2021 Volume 12 Issue 3

Effect of Psychological Stress during the COVID-19 on Patients with Irritable Bowel Syndrome in Saudi Arabia

 

Nesrin Ibrahim Tarbiah*, Nuha Abdulhamid Alkhattabi, Sukaina Ahmed Aldamen, Balqees Mohammed Qutah, Maryam Hassan Al-Zahrani, Haythum Osama Tayeb


Abstract

This study aims to assess the impact of psychological stress during the COVID-19 pandemic on patients with irritable bowel syndrome in the Saudi Arabia. We used an online questionnaire survey shared on social media to collect data. The cross-sectional study was conducted in Saudi Arabia from 1 June 2020 to 31 August 2020. Inclusion criteria were Saudi citizens aged 18 years and above. The exclusion criteria were Saudi citizens under 18 years. The data were analyzed using the SPSS program. The study included 413 participants; 53.3% of participants were affected by IBS. Severe levels of stress, anxiety, and depression were reported in 10.4%, 11.1%, and 8.4% of participants, respectively. There was a significant association between stress level and IBS symptoms based on Rome IV criteria, including frequent abdominal pain (P <0.000) more than 3 bowel movements per day (P <0.025), and less than 3 bowel movements per week (P <0.001). Anxiety level showed a significant association (P <0.000) between the last IBS symptoms, in addition to abnormal stool appearance. A significant association was also reported between depression level and frequent abdominal pain and abdominal bloating (P <0.000). The relationship between IBS medications and other factors that influence IBS symptom development was also considered. The COVID-19 pandemic has affected the psychological state of many individuals, which has led to the triggering of symptoms in IBS patients. Attending to healthy habits and lifestyle, in addition to emotional and psychological support, may decrease the occurrence of IBS symptoms.

Keywords: IBS, COVID-19, Pandemic, DASS-21


Introduction

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder (FGID), characterized by a group of symptoms that affect the digestive system chronically, resulting in the reduction of life quality. IBS manifestations include abdominal pain, bloating, as well as alternating diarrhea and constipation (Saha, 2014). These symptoms are collectively known as the Rome IV criteria for IBS diagnosis. The worldwide prevalence of IBS is estimated to be 12% (Lacy and Patel, 2017). In another study, published in 2019, the authors found that 22.9% of the Saudi population is affected by IBS (Zacharakis and Nikolaidis, 2019). Psychological stress has an impact on the triggering of bowel distress, and evidence from clinical studies has revealed that psychological stress is strongly correlated with the development of IBS symptoms. Managing stress is an important factor for patients with IBS. Psychological stress can affect intestinal sensitivity, motility, and excretion of the colon, in turn affecting the central and peripheral nervous system (Qin et al., 2014). The goal of comprehensive treatment in irritable bowel syndrome (IBS) patients should be the improvement of symptoms and life quality. There are many effective treatment options in the symptomatic management of IBS. The choice of treatment should be based on the predominant symptoms of each patient.

 Coronavirus disease 2019 (COVID19) was declared as a pandemic by the World Health Organization on March 11; the outbreak originated in China and it caused an international health crisis (Alduhisa and Demayo, 2019; Algahtani, 2020; Hanawi et al., 2020). The virus appears to be easily transmitted among people with close contact—within 6 feet, or 2 meters. Although most people who were affected by COVID-19 have mild to moderate symptoms, the disease can cause severe medical complications and even death in individuals with previous chronic disease. As such, several countries enforced lockdown and household quarantine to control the outbreak (Qin et al., 2014). Public health emergencies, such as COVID-19, can affect people mentally; they may cause stress, sadness, frustration, and feelings of guilt about the inability to accomplish normal work. Our study aims to assess the impact of psychological stress during the COVID-19 pandemic on patients with irritable bowel syndrome in Saudi Arabia.

Materials and Methods

The cross-sectional study was based on a questionnaire distributed among different groups in Saudi Arabia from 1 June 2020 to 31 August 2020. Ethical approval granted by The Biomedical Research Ethics Committee, Ministry of Higher Education, King Abdulaziz University, Faculty of Medicine (Reference Number 642-20). The survey was composed of questions to obtain demographic data from participants; we asked the participants about their nationality, age, gender, and education level, in addition to other several questions related to the study. Our study was built on around 548 people in Saudi Arabia. The questionnaire survey was shared on social media. Volunteers who agreed to participate were asked to review and sign a consent form. All participants' data were handled confidentially.

