Endoscopy in inflammatory bowel diseases during the COVID-19 pandemic and post-pandemic period
We highlight different scenarios in which endoscopy should still be performed urgently in patients with IBD, as well as recommendations regarding the use of personal protective equipment.
Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), leading to coronavirus disease 2019 (COVID-19), was declared an official pandemic by WHO on March 11, 2020, at which point infections had been reported in 114 countries. As of April 1, 2020, there had been 823 626 cases of COVID-19 reported worldwide. COVID-19 is caused by SARS-CoV-2, a RNA virus belonging to the family of Coronaviridae that was first detected in Wuhan, China, in December, 2019. The main symptoms are sore throat, fever, cough, dyspnoea, sputum production, myalgia, fatigue, and headache. Diarrhoea is reported as a COVID-19-associated symptom in 2·0–35·6% of patients, alongside nausea or vomiting (1·0–17·3%). Other atypical symptoms may include loss of sense of smell or taste. The cell entry receptor ACE2 appears to mediate the entry of SARS-CoV-2, and is not only highly expressed in the lung cells, but also throughout the gastrointestinal tract; moreover, ACE2 is important in controlling intestinal inflammation, the disruption of which may lead to diarrhoea.
Given the chronic nature of inflammatory bowel diseases (IBD) and the medications used to treat them, there is concern that patients with IBD may be at increased risk of infection or poorer disease course. This, together with the need to alter health-care utilisation during the pandemic, has led to rationing of endoscopic resources in this patient population. However, there are currently no specific endoscopic recommendations for patients affected by IBD based on direct evidence in the midst of the pandemic. Patients with IBD have been recommended to follow the general public health measures outlined by the WHO.
Patients with IBD, especially those on systemic corticosteroids, thiopurine, and biologics, are considered to be moderate-to-high risk patients who are susceptible to COVID-19 and its complications. The general strategy expressed by the British Society of Gastroenterology (BSG), the International Organization for the study of Inflammatory Bowel Disease (IOIBD), the European Crohn’s and Colitis Organisation (ECCO), and the Crohn’s and Colitis Foundation of America (CCFA) is to reduce contact with health-care settings and thus possible exposure to COVID-19: all non-essential endoscopic procedures including colon cancer screening and those for patients with suspected gastrointestinal cancers have been cancelled, as these represent a risk for both patients and health-care personnel in an overstretched health-care environment. Only emergency endoscopies are permitted. Therefore, before carrying out a diagnostic or therapeutic endoscopic examination in patients with IBD, the risks and benefits of performing the endoscopic procedure should be considered. It is important to ensure that the procedure is necessary and urgent. Candidate patients should be carefully selected, weighing the risks of transmission for patients and health-care professionals, and of making a trained endoscopy team available.
The characteristics of SARS-CoV-2 and its transmission make endoscopy a potential route for infection, and all endoscopies should be considered aerosol-generating procedures. Coughing, gagging, and retching can occur during upper endoscopy while passing flatus and pathogen-containing liquid stools can happen in colonoscopy. A prospective study has demonstrated that endoscopists are exposed to infectious particles during gastrointestinal procedures without recognising being exposed. In addition, SARS-CoV-2 may be detectable in stool for several weeks even after clinical recovery, although whether stool shedding of viral particles can transmit infection is, at present, unclear. It is not always clear when an endoscopy should be considered as urgent and needs to be performed in patients with IBD. We considered four different urgent scenarios that could necessitate endoscopy: confirmation of a new diagnosis, especially in a moderate-to-severe scenario when biologics may be chosen as a first-line treatment, given that high-dose corticosteroids might increase the risk of an adverse outcome for COVID-19; a severe acute flare-up in patients with ulcerative colitis; partial bowel obstruction in patients with IBD, which could be secondary to neoplasia or ileocolonic anastomotic stricture; and cholangitis and jaundice in patients with known primary sclerosing cholangitis (PSC) with dominant bile duct stricture. We also propose an endoscopy plan for gradual return to normal service post-pandemic.
In certain urgent situations, such as perianal abscess or fistula, emergency examination under anaesthesia and drainage or seton placement is necessary and the colorectal surgeon will generally perform an on-table flexible sigmoidoscopy to assess the rectum. We have not discussed these situations for an IBD endoscopist. In all other situations, use of non-invasive biomarkers, cross-sectional imaging such as ultrasonography, or video capsule enteroscopy to support wise clinical examination might be able to postpone or replace endoscopic investigations in patients with IBD during the pandemic.