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REMEDY : BNSSG referral pathways & Joint Formulary

Endoscopy during COVID-19

Checked: 28-07-2020 by Rob.Adams Next Review: 31-12-2020

Introduction

Access to endoscopy (other than 2WW referrals) has been severely restricted as a result of COVID-19. A variety of reasons for this are apparent:

  • Restructuring of acute trusts during initial phases of the pandemic with resources diverted to care of patients with COVID-19.
  • Closing of direct referrals to independent providers of endoscopy who were contracted to assist acute trusts in managing suspected cancer patients.
  • Infection risk to staff undertaking endoscopy - particularly upper GI endoscopy which is an aerosol generating procedure.
  • Infection control and PPE requirements which mean that capacity for endoscopy is significantly reduced.

Pre-covid demand for endoscopy was already high with long back logs of referrals that were already in the system and COVID-19 has exacerbated this .

The acute trusts (UHBW and NBT) together with independent providers (PRIME, EGTC and Nuffield) have worked hard to get on top of 2WW referral activity which is now under control. Unfortunately there has been no capacity for non-2WW work so this has largely been on hold since the beginning of the pandemic. Recovery is likely to be slow and therefore referrers and providers need to work together to manage the demand.

There are British Society of Gastroenterology guidelines (1) that give advice on how to manage the demand for endoscopy. This has to be done in a pragmatic way that will keep risk to the patient to a minimum without overloading already stretched resources. Sharing of that risk across the system is an important  consideration. A working group is being hosted by the CCG made up of local consultants and  independent providers. GPs are being represented on this group by the Clinical lead of the Referral Service. The following has been put together as a preliminary guide to referrers in managing their patients but may be subject to changes as further national and local pathways are developed.

2WW endoscopy

The criteria for 2WW referrals has not changed and referrers should continue to refer patients who have suspected cancer without delay:

Upper GI 2WW

Lower GI 2WW

If a GP has significant concerns about malignancy but the 2WW criteria are not met then they can still refer via 2WW and use the free text box to indicate why they feel a 2WW referral is warranted. This may include:

  • abnormal findings on imaging where malignancy may need to be excluded.
  • new onset dyspepsia in patient >55 associated with anaemia (1).

 However, if on review by a consultant a 2WW referral is not considered necessary the referral may be returned.

If further advice on appropriateness of 2WW referral is required then consider using Advice and Guidance services although please be aware that responses from these services may take up to 7 days.

Upper GI endoscopy

Upper GI endoscopy is an aerosol producing procedure and therefore requires providers to consider carefully the value of an endoscopy before proceeding.

Pre-COVID care pathways may therefore not be appropriate during COVID-19 and referrals for direct access to endoscopy will not be currently accepted by providers.

Referral for barium swallow should not be considered as an alternative to upper GI endoscopy unless on the advice of a specialist.

Please consider the following before referral:

Indication for Endoscopy

Pre-COVID pathway

Suggested pathway during COVID-19

Dyspepsia and reflux (non-2WW)

See Dyspepsia and Reflux page

Check Upper GI 2WW referral guidelines and refer using this route if appropriate.

If there is recent onset dyspepsia in a patient >55 associated with anaemia (1) then also refer via 2WW (see 2WW section above)

Use existing dyspepsia and reflux guidelines to guide initial management (including helicobacter pylori stool antigen test and treat if positive)

Patients who have no red flags should be maintained on oral treatment and lifestyle advice.

If symptoms are still not controlled on oral treatment then consider alternative explanations such as functional dyspepsia.

Consider referral to upper GI / gastroenterology/ Prime community GI clinic via eRS for advice on further management.

Referrals for consideration of surgical management should be made to upper GI surgeons but are likely to be subject to long delays so please manage patient expectation.

Iron deficiency anaemia without red flags

See Anaemia page.

Confirm anaemia is due to iron deficiency before considering GI causes.

Consider lower GI 2WW indications and/or FIT test and refer appropriately.

If lower GI and other causes have been excluded and ongoing concerns persist then refer to upper GI/ gastroenterology via eRS.

Acute GI bleed (haematemesis or malena)

 

If suspected acute GI bleed (within the last 7 days) then discuss with on call surgical team.

Unintended weight loss

 

Check for other red flags that would indicate a 2WW endoscopy is required.

If associated with abdominal pain then consider urgent CT chest/abdo/pelvis rather than referral for endoscopy.

If no abdominal pain or CT scan is normal but there are ongoing concerns then refer to gastroenterology advice and guidance via eRS.

