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Endoscopy activity and COVID-19: BSG and JAG guidance

Updated on: 03 Apr 2020   First published on 03 Apr 2020

There is a clear and urgent need to plan for endoscopy activity over the coming weeks and months. It is very difficult in these challenging and uncertain times to decide what is best for patients, the population at large and healthcare staff, and there is balance of risks to consider. As a result of multiple discussions with key stakeholder groups, we are updating this advice to help Endoscopy Units and teams plan their activity during the COVID-19 outbreak. Be aware that this advice may continue to change rapidly and we will update it as required, especially as further national advice is announced.

This document has been developed with and is supported by:

  • British Society of Gastroenterology (BSG)
  • Joint Advisory Group (JAG)
  • The Association of Coloproctology of Great Britain and Ireland (ACPGBI)
  • Association of Upper Gastrointestinal Surgeons (AUGIS)
  • Pancreatic Society of Great Britain and Ireland (PSGBI)
  • UK and Ireland EUS Society (UKI-EUS)
  • The British Society of Gastrointestinal and Abdominal Radiology (BSGAR)

It is also supported across the devolved nations by:

  • Scottish Society of Gastroenterology (SSG)
  • Welsh Association of Gastroenterology and Endoscopy (WAGE)
  • Ulster Society of Gastroenterology (USG)

We have also shared it with the Irish Society of Gastroenterology (ISG).

Introduction and background

Following conversations with key stakeholders and opinion leaders involved in Endoscopy, there is agreement that there is an urgent need to plan for endoscopy activity over the coming weeks and months. Our assessment is that it will be too late if we wait for a central directive to tell us what to do regarding endoscopy activity.

NHS England and Public Health England have still to make recommendations about bowel cancer screening while this has been paused in the other devolved nations. FIT+ screened patients represent a complex problem and our rationale for recommending an immediate pause to screening has been published already.

Key Advice

It is the belief of the BSG, JAG and other key stakeholders representing the UK endoscopy community that FIT screening and Bowel Scope should be paused with immediate effect.

The other group of patients causing concern are 2 Week Wait/Urgent Suspected Cancer. NHS England advice on cancer diagnostics and treatment can be found here and recommends that “cancer diagnosis, treatment and care continues during the COVID-19 emergency”. The numbers of referrals may fall as patients who are already ill or who are self-isolating, shielding, or who cannot see their GP, stay away from hospitals.

Key Advice

Following the general strategic intent expressed by the UK Government to reduce any non-essential exposure to the COVID-19 virus and to take all reasonable measures to limit its spread, the BSG now recommends that all endoscopy except emergency and essential procedures should stop immediately (see below).

Key Advice

We recommend that 2WW referrals are risk assessed on a case by case basis before tests such as upper endoscopy, colonoscopy or CT abdomen/pelvis (or, exceptionally, CT colonography)  are organised, to prioritise those felt clinically to be at greatest need and to take account of limited availability of facilities, staff and appropriate PPE.

Discussion and Recommendations

We believe, based on the evidence available to us at this time that this action is essential to:

  1. Help flatten and delay the outbreak curve.
  2. Minimise risk to other patients and staff. In particular it is essential to reduce the sickness absence rate and the need for staff to adopt forced self isolation.
  3. The risk of faecal transmission is not clear at present but it is plausible and possible.
  4. Asymptomatic COVID-19 infected patients are a known source of infection.
  5. Stocks of standard and enhanced Personal Protection Equipment are limited and need to be prioritised, both for our own patients and for other areas of the hospitals.
  6. Staff availability will decline as infection, self-isolating, childcare and redeployment are enforced. The available staff have to be deployed to procedures where endoscopy is essential and will change the management of patients.
  7. The supply of devices and consumables (e.g. injection needles, banding kits, stents) may not be guaranteed as supply chains are placed under stress within the UK and abroad. These items need to be carefully husbanded over the coming weeks so they are used in the cases where they will be most effective.
  8. Endoscopy is a major cancer diagnostic service, but patients with endoscopically detected cancers, who have completed their staging, may be unable to be listed for major surgery in the foreseeable future, because of the pressure on ICU and HDU beds for post-operative care. There is also likely to be a shortage of theatre staff.  For this reason, we suggest that 2WW/urgent suspected cancer patients are risk assessed on a case by case basis and only endoscoped where the clinical need is felt to be a priority.

 

This list is not exhaustive and may have to be modified as the COVID-19 epidemic evolves, or new evidence becomes available.

