key: cord-0947889-j4ambec5 authors: Sinonquel, P.; Roelandt, P.; Demedts, I.; van Gerven, L.; Vandenbriele, C.; Wilmer, A.; Van Wijngaerden, E.; Bisschops, R. title: COVID‐19 and gastrointestinal endoscopy: what should be taken into account? date: 2020-04-26 journal: Dig Endosc DOI: 10.1111/den.13706 sha: ed013cc62b16fe71ad5e7b934745332933d28c10 doc_id: 947889 cord_uid: j4ambec5 On March 11(th) 2020 the World Health Organisation (WHO) declared COVID‐19 pandemic, leading to a subsequent impact on the entire world and health care system. Since the causing Severe Acute Respiratory Syndrome Coronavirus 2 (SARS‐CoV‐2) houses in the aerodigestive tract, activities in the gastrointestinal outpatient clinic and endoscopy unit should be limited to emergencies only. Health care professionals are faced with the need to perform endoscopic or endoluminal emergency procedures in patients with a confirmed positive or unknown COVID‐19 status. With this report we aim to provide recommendations and practical relevant information for gastroenterologists based on the limited amount of available data and local experience, to guarantee a high‐quality patient care and adequate infection prevention in the gastroenterology clinic. Since the first reports of cases with pneumonia of unknown origin at the end of December 2019 in Wuhan, Hubei Province, China our world is in state of high vigilance. On December 31 st 2019, the etiological virus was identified as a novel Severe Acute Respiratory Syndrome (SARS) coronavirus, originating from bats. The World Health Organisation (WHO) officially named it the SARS-CoV-2 virus, causing the disease COVID-19. [1] From then on, the number of infections and subsequent need of hospitalization increased rapidly, first throughout China and later on to Italy, subsequently to Spain and the rest of Europe and the World. [2] In the beginning of February a first COVID-19 positive patient, returning from Wuhan, was identified by the Belgian government leading to gradual implementation of increasingly stringent measures to control this highly contagious disease effective immediately. Strict isolation measures have been imposed on the 17 th of March 2020 up till present day. [3] These measures and rules also involve changes to the organization of health care installations, staff, and services. SARS-CoV-2 virus, as other coronaviruses, causes a variety of possible symptoms ranging from mild rhinitis, fever, cough or diarrhoea, to pneumonia and acute respiratory distress syndrome (ARDS) with need of ventilatory support. The number of hospitalizations, the need of intensive care and number of deaths is still rising. The global impact is tremendous as described by Perisetti et al . [4, 5] Currently, published mortality rates range between 2 -4,3%, though true mortality is probably lower in view of an underestimated denominator. [6] Risk factors have not yet all been identified in large (ongoing) trials, but observational data and case series suggest arterial hypertension and diabetes mellitus as risk factors for severe disease . [6] SARS-CoV-2 virus spreads via droplets and aerosols, and indirectly by contact with contaminated surfaces which implies the absolute need of personal protective equipment (PPE) for both patients and health care workers/professionals, especially those operating in the aero-digestive tract. [6] [7] [8] This article is protected by copyright. All rights reserved gastroenterologists given the fact that the highest viral loads have been measured in the nasopharynx. [9, 10] Although the respiratory and upper gastrointestinal (GI) tract seem the most harmful, recent data show an important presence of viral ribonucleic acid (RNA) in faecal sample up to a mean of 27,9 days versus 16,7 days in respiratory samples. [11] The possibility of faecaloral transmission has been suggested but hard evidence has not been established yet. [12] However, faecal excretion might contribute to viral transmission considering the evidence of faecal excretion for both SARS-CoV and Middle East Respiratory Syndrome Coronavirus (MERS-CoV), and their ability to remain viable in conditions that could facilitate faecal-oral transmission, it is possible that SARS-CoV-2 could also be transmitted via this route. [13, 14] Therefore, we propose to consider both flexible upper and lower GI tract endoscopy also as a high risk procedure for disease transmission and we suggest to foresee proper PPE measures as well. The aim of this report is to provide a practical guide for the protective management when performing endoscopic/endoluminal procedures of the GI tract in emergency, ambulatory or hospitalized patients, based upon the current available information worldwide and local experience in our tertiary university hospital. We performed a Pubmed, Medline and Embase search between the 23 rd of March 2020 and the 3 rd of April 2020 using 'SARS-CoV-2', 'COVID-19', 'gastrointestinal endoscopy', 'endoscopy, digestive system endoscopy' as MeSH terms. We only used published data, reports and articles written in the English language. After exclusion, 36 of 46 articles were eligible for enrolment. An extensive authors' methodology for systematic searches is available on request. Since we aim to provide a practical guidance and clinical recommendations, we prioritized statements by international medical associations such as the World Health Organization and the European and US Center for Disease Prevention and Control. Before performing any type of endoluminal