Sampling Design

Data collection for this observational study was conducted by an online questionnaire survey. Inclusion criteria are Saudi citizens aged 18 years and above. Exclusion criteria are Saudi citizens under 18 years.

Validity and Reliability

In terms of reliability, Cronbach's alpha coefficient was used to measure the internal consistency of the measurement scale DASS-21 scores, using SPSS; the internal consistency of the items in the scale was α=0.940.

Statistical Analysis

The data were analyzed using the Statistical Package for the Social Sciences (SPSS) program. A p-value < 0.05 was considered for significant difference.

Results and Discussion

A survey was taken by 413 participants. The web-based questionnaire was divided into three sections, the first of which was aimed at obtaining demographic data shown in (Table 1). The number of female respondents was greater than (n = 351) the number of male respondents (n = 62). The great bulk of Saudi participants (n = 394) represented the majority of the population, whereas fewer participants (n =19) were of different nationalities. The percentage of the participants from the age group 18-29 reached 54.2%, 45.3% were from the age group 30-63, and only 0.5% were ≥64. Participants who were diagnosed with irritable bowel syndrome in the study represented 53.3% and 46.7% of participants were shown to be healthy. We also asked the participants whether they were diagnosed with a mental illness before, only n = 6 answered “yes,” whereas n = 407 answered “no.” The number of participants who were affected by COVID-19 was only n = 2.

The second section of the questionnaire was based on the Depression Anxiety Stress Scale-21 (DASS-21) as shown in (Table 2) Our results in respect to depression level showed that n = 47 were extremely severely depressed during the outbreak of COVID-19, n = 35 were severe, n = 73 were moderate, n = 32 were mild, and n = 192 were normal. Concerning anxiety level, n = 39 were suffering from extremely severe anxiety, n = 46 with severe anxiety, n = 73 with mild anxiety, and finally, n=223 were normal. With regards to stress levels, n = 8 were extremely stressed, n = 43 were suffering from severe stress, n = 44 were moderate, n = 53 were mildly stressed, and finally, n = 265 individuals did not suffer from any stress during the quarantine.

The third section of the questionnaire was to evaluate the frequency of irritable bowel syndrome flares and the management of symptoms during quarantine enforcement in patients with IBS. The evaluation was based on Depression Anxiety Stress Scales-21 (DASS-21) and Rome IV criteria for the diagnosis of IBS. The overall prevalence of IBS was 53.3% (n = 220), with a higher prevalence among females (45.27%, n = 187) (Table 1). Our results showed a significant correlation between flare frequency of IBS symptoms and psychological distress, as shown in (Table 3). A significant difference between frequent abdominal pain and stress level was found (P = 0.000). Moreover, a significant difference (P = 0.025) with bowel movements that were more than 3 per day, (P = 0.001) with bowel movements that were fewer than 3 per week, and no significant difference was found between abnormal stool appearance and stress level (P = 0.145). Nevertheless, a statistical difference of P = 0.001 was found between abdominal bloating and stress level.

Table 1. Socio-demographic characteristics of the respondents.

Percentage (%)

Number

 

100%

413

Total

 

 

Gender

15%

62

Male

 

85%

351

Female

 

 

 

Age

54.2%

224

18-29

 

28.6%

118

30-41

 

11.9%

49

42-51

 

4.8%

20

52-63

 

0.5%

2

≥ 64

 

 

 

Nationality

95.4%

394

Saudi

 

4.6%

19

Non-Saudi

 

 

 

COVID-19

.5%0

2

Yes

 

99.5%

411

No

 

 

 

IBS

53.3%

220

Yes

 

46.7%

193

No

 

 

 

Mental Illness

1.5%

6

Yes

 

98.5%

407

No

 

Table 2. DASS-21 score.

