British Society of Paediatric Gastroenterology, Hepatology and Nutrition

I know that you are all supporting each other and working together in new ways remotely and face to face.

Please do sign post your families to the excellent links that are updated regularly for patients with IBD by CCUK https://www.crohnsandcolitis.org.uk/news/coronavirus-covid-19-advice

See  https://childliverdisease.org/coronavirus-updates/ for patients with liver disease

I want to draw your attention to the Urgent message from BSG/JAG on Endoscopy 26/3/20 ( message below) and message

Summary of message

  1. Stop 
  2. Review 
  3. Re-organise NOW

Below also see Updated Intercollegiate General Surgery Guidance on COVID-19               25th March 2020

https://www.rcsed.ac.uk/news-public-affairs/news/2020/march/intercollegiate-general-surgery-guidance-on-covid-19

Risk situations in surgery also include:

  • Approaching a coughing patient, for example, even if COVID-19 has not been diagnosed. Protection including eye shield is needed.
  • Naso-gastric tube placement is an aerosol generating procedure (AGP). AGPSs are high risk. Full PPE is needed. Consider carrying out in a specified location.
  1. Only emergency endoscopic procedures should be performed . No diagnostic work to be done and BSG guidance followed. Upper GI procedures are high risk AGPs and full PPE must be used

GI Endoscopy Activity and COVID-19: Next steps

INTRODUCTION

The BSG has produced recommendations(1,2) based on the best available evidence from China(3), Italy(4) and the USA(5) that show:

  • The virus causing COVID-19 is potentially present in all GI secretions.
  • That all endoscopic procedures, but particularly upper GI endoscopy, are aerosol generating procedures (AGP).
  • That transmission can occur at the time of endoscopy.

Endoscopy activity and COVID-19: BSG and JAG guidance (1)
BSG rationale around current advice to all Endoscopy Units (2)

We have received reports that some centres are continuing to run booked endoscopy lists, requiring patients:

  • To travel.
  • To enter hospitals already treating significant numbers of COVID-19 patients.
  • To wait in areas that do not meet any of the Government’s social isolating directives.

For these reasons, the BSG has recommended that all but emergency procedures should stop immediately.

  1. The main issues of contention remain whether Urgent 2 Week Wait (2WW) patients, (or Urgent Suspected Cancer (USC) patients in Scotland,) and patients already diagnosed as FIT positive under Bowel Cancer Screening Programs (BCSP), should be “paused” during the current crisis. 

How any potential damage from delayed diagnosis can be mitigated.

 

2WW/USC, and BCSP referrals: Relative Diagnostic Yield.
The Risks of Pausing

  • 2WW/USC referrals – yield of cancer = 3% 
  • Bowel cancer screening programmes (BCSP) (FIT+) – yield of cancer = 8-10% 
  • Another, small percentage of patients will have advanced disease at the time of referral and the delay will not alter their prognosis, which unfortunately will already be very poor. 
  • For this group, a delay of 3 months is unlikely to materially alter the risk of an adverse outcome.  
  • Some of those who do not have established malignancy will have benign lesions such as polyps. 

In the majority of these cases, progression to malignancy, if it occurs, may take years. 

  • Conclusion: Very few patients are likely to come to harm from a pause of 3 months.  

Risks of continuing 2WW/USC, BCSP and urgent referrals. 

  • Removing polyps, particularly those over 1 cm, carries risks of haemorrhage and perforation often requiring admission to hospital.  
  • During the COVID-19 crisis, ICU beds are unlikely to be available and even urgent surgical procedures will be restricted.   
  • The risks of death from polypectomy usually quoted, are based on entry into a hospital operating under normal conditions, but not during a COVID-19 epidemic, where the risks of death will be significantly higher. 
  • Patients who are diagnosed with cancer may not be offered surgery at the height of the epidemic. Their anxiety is likely to be equal to or even greater, than those with a positive FIT test whose colonoscopy is paused. 

In addition: 

  • All patients attending for a non-emergency endoscopy now enter a high-risk environment. 
  • The benefit of endoscopy may be offset by the risk of COVID-19 infection to themselves. 
  • The majority will be older than 60 years with higher mortality from COVID-19 if they become infected. 
  • They become a potential risk to their families and contacts. 
  • Patients with asymptomatic COVID-19 infection pose a significant risk to staff.  By definition, their infection will not be detected before having a procedure.  
  • The aerosol or droplets take up to an hour disperse, so they remain a risk to staff and other patients after they leave the room. 
  • Endoscopic procedures generate aerosols, so staff will require PPE at an appropriate level, at a time when it will be in short supply. (See PPE recommendations from the BSG pending further Government recommendations.)

Conclusions: 

There is, therefore, little evidence that a pause of 3 months will pose a significant risk to the great majority of 2WW/USC or BCSP patients, although it is accepted that a small number of patients may have a delay in their diagnosis. 

On the other hand, a much larger number of patients and staff will be put at significant risk of COVID-19 if the 2WW/USC and BCSP is continued even at a scaled-down level. 

Conclusions and Actions.

  • Stop all non-emergency endoscopy immediately. 
  • Triage plan to identify patients who fall into the emergency category. The evidence base for this is laid out in previous BSG documents. (1) and follows experience from China(3), Italy(4) and the USA(5).  
  • List all patients on to a separate Urgent Deferred Waiting List to prioritise their investigation when services resume.  

For patients needing immediate investigation, the British Society of Gastrointestinal and Abdominal Radiology (BSGAR) have issued pragmatic guidance for the Investigation of patients with lower GI symptoms during the COVID-19 epidemic. 

Conclusion: The BSG/JAG guidance on prioritisation should be followed by all units.  This will be updated regularly. 

Looking to the Future

Hospitals should ONLY resume endoscopy for 2WW/USC, BCSP patients when: 

  • National circumstance permit. Further guidance will be issued. 
  • Sufficient PPE, appropriate for the current risk level, is available for staff. 
  • Patient flow is safely adjusted through units to minimise risk. 

2WW/USC patients may need to be reassessed to determine if their cancer risk has changed by phone triage.


Summary

  1. Stop 
  2. Review
  3. Re-organise NOW

 

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