procedure of the GI tract (eg: oesophagogastroduodenoscopy, placement of feeding tubes, endoscopic retrograde cholangiopancreaticography (ERCP)) a general assessment of the urgency and need of the procedure is strongly recommended. All endoluminal procedures should be considered high risk, therefore only procedures in which time delay is unacceptable or affects the patient's survival should be performed. Before any procedure can be performed, the patient should wear a surgical mask and should be questioned about contact with COVID-19 positive individuals and recent or present symptoms like fever, cough and dyspnea, rhinitis, sudden loss of smell and/or taste. A new onset of nausea, diarrhoea or abdominal discomfort can be considered as suspect for (entero)colitis, especially when combined with fever. [11] Additionally, temperature can be measured and real-time reverse transcription polymerase chain reaction (RT-PCR) testing on nasopharyngeal swab is recommended before performing any endoluminal procedure. In line with social distancing and avoiding contacts, optimization of consultation via telephone or video consultation is highly recommended if possible. If clinical evaluation is mandatory in case of alarm symptoms like involuntarily loss of weight, inability of oral intake, jaundice, we advise to take some precaution in the outpatient clinic. Before entering the waiting room, temperature measurement can be considered and symptoms as abovementioned should be questioned. Recognition of the early COVID-19 signs is of high importance to avoid further spreading, since people are most likely contagious in the 24 hours before developing respiratory symptoms. [9] Rules for social distancing should be applied in the In the ideal scenario, all patients should be offered a surgical mask. However due to resource allocation, the use of surgical masks can be (temporarily) limited. Therefore, patients with (preliminary) symptoms should be prioritised in providing a surgical mask and should be isolated as much as possible. Since the COVID-19 status of ambulatory patients is currently still mostly unknown and since the procedures are at high risk for transmission, wearing adequate PPE is mandatory. This includes (1) a surgical hat, (2) long nitrile gloves (considered to be a second skin), (3) an impermeable gown, (4) a FFP2/3 mask and (5) goggles and/or face visor for the attending health care worker, as suggested by the WHO. [15] Specific "donning and doffing" measures have to be taken into account (see paragraph Dressing and undressing, figure 1a-b). Although protective materials as gloves and masks are scarce, any type of unprotected patient contact is prohibited and cannot be tolerated. This article is protected by copyright. All rights reserved malignant pathologies has to be reconsidered since disease progression can cause patients to be no longer amenable for endoscopic curative treatment. An overview of recommendations by 21 endoscopic associations for performance of an endoscopic procedure during this COVID-19 pandemic is available by Castro Filho et al. [17] In case of emergency where COVID-19 screening would imply an unacceptable time-delay, the patient should be considered as possibly COVID-19 positive and the same protective measures should be taken into account as described for a confirmed COVID-19 positive patient. [18] The COVID-19 status (5) clustering. In case of presence of one of these 5 risk factors, the patient is to be considered as a suspected case and COVID-19 RT-PCR should be conducted prior to the endoscopic procedure. In case of a positive or inconclusive RT-PCR test the procedure is high risk allowing only urgent endoscopies. In absence of one of these risk factors symptoms should be questioned and if This article is protected by copyright. All rights reserved present the procedure is considered intermediate risk permitting only urgent endoscopy. Low risk patients are patients with no risk factors and no symptoms or at least 1 positive risk factor but a negative laboratory RT-PCR test. [19] Patient screening is highly variable in different centres due to resource allocation. The patient's COVID-19 status can be determined by a combination of the clinical presentation, RT-PCR-test (nasopharyngeal swab and/or bronchoalveolar lavage) and/or multi-sliced chest computed tomography (CT) scan. [20] Sensitivity of RT-PCR-tests are moderate to high depending on the timing and type of test. [21] Anal swabs have also been tested but seem to be positive in later For doubtful cases, we suggest considering them "unknown" and take the same precautions as for a confirmed COVID-19 positive patient. Routine RT-PCR testing could be implemented to optimize classification of patients. This article is protected by copyright. All rights reserved This article is protected by copyright. All rights reserved PPE: disposable gown, surgical hat, surgical mask, goggles or disposable face shield and one pair of nitrile gloves For other endoluminal procedures like insertion of nasogastric tubes, distance between the physician and patient should be maximized as much as possible. Rather not use local oral anaesthetic sprays in order to minimize oral aerosolization. [24] Manipulations should be minimized and proper cleaning and disinfecting tools have to be accessible immediately. Patients wear a surgical mask at all times covering their mouth (the nose can be cleared of the mask during the procedure) to reduce the aerosolization due to