Persistent nausea or vomiting

 

If no other red flags and not responding to treatment in primary care then request advice and guidance from gastroenterology or refer to PRIME community gastro clinic.

Surveillance of Barrett’s oesophagus

Should be already on surveillance list in secondary care.

Patients may have their surveillance endoscopy suspended. Please do not refer to expedite as this will not be possible unless there are new or concerning symptoms.

If there are new symptoms of dyspepsia that are not controlled by maximal treatment with PPI  or dysphagia then refer via upper GI 2WW.

Surveillance endoscopy is rarely indicated in patients >75 or with significant frailty or comorbidities who would not do well with surgery.

Suspected coeliac disease

See Coeliac disease page of Remedy

Currently advice is not to refer directly from primary care for D2 biopsies for confirmation of diagnosis.

Treat on basis of symptoms and positive blood test with gluten free diet/dietician referral or refer to gastroenterology via eRS if indicated. See detailed advice below:

https://www.bsg.org.uk/covid-19-advice/covid-19-specific-non-biopsy-protocol-guidance-for-those-with-suspected-coeliac-disease/

Family history of upper GI cancer

If 2 or more first degree relatives have been diagnosed with upper GI cancer then routine endoscopy would normally be suggested.

Do not refer for endoscopy.

Obtain detailed family history and refer to gastroenterology via eRS or advice and guidance.

 

 

 

Lower GI endoscopy

Lower GI endoscopy is not an aerosol producing procedure but providers still have reduced capacity to undertake endoscopy due to infection control and PPE guidelines.

Pre-COVID care pathways may therefore not be appropriate during COVID-19 and referrals for direct access to endoscopy will not be currently accepted by providers..

Referral for barium enema should not be considered as an alternative to lower GI endoscopy unless on the advice of a specialist.

Please consider the following before referral:

Indication for Endoscopy

Pre-COVID pathway

Suggested pathway during COVID-19

Iron deficiency anaemia (non-2WW)

See Anaemia page on Remedy.

Consider FIT test in patients 50 or over and refer via 2WW if positive.

Existing guidelines still apply.

If ongoing concerns of a GI cause for anaemia then refer to gastroenterology for advice and guidance.

FIT testing may shortly be expanded for all age groups in future to exclude GI cause of iron deficiency anaemia (not currently available but pathway is under development).

Family history of colorectal cancer

See FH of colorectal cancer page on Remedy

Do not refer directly for endoscopy.

Existing guidelines apply - take detailed family history and refer to gastroenterology or clinical genetics via eRS.

Evaluation of abnormality on imaging

 

If malignancy is considered a possible cause then refer via 2WW pathway.

Surveillance colonoscopy

Surveillance colonoscopies are normally arranged by secondary care

Please do not refer to expedite surveillance colonoscopies as delays are likely and providers will catch up when they can.

If a patient develops red flag symptoms then refer via lower GI 2WW.

Rectal bleeding (non-2WW)

See Rectal Bleeding page on Remedy.

Direct access sigmoidoscopy

Check Lower GI 2WW page and refer if criteria for 2WW referral are met or if IBD is suspected see entry below.

If low risk /criteria not met then referral for endoscopy should be avoided and patients managed in primary care.

Do rectal exam in primary care (and protoscope if possible). Check bloods for iron deficiency anaemia and consider stool for faecal calprotectin.

If ongoing symptoms/concerns then refer to colorectal surgeons via eRS.

If referring for treatment of haemorrhoids then ensure that you check the Haemorrhoids page which include a link to the criteria based access funding policy.

Suspected Inflammatory bowel disease

Direct access colonoscopy.

See IBD page on Remedy.

If IBD is suspected then check bloods and faecal calprotectin. Do not refer directly for endoscopy.

If faecal calprotectin is normal (<100) then IBD Is unlikely – consider other causes (such as irritable bowel syndrome).

If faecal calprotectin is raised then check guidelines to interpret results and consider referral to IBD clinic via eRS (urgent if indicated) where patients will usually be managed empirically initially.

Suspected Irritable bowel syndrome

See IBS page on Remedy.

Endoscopy not usually indicated in low risk patients.

Refer to IBS guidelines on Remedy and manage in primary care.

Do not refer for endoscopy.

If symptoms not controlled then consider gastroenterology A and G or refer to community GI clinic (PRIME)

 

 

 

  

References

(1) Restarting gastrointestinal endoscopy in the deceleration and early recovery phases or COVID-19 pandemic: Guidance from the Bristish Society of Gastroenterology.DOI: https://doi.org/10.7861/clinmed.2020-0296.