Results: twenty-three subjects enrolled. Two children excluded (acute gastroenteritis, COVID-19 contact). 20 completed the study (4- 14 years), (8,4+/-3,2years, 71.4 % female). We found significant improvement in the consistency of Bowel Movements (BM) (p=0.005), Fecal Incontinence (FI) (p=0.005), Abdominal pain presence (p= <0.001) and intensity (p=0.005), and a significant for improvement in blood in stools (p=0.037). There was 86.3% improvement in abdominal pain. 96.7% reported treatment satisfaction. Only one child required rescue therapy. Conclusion: We found significant improvement in stool consistency, FI, abdominal pain and hematochezia. This suggests that transcutaneous PTNS could be a promising noninvasive treatment for FC in children. Large studies are needed.
Subject(s)
COVID-19ABSTRACT
Introduction: Management of intractable Functional Constipation (FC) can include antegrade enemas, transanal irrigation and in some cases sacral nerve stimulation (SNS). SNS is expensive, invasive and not available in all centers. Although the mechanism of action of SNS in the treatment of FC is unclear, one of its effects is through direct modulation of nerve activity. Percutaneous tibial nerve stimulation (PTNS) allows transmission of electronic impulses and retrograde stimulation to the sacral nerve plexus in a simple and non-invasive fashion. Methods: Single-center, prospective interventional study. Children between the ages of 4-14 with Rome IV diagnosis of FC. Exclusion criteria: Neurological problems or organic causes of fecal or urinary incontinence. Over a 2-week period, children received 10 daily sessions of PTNS (30 min/day) during weekdays. Electrodes were placed over the skin of the ankle posteriorly. Placement of electrodes on the anatomic route of the posterior tibial nerve was confirmed through visualization of rhythmic flexion of toes during initial stimulation. Strength of the stimulus was below pain threshold. Children recorded characteristics of bowel movements (BMs) daily during the intervention and the following 7 days. Consistency was assessed through Bristol scale and quality of life (QOL) via PedsQL GI questionnaire. Results: 23 children were enrolled. One child was excluded for acute gastroenteritis (on the 7th session of PTNS) and one child for COVID-19 exposure. 20 patients completed the study (4-14 years) (8,4+/-3,2years, 71.4 % female) day 1 (n=21) to day 17(n=20). By the end of the trial, there was a significant improvement in consistency of BMs, fecal incontinence (FI) (no episodes of FI), presence and intensity of abdominal pain and a trend for improvement in blood in the stools (no children had blood in the stools) (Table 1). In PedsQL GI questionnaire, there was a 91.3% improvement of incomplete BM and 86.3% improvement in abdominal pain. Only one child required rescue therapy (no BM for 3 days). This child was the only treatment failure. Two children reported leg cramps that resolved by changing the side of PTNS application. At 7 days follow-up, there was persistently significant improvement in presence and intensity of abdominal pain and no children had FI or blood in the stools. Conclusion We found an improvement in stool consistency, FI, blood in stools and QOL at the end of the trial with sustained benefits in abdominal pain, blood in stools and FI at follow-up. The study suggests that PTNS may be a promising noninvasive treatment for FC in children. Larger studies with long-term follow-up should confirm our findings. Controlled randomized clinical trials with various protocols are recommended. (Table Presented)