Percentage (%)

Number

Psychological State

 

 

 

Stress Level

 

64.2%

265

Normal

 

12.8%

53

Mild

 

10.7%

44

Moderate

 

10.4%

43

Sever

 

1.9%

8

Extremely Severe

 

 

 

Anxiety Level

 

54%

223

Normal

 

7.7%

32

Mild

 

17.7%

73

Moderate

 

11.1%

46

Sever

 

9.4%

39

Extremely Severe

 

 

 

Depression Level

 

46.5%

192

Normal

 

16%

66

Mild

 

17.7%

73

Moderate

 

8.5%

35

Sever

 

11.4%

47

Extremely Severe

 

100%

413

Total

 

         

 

Regarding anxiety level and IBS symptoms, a statistical difference of P = 0.000 was found.

Concerning depression level and IBS flares, a significant association was found (P = 0.00) between frequent abdominal pain and abdominal bloating, and P = 0.007 between depression and bowel movements that were fewer than 3 per week, P = 0.022 for abnormal stool appearance, and, finally, P = 0.026 between depression and bowel movement that was more than 3 per day.

We asked the participants whether they used any of the following medications to relieve IBS symptoms during the quarantine: antidiarrheals, anti-constipation, antispasmodics, fiber supplements, probiotics, or any other medications. We found a significant association between psychological distress in IBS patients and medication used to relieve symptoms as shown in (Tables 4 and 5), in terms of frequent abdominal pain, anti-constipation (P = 0.001), and (P = 0.000) of anti-spasmodic, (P = 0.031) of antacid, (P = 0.008) of probiotics, and, finally, (P = 0.000) of other medication used to relieve their symptoms.

In terms of bowel movements that were more than 3 per day, the only variable significantly associated was the use of antispasmodics (P = 0.001).

Regarding bowel movements that were fewer than 3 per week, a significant association was found with the use of anti-constipation medication (P = 0.009), and of antispasmodics (P = 0.004), in addition to other medication used to relieve IBS symptoms (P = 0.002).

In patients with abnormal stool appearance, a significant association was found between the usage of all medications except for anti-foaming. In Patients with abdominal bloating, we found a significant association between IBS symptoms and all medications, except for anti-diarrheal and anti-constipation medications, as no correlations were found.

We asked the participants about other factors associated with the development of IBS symptoms during the outbreak of COVID-19, such as smoking, eating habits, or a particular diet they followed to prevent or relieve IBS symptoms. As data shown in (Table 6), we found a significant correlation between Low-FODMAP diet and frequent abdominal pain (P = 0.013), and abdominal bloating (P = 0.006); concerning the change in eating habits during the quarantine, we found a significant correlation with frequent abdominal pain (P = 0.045).

 

 

Table 3. Correlation between irritable bowel syndrome symptoms and psychological stress.

Did not Suffer from Any Symptoms

Abdominal Bloating

Abnormal

Stool

Movement Per Week

Movement Per Day

Frequent Abdominal

 Pain

 

 

 

P-value

No

Yes

P-value

No

Yes

P-value

No

Yes

P-value

No

Yes

P-value

No

Yes

P-value

Sometime

No

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Stress

 

.000

156

109

.001

150

115

.145

217

48

.001

228

37

.025

210

55

.000

85

121

59

Normal

 

 

42

11

21

32

38

15

35

18

39

14

17

11

25

Mild

 

 

35

9

15

29

30

14

29

15

30

14

17

4

23

Moderate

 

 

38

5

13

30

32

11

35

8

26

17

12

7

24

Sever

 

 

8

0

3

5

7

1

6

2

4

4

1

1

6

Extremely Sever

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Anxiety

 

.000

114

109

.000

138

85

.000

196

27

.001

196

27

.000

190

33

.000

66

117

40

Normal

 

 

23

9

17

15

25

7

22

10

22

10

11

6

15

Mild

 

 

65

8

17

56

49

24

57

16

44

29

30

11

32

Moderate

 

 

40

6

21

25

26

20

30

16

32

14

14

6

26

Sever

 

 

37

2

9

30

28

11

28

11

21

18

11

4

24

Extremely Severe

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Depression

 

.000

105

87

.000

110

82

.022

160

32

.007

168

24

.026

156

36

.000

55

92

45

Normal

 

 

44

22

40

26

55

11

50

16

50

16

23

24

19

Mild

 

 

59

14

25

48

54

19

58

15

51

22

28

18

27

Moderate

 

 

30

5

11

24

22

13

26

9

23

12

15

3

17

Sever

 

 

41

6

16

31

33

14

31

16

29

18

11

7

29

Extremely Severe

 

                                                         

Table 4. Demonstrate the relationship between IBS medications that are commonly used among IBS patients and IBS symptoms based on the Roma IV criteria.

