Professor Rupert Leong is the Director of Endoscopy at Concord Hospital, Sydney. He conducts private endoscopy services at both Macquarie University Hospital (9812 3880) and Sussex Medical Centre, Haymarket, Sydney (9281 9133)

Gastroscopy

Gastroscopy is the visualisation of the oesophagus, stomach and duodenum using a flexible telescope. This is a quick and simple procedure performed under sedation, typically administered by an anaesthetist. The procedure takes approximately 15 minutes. 

The indications of gastroscopy includes difficult-to-manage or chronic acid reflux, stomach discomfort, iron deficiency or anaemia, diarrhoea, exclusion of coeliac disease or gastric cancer. Family history of upper gastrointestinal cancers may require gastroscopy. General practitioners may refer you for gastroscopy directly (Direct Access Gastroscopy).  

Colonoscopy

Colonoscopy is the visualisation of the large bowel and the tip of the small bowel (terminal ileum) using a flexible telescope. This is a quick and simple procedure performed under sedation, typically administered by an anaesthetist. The procedure takes approximately 20 minutes. 

The indications of colonoscopy includes investigation of abdominal discomfort, iron deficiency or anaemia, diarrhoea, blood in the stools or on toilet paper, weight loss or concern regarding bowel cancer and inflammatory bowel diseases. Screening colonoscopy may be appropriate. General practitioners may refer you for gastroscopy directly (Direct Access Colonoscopy).  

Polypectomy

Polypectomy is the removal of polyps in the bowel to prevent them for progressing onto bowel cancer. This is achieved using electrocautery and rarely complicated by bleeding or bowel perforation. 

Needle Knife Stricturotomy, Balloon Dilatation 

These are techniques that open up strictures in Crohn's disease or strictures that complicate ileopouch anal anastomoses in ulcerative colitis. 

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Corona virus COVID-19 

Overall the risk is low. You are more at risk of common cold and influenza (which you should be immunized against via your GP). See risk stratification according to the BSG (scroll down).

Any symptoms you can contact the virus hotline or your GP to organise throat swabs if deemed appropriate.

You should continue your medical therapy. Your medical therapy is actually not major at all. 

1. Standard precautions - avoid crowds, unnecessary travel or congregations or crowds eg conferences, sporting events/ festivals. Community spread is still very rare but avoid gatherings.   

2. Abide by hygiene standards and new social norms - eg no need to kiss, hug or shake hands with people. I already stopped doing this.  

3. Wear mask if you are coughing or sneezing. If more severe symptoms like shortness or breath call the emergency department and attend wearing mask.

4. Self isolate if you are symptomatic at home. So far without additional risks the government is not requested throat swabs for COVID-19. Testing IS done if there is a CONFIRMED case - please obtain advice from your work whether your colleague tested positive or negative if there is someone sick at work. 

5. Have masks on standby and use if in confined spaces. Especially when COVID is more common. Masks are effective strategy in Asia.

6. Check with all your close contacts daily on whether they have had symptoms and excuse them if they have. Fever remains the most sensitive symptom. Next is dry cough. 

 

These are the current recommendations but the situation is constantly changing. These would be recommendations made to people whether they have IBD or not and whether they are on medications or not. 


BSG Guidelines for IBD 23 Mar 2020

Highest risk "shielding" 

 1.  IBD patients who either have a co-morbidity (respiratory, cardiac, hypertension or diabetes mellitus) and/or are ≥70 years old

 

and* are on any therapy for IBD (per middle column) except 5ASA, budesonide, beclometasone or rectal therapies

2.      IBD patients of any age regardless of co-morbidity and who meet one or more of the following criteria:

  •  on oral or intravenous prednisolone ≥20 mg per day (only while on this dose)

  • new induction therapy with combo therapy (starting biologic within previous 6 weeks)

  • moderate-to-severely active disease despite immunosuppression/ biologics

  • short gut syndrome requiring nutritional support

  • requirement for parenteral nutrition

 

Moderate Risk "stringent social distancing" 

‘Patients on the following medications:

 

  • Ustekinumab

  • Vedolizumab

  •  Methotrexate

  •  Anti-TNF alpha monotherapy (infliximab, adalimumab, golimumab)

  •  Thiopurines (azathioprine, mercaptopurine, tioguanine)

  • Calcineurin inhibitors (tacrolimus or ciclosporin)

  • Janus kinase (JAK) inhibition (tofacitinib)

  • Combination therapy in stable patients**

  • Immunosuppressive/biologic trial medication

 

Lowest risk "social distancing" 

Patients on the following medications:

 

  • 5ASA

  • Rectal therapies

  • Orally administered topically acting steroids (budesonide or beclometasone)

  • Therapies for bile acid diarrhoea (colestyramine, colesevelam, colestipol)

  • Anti-diarrhoeals (e.g. loperamide)

  • Antibiotics for bacterial overgrowth or perianal disease

BSG Updates on Endoscopies:

Needs to Continue

  • Acute Upper GI bleeding

  • Acute oesophageal obstruction – foreign bodies, food bolus, pinhole stricture/cancer where stenting is considered essential.

  • Endoscopic vacuum therapy for perorations/leaks.

  • Acute cholangitis/jaundice secondary to malignant/benign biliary obstruction

  • Acute biliary pancreatitis and/or cholangitis with stone and jaundice

  • Infected pancreatic collections/WON

  • Urgent inpatient nutrition support – PEG/NJ tube

Defer until further notice

  • All routine symptomatic referrals

  • Planned POEM, pneumatic dilatation for achalasia

  • Other elective therapy/intervention –PEG, stricture dilatation, APC for GAVE, RFA, pneumatic dilatation, ampullectomy etc

  • Bariatric endoscopy

  • Low-risk follow-up and repeat scopes – oesophagitis healing, gastric ulcer healing, ‘poor views’, check post therapy e.g. EMR/RFA/polypectomy (unless felt to be clinically high risk neoplasia still present) etc

  • Surveillance -polyp FU, IBD, Barrett’s (unless felt to be clinically high risk neoplasia still present)

  • Routine/ non urgent Small bowel endoscopy

  • 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/change; ampullectomy follow up.

  • FIT+ bowel screening colonoscopy should be paused immediately.

  • Bowel Scope flexible sigmoidoscopy should be paused immediately.

  • Patients undergoing endoscopy / biopsy as part of clinical trials.

Needs discussion (possibly case-by-case)

  • 2 Week Wait cancer referrals –to be 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 priority

  • Planned EMR/ESD for complex polyps/ high risk lesions

  • New suspected IBD – acute colitis

  • Cancer staging EUS – biopsy and/or staging

  • SB endoscopy- ongoing transfusion dependent bleeding / suspected SB cancer on radiology/capsule endoscopy

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 or rebooking can occur when it is safe to resume normal activities. Local discussions with colleagues in Radiology may also be helpful when considering this.

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 coming weeks

  • Considering alternatives for diagnostic testing –FIT/calprotectin; radiology (already hard pressed); telephone triage of e.g. 2WW referrals

New consensus statements from the Asia Pacific Association of Gastroenterology relating to IBD and COVID 

8 Apr 2020

http://apage.org/files/APAGE_COVID_and_IBD.pdf

SECURE International Registry: 

https://covidibd.org/current-data/ 

Macquarie University Hospital
Suite 404, 2 Technology Place, Macquarie Uni:
T: (612) 9812 3880
Specialist Medical Services, Sydney
Level 11, 501 George St, Sydney:
T: (612) 8378 1721  

© Rupert Leong

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