Decision making on Endoscopic Procedures

We recommend that activity is prioritised under 3 categories:

  • Emergencies/essential (need to continue);
  • Defer until further notice;
  • Needs discussion (case-by-case, at consultant level)

Emergency/essential procedures (need to continue)

  • Acute Upper GI bleeding (risk stratified to those predicted to require endotherapy)
  • Upper GI foreign bodies requiring removal/food bolus
  • Obstructing upper or lower GI lesion that requires stenting/therapy
  • Hepato-pancreaticobiliary: acute biliary obstruction requiring stenting; cholangitis; infected pancreatic fluid collection
  • Nutrition support – urgent inpatient PEG/NJ tube (see joint advice from BAPEN and BSG)
  • Endoscopic vacuum therapy for perforations/leaks
  • Ongoing lower GI bleeding where interventional radiology not possible or unsuccessful

Needs discussion (case-by-case)

  • 2 Week Wait / USC referrals –to be risk assessed on an individual basis. We recommend a group of consultants reviews and triage these referrals, reserving endoscopic procedures for those judged to be highest risk. The availability of cancer staging, surgery and oncology services needs to be considered. BSG-JAG guidance on 2WW referrals can be found here.*
  • EUS for cancer staging/treatment planning where this will significantly impact therapy.*
  • Planned EMR/ESD for high risk lesions: some cases may be considered essential.*
  • New suspected acute colitis e.g. infection excluded, not settling after empirical treatment
  • Small bowel endoscopy for therapy
  • Variceal banding in high risk cases (recent bleeding)

* NHSE guidance on management of patients requiring acute treatment for cancer is here.  The recommended priority categories for cancer patients will help inform MDT decisions on endoscopic interventions.

Defer until further notice:

  • All symptomatic routine referrals
  • FIT+ bowel screening colonoscopy
  • Bowel Scope flexible sigmoidoscopy
  • Surveillance -polyp follow-up, IBD, Barrett’s, varices
  • Disease assessment for IBD
  • Outpatient rigid sigmoidoscopy
  • Low-risk follow-up and repeat scopes – oesophagitis healing, gastric ulcer healing, ‘poor views’, check post therapy e.g. EMR/RFA/polypectomy
  • Elective therapeutic procedures: stricture dilatation, APC for GAVE, RFA, POEM, pneumatic dilatation, ampullectomy, variceal banding (no recent bleeding)
  • Bariatric endoscopy
  • Routine/ non urgent Small bowel endoscopy
  • EUS for biliary dilatation, possible stones, submucosal lesions, pancreatic cysts without high-risk features
  • Endoscopy as part of clinical research
  • ERCP: stones where there has been no recent cholangitis and a stent is in place; therapy for chronic pancreatitis; metal stent removal/change; ampullectomy follow-up

Important Notes

  • This list is neither exhaustive nor prescriptive and is meant to serve as a guide to clinical teams when planning during the current emergency.
  • The situation continues to evolve rapidly and this advice may change from day-to-day, so clinicians and managers need to check regularly and look for updates and briefings from the relevant Government agencies in the four nations.
  • Teams need to consider resources- both staff and equipment (PPE and endoscopy kit) – when planning and think well ahead as we get closer to the peak of the outbreak.
  • Systems need to be in place to keep records of patients who have been deferred or cancelled so that either alternative arrangements (e.g. clinic follow up, radiological imaging) can be made and proactive, priority rebooking can occur when it is safe to resume normal activities.

More general operational considerations

  • Restricting numbers of staff in rooms for all procedures –e.g. limit trainees (may be redeployed anyway)
  • Limiting advanced endoscopy cases above to a smaller number of specialist consultants, based in Endoscopy and ensuring that they are fitted appropriately for enhanced PPE
  • Assessing stocks of consumables and devices daily – without panic buying. Keep in touch with suppliers and local representatives regarding the supply chain in the coming weeks
  • Considering alternative pathways for diagnostic testing –qFIT/calprotectin; telephone triage of e.g. 2WW referrals. British Society of Gastrointestinal and Abdominal Radiology (BSGAR) advice on use of radiology for lower GI symptoms is here.

We believe that GI endoscopy of all kinds, but especially upper procedures, are aerosol generating procedures (AGP). The latest PHE guidance recognises upper GI procedures as AGP and recommendations for PPE are available here. Adequate PPE is also vital as part of the wider infection and prevention control strategy to limit spread of the virus.

We understand how difficult these times are for everyone and that decision-making around endoscopy will be challenging. We wish everyone the best in the coming weeks and will continue to support you as much as possible throughout.


Ian Penman, Vice-President Endoscopy, BSG                                                       

Cathryn Edwards, President, BSG

Mark Coleman, Chair, JAG Endoscopy

Alastair McKinlay, President Elect, BSG

 

On behalf of:

  • British Society of Gastroenterology (BSG)
  • Joint Advisory Group (JAG)
  • The Association of Coloproctology of Great Britain and Ireland (ACPGBI)
  • Association of Upper Gastrointestinal Surgeons (AUGIS)
  • Pancreatic Society of Great Britain and Ireland (PSGBI)
  • The British Society of Gastrointestinal and Abdominal Radiology (BSGAR)
  • UK and Ireland EUS Society (UKI-EUS)
  • Scottish Society of Gastroenterology (SSG)
  • Welsh Association of Gastroenterology and Endoscopy (WAGE)
  • Ulster Society of Gastroenterology (USG)