 

Anti-foaming

Antacid

Anti-spasmodic

Anti- constipation

Anti-diarrhea

 

 

P-value

No

Yes

P-value

No

Yes

P-value

No

Yes

P-value

No

Yes

P-value

No

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Frequent Abdominal Pain

 

.439

134

3

.031

128

9

.000

78

59

.001

122

15

.677

133

4

Yes

 

 

143

1

143

1

128

16

139

5

142

2

No

 

 

131

1

127

5

100

32

130

2

129

3

Sometimes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Movement Per Day

 

.788

103

1

.051

 

97

7

.001

64

40

.214

96

8

.178

100

4

Yes

 

 

305

4

301

8

242

67

295

14

304

5

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Movement Per Week

 

.240

78

2

.950

77

3

.004

49

31

.009

71

9

.827

78

2

Yes

 

 

330

3

321

12

257

76

320

13

326

7

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Abnormal Stool

 

.313

87

2

.016

82

7

.000

47

42

.001

78

11

.001

83

6

Yes

 

 

321

3

316

8

259

65

313

11

321

3

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Abdominal Bloating

 

.028

206

5

.023

199

12

.000

133

78

.226

197

14

.345

205

6

Yes

 

 

202

0

199

3

173

29

194

8

199

3

No

 

 

                                                 

 

 

Additionally, we asked the participants several questions about their psychological state during the pandemic and how many times they experienced flares as follows: In general, did fear and anxiety due to the outbreak of COVID-19 affect your IBS symptoms negatively? About 94 of the participants answered “yes,” and n = 26 said that one or more of their family members were diagnosed with COVID-19. Additionally, we asked the participants whether they were worried that a member of their family may get affected by the coronavirus; n = 284 of our sample answered “yes.” Regarding mental illness, 1.5% of participants said that they had been diagnosed with a mental illness before the pandemic.

 

 

Table 5. Demonstrate the relationship between IBS complementary medications that are commonly used among IBS patients and IBS symptoms base on the Roma IV criteria.

 

None for IBS

Other for IBS

Probiotic

Fiber supplement

 

 

P-value

No

Yes

P-value

No

Yes

P-value

No

Yes

P-value

No

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Frequent Abdominal Pain

 

.000

81

56

.000

98

39

.008

126

11

.067

127

10

Yes

 

 

25

119

134

10

143

1

141

3

No

 

 

49

83

107

25

127

5

128

4

Sometimes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Movement Per Day

 

.002

52

52

.060

79

25

.682

99

5

.121

97

7

Yes

 

 

103

206

260

49

297

12

299

10

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Movement Per Week

 

.000

46

34

.002

56

24

.658

76

4

.285

75

5

Yes

 

 

109

224

283

50

320

13

321

12

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Abnormal Stool

 

.000

57

32

.000

61

28

.001

80

9

.009

81

8

Yes

 

 

98

226

278

46

316

8

315

9

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Abdominal Bloating

 

.000

110

101

.000

155

56

.008

197

14

.008

197

14

Yes

 

 

45

157

184

18

199

3

199

3

No

 

 

                                         

 

Table 6. Factors associated with the development of IBS symptoms.

