Guest Commentary: Gastrointestinal endoscopy during a global pandemic
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In this guest commentary, Farhan Quader, MD, of Washington University School of Medicine, and Zachary Smith, DO, of Case Western Reserve School of Medicine, discuss how endoscopists should navigate the COVID-19 pandemic.
During the modern era of GI endoscopy, we have not encountered a global outbreak of a pandemic virus to which nobody on Earth possesses immunity. The practice of GI endoscopy will continue to evolve dramatically as this COVID-19 pandemic progresses. In its simplest terms, there are two main forces that drive this evolution: the first is the need to mitigate patient traffic from the community or inpatient units into the endoscopy unit; the second is to conserve personal protective equipment (PPE) as institutional shortages become inevitable. During this crisis, many patients will require urgent, or semi-urgent endoscopy, some of whom will be suspected or confirmed to have COVID-19. There is substantial guidance available from our GI societies, as well as from international centers that have faced this crisis firsthand.
On March 15, four GI societies published a joint statement, offering guidance on various subjects pertinent to endoscopy, including the classification of procedure urgency, patient risk-stratification, PPE management and post-procedure follow up. This was published the day after the U.S. Surgeon General recommending the postponement of elective surgeries or procedures.
Regarding GI endoscopy, there is broad consensus for most procedures classified as urgent (eg, upper endoscopy for acute foregut hemorrhage, ERCP for acute cholangitis) or elective (eg, screening and surveillance colonoscopy in average-risk patients). In contrast, there is wide variability when it comes to the middle-ground of semi-urgent endoscopy. The decision to proceed or delay semi-urgent endoscopy involves significant vetting. Factors including patient age and comorbidities, symptom severity, and risk for disease/symptom progression all are considered when making these decisions, and this review process is labor-intensive.
Viral Presence in Stool
Our understanding of the roles of fecal-oral transmission and gastrointestinal aerosolization of SARS-CoV-2 continue to evolve. Recent data show that SARS-CoV-2 is detectable in stool by polymerase chain reaction (PCR) in most COVID-19 patients. Remarkably, it has become evident that patients often have positive stool PCR tests after respiratory samples have become negative.
Chinese investigators have also demonstrated that the SARS-CoV-2 viral host receptor angiotensin-converting enzyme 2 (ACE2) is found in the cytoplasm of gastrointestinal epithelium, with staining for viral nucleocapsid found in GI mucosa, thus explaining a mechanism of fecal-oral transmission. In light of these emerging findings, it is plausible that the risk for SARS-CoV-2 transmission during colonoscopy and other lower GI procedures has thus far been under-appreciated.
General Principles When Performing Endoscopy
At scheduling and immediately prior to endoscopy, all patients should be pre-screened for COVID-19 symptoms and risk factors, including travel history. In light of emerging data, it will also be prudent to screen for unexplained digestive symptoms.
During endoscopy, appropriate PPE should be emphasized for all endoscopy unit staff. Strict precautions need to be undertaken in those with confirmed COVID-19. Recent data have demonstrated a significant rise in bacterial burden on face shields of gastroenterologists after performing colonoscopy, and we must assume this translates to viral transmission. With evidence of viral RNA present in stool, there is high-concern for transmission, however, the precise infectivity of SARS-CoV-2 through endoscopy remains understudied.
There should be a continued strong emphasis placed on high-quality, high-level disinfection. Caution should be undertaken to avoid splashing during the precleaning process to avoid contamination of surfaces. Reusable medical equipment should be cleaned with products that are effective against bacteria, fungi, viruses and mycobacteria. Single-use, disposable accessories should be used to avoid cross-contamination.
With high rates of asymptomatic carriers, follow-up phone calls to outpatients should be made at 7 and 14 days to inquire about COVID-19 symptoms. Positive answers may result in testing or voluntary quarantine of exposed staff members. Attempts should be made to pair endoscopy staff, including physicians, nurses, and technicians, for future cases to reduce transmission.
Cooperatively Navigating the Path Ahead
The effect this pandemic is having on our endoscopic practice is unprecedented, and it is paramount that we navigate this crisis together. Whether it is a fear of personal exposure or uncertainty as to how to reuse a single-use N95 mask in a time of ration, there exists a large international community of health care professionals with similar inquiries, as well as novel solutions to problems we will encounter.
Social media platforms such as Twitter have thousands of engaged physicians all over the world, including gastroenterologists, who are sharing their experiences with SARS-CoV-2 in real-time. This instant transfer of knowledge is invaluable in this extraordinary crisis. The more physicians actively partake in these discussions, the clearer our path will become.
Contributing To Growing Knowledge
As GI health care professionals, we are positioned to help cultivate the understanding of the digestive manifestations and epidemiology of this virus. Last week saw the launch of the North American Coalition for the study of GI manifestations of COVID-19. This coalition aims to survey GI endoscopic practices to assess the changing landscape of endoscopy during this pandemic while creating a growing registry of the digestive manifestations of COVID-19. Institutional Review Board (IRB) documents are available to assist in submitting an exempt or expedited review. We should all feel compelled to contribute to the growing science that helps understand this global pandemic.
We are in for the greatest challenge of our careers. Some sobering models predict this pandemic lasting into 2021, with a death toll exceeding 1 million people in the U.S. alone. These are uncharted waters, and at times we will undoubtedly feel lost. However, if we navigate this crisis together, with unimpeded international communication, knowledge contribution, and moral support, we will get to the other side, together.
References:
Johnston ER, et al. Gastrointest Endosc. 2019;doi:10.1016/j.gie.2018.10.034.
ASGE. JOINT GI SOCIETY MESSAGE: COVID-19 Clinical Insights for Our Community of Gastroenterologists and Gastroenterology Care Providers. Available at: https://www.asge.org/home/joint-gi-society-message-covid-19. Accessed March 23, 2020.
Pan L, et al. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional, multicenter study. Am J Gastroenterol. 2020.
Repici A, et al. Gastrointest Endosc. 2020;doi;10.1016/j.gie.2020.03.019.
Soetikno R, et al. Considerations in performing endoscopy during the COVID-19 pandemic. Gastrointest Endosc. 2020.
Xiao F, et al. Evidence for gastrointestinal infection of SARS-CoV-2. Gastroenterology. 2020.
Disclosure: Quader and Smith report no relevant financial disclosures.
Perspective
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John Vargo, MD, MPH
The COVID-19 pandemic has been a journey of discovery coupled with ongoing patient care. It is an outbreak of historical proportions. The gastroenterology community has come together to provide the best care possible. We will be setting a new normal in the future for how to take care of patients. We should be thankful that we have the ability to take care of patients while advancing the science to curtail this pandemic.
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