possible cuffing or gagging. These measures can also be applied for other endoscopic/endoluminal examinations within the field of otorhinolaryngologists who perform their laryngoscopy during consultation. Before every procedure with a COVID-19 positive patient, special PPE measures have to be taken. As described by the WHO, COVID-19 is a highly contagious infection spreading through droplets and therefore specialized PPE measures have to be implemented, different from those of other highly contagious diseases as Ebola that spreads via bodily fluids. The use of coveralls is not necessary in case of COVID-19. [15] The sequence of dressing and undressing with these PPE is very particular and should be followed in the correct order at all times to avoid patient to health care worker transmission. The dressing-procedure is called 'the donning' and the undressing-procedure is called 'the doffing'. This article is protected by copyright. All rights reserved After an endoluminal procedure the room has to be considered contaminated during at least one hour for rooms without negative pressure. When the latter is present, a new patient can be allowed in the COVID-19 room after 30-60 minutes. [18] Stable data on the virucide effect of chemical against SARS-CoV-2 are not yet available. Hence, we based our recommendation on data from other SARS-CoV viruses. Since SARS-CoV is known to be stable in faeces and on smooth surfaces, we recommend using special (virucide) disinfection (eg. sodium hypochlorite) products or UV-C to clean the room and surfaces. [18, 25] To minimize the consumption of PPE and to optimize patient flow and reduce the in-room time, we suggest working in a two-persons system, one experienced medical doctor ('the attending physician') and one assistant ('the buddy) together in the room with the COVID-19 positive or high risk patient when performing an endoscopy. For optimizing the workflow and provision of unforeseen equipment and to reduce the amount of consumed PPE, a third assistant outside of the endoscopy room is preferable. We recommend these 'assistants' to be experienced In low risk or confirmed COVID-19 negative patients this buddy system is not required and the endoscopist can be assisted by one (or more) endoscopic nurse without taking the enhanced but only the standard PPE and infection control measures. Special situations require special measures. Since the outbreak of the COVID-19 pandemic the entire world has been set upside down and strict rules have been implemented. The fact that this new virus is highly contagious and pathogenic, adjustments to our general practical guidelines for This article is protected by copyright. All rights reserved endoluminal procedures were prompted. [15] With this document we aim to provide a practical Nevertheless, the authors strongly believe that any contribution to increase the awareness of the vulnerability of endoscopists is of the highest importance at this stage of the pandemic. CONCLUSION SARS-Cov-2 infection is a highly contagious new disease primarily spreading via droplets and with the highest concentration of virus in the naso-oropharynx but also presence of SARS-CoV-2 virus European Centre for Disease Prevention and Control. 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Virological assessment of hospitalized patients with COVID-2019 Rational use of personal protective equipment for coronavirus disease 2019 ( COVID-19 ) Endoscopy activity and COVID-19: BSG and JAG guidance -update 22.03.20 | The British Society of Gastroenterology Gastrointestinal endoscopy during COVID-19 pandemic: an updated review of guidelines and statements from international and national societies COVID-19) outbreak: what the department of endoscopy should know Practice of endoscopy during COVID-19 pandemic: position statements of the Asian Pacific Society for Digestive Endoscopy (APSDE-COVID statements) Clinical, laboratory and imaging features of COVID-19: A systematic review and meta-analysis Rapid establishment of laboratory diagnostics for the novel coronavirus SARS-CoV-2 in Timely implementation of molecular diagnostics for SARS-CoV-2 Molecular and serological investigation of 2019-nCoV infected patients: implication of multiple shedding routes Outbreak of a new coronavirus: what anaesthetists should know Editorial I Anaesthesia and SARS Perioperative COVID-19 Defense Indications Acute colitis n, (%) Melena n, (%) Feeding tubes n, (%) Biliary stenting n, (%) EUS n, (%) Volvulus n, (%) Hematemesis n, (%) Anemia n, (%) Colorectal stenosis n, (%) Oesophageal impaction n Changed stool pattern n, (%) Pyrosis n, (%) Posttransplant control n, (%) POEM n, (%) Evaluation post Barrett n, (%) Follow-up IBD n, (%) Pretransplant evaluation n, (%) Polyp treatment n 6 (11,8) 4 (7, 8) 1 (1, 9) 3 (5, 9) NA Doffing procedure (inside the room -disposable items): (1) take off the short nitrile gloves, (2) take off the impermeable gown and (3) remove the long nitrile gloves. Between every step disinfection of the hands is necessary. Before leaving the room a new pair of short nitrile gloves has to be put on as protection against possible skin transmission. Doffing procedure (outside the room -recyclable items): (1) take off the face shield, (2) remove the goggles, (3) remove the FFP2/3 mask (4) take of the surgical hat and remove the second pair of short nitrile gloves. Between every step disinfection of the hands is necessary. The face shield, goggles and FFP2/3 mask should be collected for recycling.