 

Frequent Abdominal

Pain

Movement Per

Day

Movement Per

 Week

Abnormal

Stool

Abdominal

Bloating

Yes

No

Sometime

P-value

Yes

No

P-value

Yes

No

P-value

Yes

No

P-value

Yes

No

P-value

Smoking

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

25

25

15

.242

20

45

.258

10

55

.376

16

49

.513

29

36

.255

 

No

112

119

117

84

264

70

278

73

275

182

166

Low-FODMAP diet

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

22

11

26

.013

19

40

.180

11

48

.879

16

43

.261

40

19

.006

No

115

133

106

85

269

69

285

73

281

171

183

Changing in eating habits

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

83

66

68

.045

60

157

.224

47

170

.216

47

170

.955

117

100

.226

No

54

78

64

44

152

33

163

42

154

94

102

Stress and IBS symptoms

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

132

91

119

.000

98

244

.000

72

270

.058

83

259

.003

197

145

.000

No

5

53

13

6

65

8

63

6

65

14

57

symptoms and quarantine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

112

19

72

.000

78

125

.000

55

148

.000

60

143

.000

146

57

.000

No

25

125

60

26

184

25

185

29

181

65

145

 

 

 

Our study aimed to assess the impact of psychological stress on patients with IBS during the COVID-19 pandemic. According to our hypothesis, people with IBS were expected to experience worsening symptoms due to the psychological impact of the outbreak of COVID-19. Our results showed 10.4% of respondents suffered from a severe level of stress, 11.1% reported a severe level of anxiety, whereas a severe level of depression was expressed by 8.4%, which indicated that the presence of psychological symptoms was a normal response during the pandemic. People had to deal with such lockdown rules as keeping social distance and avoiding physical contact, as well as the huge number of infected people and the deaths. Our results are supported by a previous study on the Saudi Arabian population that concerned the effect of the COVID-19 pandemic on their psychological state and reported nearly identical results, with 13.7%, 13.9%, and 16.4% respondents reporting severe level of stress, anxiety, and depression, respectively (Alkhamees et al., 2020).

The main findings (Table 3) showed that the presence of stress, anxiety, and depression are associated with the presence of IBS symptoms (frequent abdominal pain, more than 3 movements per day, less than 3 movements per week, abnormal stool appearance, and abdominal bloating) in which there was a highly significant correlation between these variables. According to previous studies, IBS and other gastrointestinal disorders are sensitive to psychological stressors, as the hypothalamic-pituitary-adrenal (HPA) axis plays a major role in the body’s response to stress by reciprocal interaction between the brain and gut. The mirror image of a distressed, anxious, and hyper-vigilant brain is considered to be a reactive, sensitive, irritable bowel, and the opposite is true, as reported by (Outhoff, 2016).

 Another study concerned with stress as a risk factor for IBS reported a high prevalence level of IBS among medical students, ranging from 9.3% to 35.5% in China and Japan, 20.61% in Canada, 16.5% in India, whereas Pakistan showed 28.3% for three medical colleges, and last, 31.8% of medical students and interns in Jeddah; they suggested that the high level of prevalence may be due to their study environment, which is considered to be stressful (Ibrahim, 2016). Moreover, an alternative or additional IBS therapy suggested is emotional schemes therapy (EST), which reduces the psychological symptoms of those patients and reflects a good life quality (Erfan et al., 2018).

Irritable bowel syndrome imposes a huge burden on the healthcare system globally; healthcare is being used by 30,000 IBS patients in France alone (Sabaté et al., 2019). In general, IBS affects around 11% of the population globally (Canavan et al., 2014); the prevalence of IBS in Saudi Arabia was reported to be 22.9% (Zacharakis and Nikolaidis, 2019). All food intolerance, anxiety, depression, and family history were predictors of IBS; because this disorder is idiopathic, it is challenging to manage its symptoms (Soares, 2014).

IBS is characterized by several common symptoms, according to Roma lll criteria, including recurrent abdominal pain for a minimum of 3 days per month for 3 successive months (Vork et al., 2018). More than half of the participants in this study met Roma lll criteria (n=264, 63%). Commonly, an IBS patient takes one or more medications to relieve their symptoms. These medications include anti-diarrheal, anti-constipation, and, antispasmodic medications, as well as antacids, and defoamer agents; probiotics and fiber supplements were used as complementary therapies (Malone et al., 2018). Hence, we asked the participants whether they were taking any of these medications to manage their symptoms, and surprisingly, (n = 258, 62.5%) were not using any medications with a statistical difference of (P < 0.000) between all symptoms, and (P < 0.002) for patients who were having more than 3 bowel movement per day. Only about 30% of patients who experience IBS symptoms consult a physician for their symptoms true (Canavan et al., 2014)

