Upper GI Physiology
Upper GI Physiology procedures requiring nasal intubation (oesophageal manometry, impedance/pH studies, small bowel manometry etc.) are Aerosol Generating Procedures (AGP). As such, Level 2 Personal Protective Equipment (PPE) should be worn as recommended by the BSG for Upper GI Endoscopy procedures and Public Health England1 for all AGPs irrespective of whether the patient is suspected to have COVID-19 or not.
Non-urgent breath tests undertaken by GI Physiology departments such as Hydrogen methane breath tests, 13c urea breath tests, 13c gastric emptying tests etc. could be considered AGPs. Please note that there are home testing kits available for Hydrogen methane breath test procedures which would allow patients to carry out the test at home rather than coming into the hospital environment.
Lower GI Physiology
Lower GI Physiology procedures (anorectal manometry, endo-anal ultrasound, biofeedback therapy etc.) are not considered to be an AGP; however, Level 1 PPE with the addition of eye & face protection (fluid-resistant Type IIR surgical face mask & full-face visor or goggles) should still be worn2. It is important that a patient should not be asked to cough during an anorectal manometry even that is part of your local protocol. Providing patients with a mask to wear during any procedure/treatment is advisable.
Provision for the Restoration of GI Physiology Services
The reintroduction of services must be planned and phased according to urgency and consequent therapeutic availability. Whoever triages referrals, determines who is considered to be urgent (i.e. primarily achalasia/functional obstruction with nutritional compromise or similar) in whom physiology will have an impact on endoscopic management which can be provided imminently. As such, it would be appropriate that these urgent cases are discussed at a local MDT to re-affirm the appropriateness for proceeding. Other subgroups of patients can be considered with the re-emergence of therapeutic availability (e.g. reflux testing with a view to referring for anti-reflux surgery).
Wherever GI physiology procedures are undertaken, published BSG Endoscopy Guidance should be adhered to in conjunction with relevant local guidance (including infection control etc.). Here are a few points to consider:
- Allow extra time for and between procedures, to account for enhanced infection control SOP and cleaning processes
- If your hospital’s SOP recommends testing for COVID-19 prior to endoscopy then it should be undertaken for GI Physiology patients as well; however not all hospitals currently test for COVID-19. A screening questionnaire and temperature check on the day is required (a high temperature is usually considered to be 37.5°C or above)
- Adequate PPE provision should be ordered and confirmed in advance of initiating the service
- Staff should be trained on donning and doffing PPE as well as hand hygiene as per the local endoscopy protocols
This interim advice will be subject to change as new evidence becomes available.
1 https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/covid-19-personal-protective-equipment-ppe (specifically under section 8.1 “Aerosol generating procedures”)