Shaping better health
REMEDY : BNSSG referral pathways & Joint Formulary

Endoscopy during COVID-19

Checked: 27-08-2020 by Rob.Adams Next Review: 31-12-2020

Introduction

From 1st September 2020 Prime Endoscopy Bristol reopened to routine  (non-2WW) GP endoscopy referrals.  Referrals will be seen in clinical priority order. Please include the results of a coeliac screen, FIT, helicobacter pylori faecal antigen or faecal calprotectin where indicated as this will help with the prioritisation of patients. As well as new routine GP referrals, Prime will also be working through their own backlogs and routine referrals from both trusts so waiting times will be longer than offered pre-Covid-19. Please manage patient expectations by explaining that the providers are booking patients in order of clinical priority and that wait times may be very long. Please use the appropriate BNSSG standard endoscopy referral form when making referrals (should be embedded in EMIS systems)

2 week wait referrals should continue to be referred directly to the acute providers via existing pathways (direct to test via ICE if possible)

In order to manage demand please consider carefully the need for endoscopy prior to referral. There are British Society of Gastroenterology guidelines (1) that give advice on how to manage the demand for endoscopy and the guidance below may also help.

The Prime endoscopy team have particularly made the following suggestions regards certain presentations where endoscopy may not be required:

1) Refractory GORD
There is seldom any need to scope younger patients with refractory reflux symptoms that return upon stopping PPI  (unless red flags). Whether these patients have oesophagitis or not, we will still recommend PPI prn if conservative management is inadequate and PPIs are effective.
The only real exception is if seeking to screen for Barretts- but that tends to be seen in individuals who have had  reflux  for more than 15yrs, especially men aged >50yrs with high BMI. Younger patients under 40yrs seldom have Barrett's and so OGD adds very little, other than reassurance.
2) Already had multiple OGDs
Some patients may have had several endoscopies which can be a particular issue in those who have moved around a lot and GP does not have access to most recent report. These can often then be triaged to the community GI clinic. Asking for copy of past OGD report in these situations is very helpful if available.   
3) High dysphagia
If swallowing problem in neck/throat then Barium swallow (or ENT assessment) invariably a lot more useful than OGD as we typically don't get good views in this area.
4) Other presentations where need for endoscopy is not clear
Consider referral to the community GI clinic run by Prime (available via eRS). See their service guide for details.

 

Sharing of risk across the system is an important  consideration. The following guidance has been put together by local consultants and GPs 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

Please see below for current criteria for 2WW referrals. 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.

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

Prime endoscopy are now accepting direct referrals for endoscopy if criteria are met and will prioritise according to clinical need. Please use the standard BNSSG upper GI endoscopy referral form.

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 refer via 2WW.

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.

If the advice is to refer for non-2WW endoscopy then please refer via eRS using the standard BNSSG endoscopy form and referrals will be forwarded to Prime if criteria are met.

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 then refer for routine endoscopy via eRS using the standard BNSSG endoscopy referral form. Referrals will be forwarded to Prime if criteria are met.

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 the patient does not have abdominal pain or CT scan is normal, but there are ongoing concerns then refer to gastroenterology advice and guidance via eRS.

If the advice is to refer for non-2WW endoscopy then please refer to Prime via eRS using the standard BNSSG endoscopy referral form.

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.

If the advice is to refer for non-2WW endoscopy then please refer via eRS to Prime using the standard BNSSG endoscopy referral form.

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

In guidance on restarting endoscopy services the BSG has suggested treating patients (< 55 years) with suspected coeliac disease and a tTG >x10ULN without biopsy.

For other patients 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/

If referral for non-2WW endoscopy is indicated then please refer via eRS to Prime using the standard BNSSG endoscopy referral form for consideration of duodenal biopsy (please warn patients that there may be long waits at his time).

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 initially.

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

If the advice is to refer for non-2WW endoscopy then please refer via eRS to Prime using the standard BNSSG endoscopy referral form.

 

 

 

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.

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

Prime endoscopy are now accepting direct referrals for endoscopy if criteria are met and will prioritise according to clinical need. Please use the standard BNSSG Lower GI endoscopy referral form.

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.

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

If the advice is to refer for non-2WW endoscopy then please refer via eRS to Prime using the standard BNSSG endoscopy referral form.

As from 5.10.20 FIT testing has been extended for certain patients who previously met 2WW criteria. See Lower GI 2WW page for details.

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.

If the advice is to refer for non-2WW endoscopy then please refer via eRS to Prime using the standard BNSSG endoscopy referral form.

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.

See BSG pathway on Post-polypectomy and Post cancer resection Surveillance (2019)

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. If IBD is suspected see section below.

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

If non-2WW endoscopy is still indicated then please refer via eRS to Prime using the standard BNSSG endoscopy referral form.

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 (if possible off NSAIDS /PPI).  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 and minimal symptoms consider repeating the test as up to 50% of repeat tests are normal

If faecal calprotectin is raised and patient significantly symptomatic 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.

Alternatively, the Prime community GI clinic can see patients who are less likely to have IBD (particularly if symptoms are mild or faecal calprotectin is in 100 -250 range). Patients can be referred via eRS.

If non-2WW endoscopy is considered appropriate then please refer via eRS to Prime using the standard BNSSG endoscopy referral form but please be aware that there may be long waits at this time.

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).

If the advice is to refer for non-2WW endoscopy then please refer via eRS to Prime using the standard BNSSG endoscopy referral form.

 

 

 

  

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.