The predominant stool pattern allows for the classification of IBS into four clinical variants: with constipation, with diarrhea, mixed, and unsubtyped. Regarding medications (Table 4), only 2.2% of participants used anti-diarrheal medications, which are widely used among IBS with diarrhea (IBS-D) patients. There was a significant association between abnormal stool appearance and the consumption of anti-diarrheal medications, which is because anti-diarrheal medications work by bulking up the stool, leading to an increasing volume. Data showed that 5.3% of participants used anti-constipation medications that most IBS with constipation (IBS-C) patients use; there was a significant association between anti-constipation medications and frequent abdominal pain (P < 0.001), which is a common side effect of laxatives, as along with abnormal stool appearance (P < 0.001), as it tends to become watery.

Antispasmodics are smooth muscle relaxants and reliable therapeutic options for IBS symptom relief; they are the most commonly prescribed drug for IBS patients. In 2011, about 142,738 adults received ≥1 prescription for antispasmodics in Scotland (McTaggart et al., 2014). In our study, (n = 107) used antispasmodics. Patients who did not use antispasmodics suffered from frequent abdominal pain (n = 78), whereas (n = 100) reported that they felt abdominal pain sometimes during the quarantine (P < 0.000), and (n = 133) who did not use the medication reported frequent abdominal bloating during quarantine (P < 0.000).

Several studies reported an overlap between functional heartburn (FH) and IBS (de Bortoli et al., 2016) FH is defined as an episodic retrosternal burning in the absence of pathological gastroesophageal reflux, pathology-based motility disorders, or structural alterations FH prevalence was reported to be 39% among patients with IBS who met Roma III criteria (Lee et al., 2009); antacids, which neutralize stomach acid to cut down on heartburn, are commonly administered to people who are suffering from FH. Patients who fulfilled the criteria for IBS had a high tendency to self-treat their GI symptoms. The usage of acid-suppressive agents was common among patients. Around one-third of patients self-treated GI symptoms inappropriately (Niknam et al., 2016.)

 In the current study, only (n = 9) who used acid-suppressive reported frequent abdominal pain, whereas (n = 128) who did not them reported frequent abdominal pain during the quarantine (P < 0.031).

The sensation of bloating is prevalent among IBS patients, regardless of bowel habits; all patients reported a significant increase in bloating (P < .0001). Hence, antiflatulents agents are administrated orally to relieve or prevent gas formation in the stomach and intestines (Houghton et al., 2006). In our study, (n = 211, 51.1%) reported frequent abdominal bloating during the period of quarantine. Only (n = 5) felt abdominal bloating while using antiflatulents to relieve their symptoms, whereas (n = 206) felt frequent abdominal bloating and did not use any antiflatulents (P < 0.028); no statistical difference was found between all other symptoms, including abdominal pain and antiflatulents.

Many studies have suggested that probiotics are effective in the treatment of IBS; probiotics are used to improve IBS symptoms through manipulation of the gut microbiota. In the last five years, several studies (63.6%) reported that supplementation with probiotics significantly improved symptoms of IBS patients, compared to placebo (Dale et al., 2019).

In the current study (Table 5), only (n = 17) used probiotics as a complementary treatment. We found a significant association between frequent abdominal pain (P < 0.008), abdominal bloating (P < 0.008), and abnormal stool appearance (P < 0.001).

Complementary medications, such as fiber supplements and probiotics, are frequently used among IBS patients. Fiber supplements are administered to patients with constipation, which affects more than half of patients with IBS. These supplements have bulking-laxation effects, which is helpful in the elevation of constipation (Muir, 2019). Seventeen participants reported using fiber supplements, of which (n = 8) suffered from abnormal stool appearance; on the other hand, (n = 81) suffered from abnormal stool appearance, but did not use fiber supplements (P < 0.009). Regarding other IBS symptoms, (n = 197) did not use fiber supplements, but suffered from abdominal bloating, relative to patients (n = 3) who consumed fiber supplements and suffered from abdominal bloating (P<0.008).

