Table 1

Summary of recommendations for patient selection in GI endoscopy during the COVID-19 pandemic

Articles grouped by country:China*†‡USA§¶UK**††Spain‡‡Singapore
Patient selection in endoscopy Triaging:
  • Suspend elective cases and reduce active endoscopy rooms. Urgent or emergency cases only. Postpone all procedures in COVID-19 patients if unnecessary.

  • Postpone procedures for abdominal pain, vomiting, bloating, diarrhoea, coffee ground vomiting or mild PR bleeding, any other mild conditions.

  • Proceed if (1) ingestion of foreign bodies, for example, batteries, sharp or toxic foreign bodies, (2) GI obstruction caused by foreign bodies, and (3) endoscopic diagnosis and treatment of major gastrointestinal bleeding. For any other indication, for example, suspected cancers, endoscopist discretion is advised.


Screening protocol:
  • Screen all patients for fever at the ‘front desk’. Refer to fever clinic and provide patients with a face mask if febrile; axillary body temperature ≥37.3°C or ear temperature ≥37.5°C. CT Lung if suspicious +/−throat swab.‡ If afebrile, continue risk assessment.

  • If afebrile, screen for other COVID-19 symptoms, recent travel and close contact history. If suspected COVID-19, perform CT Lung‡


PPE recommendation (general staff):
  • Desk staff to wear surgical face masks, caps, impermeable clothing.


Contingency plan for high-risk patients detected in endoscopy:
  • All patients found to COVID-19 positive to be quarantined in an isolation ward.

Triaging:
  • Strongly consider postponing non-urgent or elective cases.

  • Triage suspected or confirmed COVID-19 patient to a designated area. Carers and relatives prohibited from the endoscopy department unless necessary.


Screening protocol for6:
  • Four questions asked before endoscopy:

    1. Fever (>37.5°C) in last 14 days?

    2. Cough/sore throat/respiratory problems?

    3. Close contact with suspected or confirmed COVID-19 individual? (including family's exposure)

    4. High-risk area?

  • Check body temperature before entering endoscopy.


Classify risk:
  1. Low=No symptoms, no contact risks, not from high-risk area

  2. Intermediate=One of any positive

  3. High risk=symptomatic with either contact risk of from the high-risk area.


PPE recommendation (general staff):
  • All patients to be offered surgical face masks


Contingency plan for high-risk patients detected in endoscopy:
  • Not stated.

Triaging:
  • Three categories: (1) Need to continue, (2) defer until further notice, (3) needs discussion.


Need to continue procedures: acute upper GI bleeding, oesophageal obstruction (foreign bodies, food bolus, pinhole stricture or cancer requiring urgent stenting), endoscopic vacuum therapy for perorations/leaks, acute cholangitis or jaundice secondary to biliary obstruction, acute biliary pancreatitis, cholangitis with stone and jaundice, infected pancreatic collections, walled-off pancreatic necrosis, urgent inpatient nutrition support (enteral feeding tubes), gastrointestinal obstruction needing urgent decompression or stenting.
Defer until further notice procedures: All routine symptomatic referrals, planned POEM, pneumatic dilatation for achalasia, elective PEG, stricture dilatation, APC for GAVE, RFA, pneumatic dilatation, ampullectomy, bariatric endoscopy
Low-risk follow-up and repeat scopes—oesophagitis healing, gastric ulcer healing, ‘poor views’, check post-therapy, for example, EMR, RFA, polypectomy (unless high-risk neoplasia present), and so on. Surveillance polyp check, IBD, Barrett’s (unless high-risk neoplasia present), non-urgent enteroscopy, EUS for ‘benign’ indications—biliary dilatation, possible stones, submucosal lesions, pancreatic cysts without high-risk features. Other ERCP cases—stones where there has been no recent cholangitis and a stent is in place; therapy for chronic pancreatitis; metal stent removal or change; ampullectomy follow-up. Flexible sigmoidoscopy should stop unless discussed with local commissioners. Patients undergoing endoscopy/biopsy as part of clinical trials.
Case-by-case decision:
2-week wait cancer referrals, FIT positive bowel screening colonoscopy, planned EMR/ESD for complex polyps or high-risk lesions, new suspected IBD, cancer staging EUS, small bowel endoscopy.
(General guidance, non-exhaustive list).


Screening protocol:
  1. Travel history

  2. Body temperature

  3. Patients are given a symptom information sheet and asked to report any symptoms at the front desk.


PPE recommendation (general staff):
  • None stated


Contingency plan for high-risk patients detected in endoscopy:
  • Not stated.

Triaging:
  • Delay all procedures for 30 days if patients have respiratory symptoms or exposure to contacts regardless of a fever unless in emergencies.


Screening protocol:
  1. Body temperature,

  2. Respiratory symptoms

  3. High-risk contacts


Contingency plan for high-risk patients detected in endoscopy:
  • Not stated.


PPE recommendation (general staff):
  • None stated


Contingency plan for high-risk patients detected in endoscopy:
  • Not stated.

Triaging
  • Non-urgent indications in the following settings to be postponed:

    1. Patients with acute respiratory Symptoms,

    2. Exposure in high-risk countries

    3. Suspect COVID-19

    4. Proven COVID −19

  • All urgent indications to proceed regardless of COVID-19 status.

  • The urgency of referral determined by endoscopists.


Screening protocol:
  1. Body temperature

  2. Cough

  3. All other COVID-19 symptoms, (iv) Travel history

  4. Contact history,


All suspected and confirmed COVID-19 patients to be managed in designated isolation areas.
PPE recommendation (general staff):
  • None stated


Contingency plan for high-risk patients detected in endoscopy:
  • Not stated.

  • Articles grouped by the country of publication; recommendations may not necessarily reflect national guidance if any.

  • *Subspecialty group of Gastroenterology, the Society of Paediatrics, Chinese Medical Association. (Prevention and control program on 2019 novel coronavirus infection in children’s digestive endoscopy centre). Zhonghua Er Ke Za Zhi 2020;58, 175–178.

  • †Luo et al (Standardised diagnosis and treatment of colorectal cancer during the outbreak of novel coronavirus pneumonia in Renji hospital). Zhonghua Wei Chang Wai Ke Za Zhi 23, 2020; E003.

  • ‡Gou et al (Treatment of pancreatic diseases and prevention of infection during outbreak of 2019 coronavirus disease). Zhonghua Wai Ke Za Zhi 2020;58, E006.

  • §Pochapin et al American College of Gastroenterology COVID-19 and recommendations for gastroenterologists. 2020.

  • ¶Repici et al Coronavirus (COVID-19) outbreak: what the department of endoscopy should know. Gastrointestinal Endoscopy 2020.

  • **British Society of Gastroenterology and British Association for the Study of the Liver. COVID-19: Advice for healthcare professionals in Gastroenterology and Hepatology. 2020.

  • ††Public Health England. COVID-19: Guidance for infection prevention and control in healthcare settings (Version 1.0). 2020.

  • ‡‡Sociedad Española de Patología Digestiva (SEPD) (Updated SEPD recommendations on infection by the SARS-CoV-2 coronavirus.)

  • APC, argon plasma coagulation; EMR, endoscopic mucosal resection; ESD, endoscopic submucosal dissection; EUS, endoscopic ultrasonography; FIT, faecal immunochemical test; GAVE, gastric antral vascular ectasia; GI, gastrointestinal; IBD, inflammatory bowel disease; PEG, percutaneous endoscopic gastrostomy; POEM, peroral endoscopic myotomy; PPE, personal protective equipment; RFA, radio frequency ablation.