Factors other than psychological stress and medications may influence the development of or relieve IBS symptoms (Table 6). Some food and dietary products are believed to serve as a trigger for IBS patients who consume them; these include dairy products, fried and fatty foods (Böhn et al., 2013). Many studies have reported an improvement in gastrointestinal symptoms in IBS patients who have adopted the low FODMAP diet (De Roest, 2013). In a study aimed to assess symptom severity concerning the low FODMAP diet, using IBS symptom severity scoring (IBS-SSS), the score was reduced in IBS patients due to a modulation in histamine levels and the microbiota that may alter symptoms (McIntosh et al., 2017). Hence, we asked the participants whether they were following this diet; (14.3%, n = 59) answered “yes,” and a significant association was found between people who were following the FODMAP diet and reported that they did not suffer from any IBS symptoms (P = 0.002). Surprisingly, (n = 22) reported frequent abdominal pain with a statistical difference of P < 0.013 and (n = 40) reported frequent abdominal bloating with a statistical difference of P < 0.006, although they were following this diet to reduce these particular symptoms.

Another factor that may be involved in the pathogenesis of IBS is smoking. A study investigated the association between smoking and the development of functional gastrointestinal symptoms in a Swedish population-based cohort of middle-aged to elder subjects. The study found an association between former and current smoking and functional abdominal pain. Former smoking was associated with functional bloating and functional constipation (Lundström et al., 2016). We asked the participants about their smoking habits: (15.7%, n = 65) were smokers, although the association between smoking and IBS is controversial, as some studies have reported smoking as a risk factor for IBS (Spiller and Garsed, 2009), whereas others have reported that smoking is not associated with IBS. In the current study, we found no significant association between any IBS symptoms and smoking (Locke et al., 2000).

The COVID-19 pandemic had a huge impact on public health. One of the consequences of this pandemic is the shift of eating habits and fitness, which may be exaggerated by the imposed quarantine. Additionally, certain emotional feelings, such as anxiety and hypochondria, have left people to consume more comfort food and feel inclined to increase food intake to feel better. Accordingly, we asked the participants whether their eating habits had changed negatively during the quarantine, such as eating more fatty food, simple carbohydrates, processed and refined sugars, and whether they demonstrated excessive consumption of caffeine, and ate meals in quantities bigger than usual. About (n = 217, 52.5%) responded “yes,” and (n = 196, 47.5%) responded “no.” No significant associations were found between changes in eating habits and IBS symptoms according to Roma lll criteria, except for frequent abdominal pain (P < 0.045). According to a study aimed to assess psychological aspects and eating habits during COVID-19 home confinement among the Italian population, 48.7% of the population uses food in response to anxious feelings, and 55.1% needed to increase food intake to feel better. Both unhealthy eating habits and psychological stress affected IBS patients, as well as non-IBS patients, by increasing emotional hunger during the COVID-19 pandemic.

As we mentioned above, psychological stress plays a major role in the pathogenesis of IBS. We asked the participants whether they felt that their IBS symptoms worsened due to anxiety and stress during the quarantine. About n = 203 responded positively, with a significant association of (P < 0.000) with all IBS symptoms. This was expected because the majority of our participants responded positively (n = 342, 82.8%) when we asked them whether they felt that stress and anxious times irritate their IBS symptoms in general.

Conclusion

The worldwide outbreak of COVID-19 in 2020 had many impacts on people and health, as well as social and economic states. The World Health Organization and governments had to increase their precautionary measures to maximum levels to minimize pressure on health care providers, as hospitals were overcrowded with COVID-19 patients in severe states. With the lockdown that was imposed in most countries, Saudi Arabia among them, people had to change many of their life routines, and that resulted in many complications. Emotional stress, depression, and anxiety were some of the psychological disorders people experienced during that period. In our study, it was observed that such complications negatively increased symptoms of IBS in people affected by this disorder. It was also observed that changes in lifestyle, caused by emotional distress, during the pandemic, and the failure to use relieving medications were the reasons for increased IBS cases in the studied population.  

Acknowledgments: We would like to express our very great appreciation to Dr. Karimah Mohammad Qutah for her valuable and constructive suggestions during the data analysis of this research work.

Conflict of interest: None

Financial support: None

Ethics statement: Biomedical Research Ethics Committee, Ministry of Higher Education, King Abdulaziz University, Faculty of Medicine (Reference No 642-20)

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