The coronavirus 2019 (COVID-19) pandemic, caused by infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has significantly affected the worldwide healthcare system since December 2019. The treatment and management of COVID-19 has been challenging on all fronts, raising concerns for both patients and health care workers (HCWs).
An area that has been specifically challenging within the field of gastroenterology is the management of how and when to perform gastrointestinal (GI) procedures, especially when many patients with COVID-19 have GI symptoms1,2. In order to aid gastroenterologists and hepatologists with these decisions, the American Gastroenterological Association (AGA) has published a series of recommendations in Gastroenterology2. These guidelines were compiled by a special panel of AGA members and were also reviewed by 2 patients who tested positive for SARS-CoV-2.
When reviewing these recommendations, it is important to note that the current research environment surrounding COVID-19 is extremely fluid and information is evolving on a daily basis. Therefore, all of the recommendations and suggestions in the AGA guidelines should be evaluated as such. It is also important to note that many of these AGA recommendations are not directly based on research involving the transmission of SARS-CoV-2, but rather prior research including other similar outbreaks of viral infection. Moreover, all HCWs should refer to all local state, government and institutional policies, as these may supersede anything outlined in the AGA guidelines.
Many of the recommendations in the AGA guidelines are based on research indicating that SARS-CoV-2 particles have been found in stool samples of patients and that the viral particles can potentially be transmitted via the fecal-oral route1,2. Patients can have detectable viral load in the stool regardless of the presence of diarrheal symptoms as well as when there is a negative nasopharyngeal swab1,2.
As SARS-CoV-2 is primarily spread through droplet formation, it is crucial to note that endoscopic procedures can lead to aerosolization and potential airborne transmission of the virus. This risk is highest during upper GI endoscopy where the endoscope passes through the mouth and pharynx and may have contact with the upper airway. These upper GI procedures include esophagogastroduodenoscopy (EGD), small bowel enteroscopy, endoscopic ultrasound (EUS), endoscopic retrograde cholangiopancreatography (ERCP), breath tests (eg urease breath tests) and esophageal manometry. Although there is still a risk of aerosolization with lower endoscopic procedures, such as colonoscopy and flexible sigmoidoscopy, data is limited.
When describing the type of personal protective equipment (PPE) required for use during endoscopy, guideline authors caution HCWs to be cognizant of the relevant terminology. Surgical masks only block large particles and are less effective in blocking aerosols (particles < 5 µm), and are therefore used more frequently in “droplet precautions”. Respirator masks include the N95 masks, which filter at least 95% of aerosols (<5 µm) and droplets 5µm to 50 µm and are also not resistant to oil. These are utilized in “airborne precautions”. In order to choose the correct N95 size, a fit test is required for individual HCWs prior to use. An alternative to an N95 mask are powered air-purifying respirators (PAPRs), which are available at certain facilities.
PPE and GI Procedures
The AGA recommends that all upper and lower GI procedures be performed with an N95 mask or PAPR and double gloves regardless of a patient’s COVID-19 status. They caution against the use of surgical masks even when resources are scarce. The recommendations regarding N95 masks and PAPR were primarily based on 2 prior systematic reviews that showed benefits in using N95s over standard surgical masks in protecting health care workers from SARS3,4.
The authors of the AGA guideline also included the results of their own meta-analysis of retrospective cohort studies identified while writing this review. The analysis found that there was a higher risk for viral transmission to HCWs exposed to aerosol generating procedures compared with unexposed HCWs (relative risk [RR], 4.66; 95% CI, 3.13-6.94). Therefore, because GI procedures are considered aerosol-generating procedures, the N95 and PAPR recommendations were made.
The AGA recommends extended use and/or reuse of N95 masks over surgical masks in areas where PPE is limited. There is limited data regarding the placement of a face shield or surgical mask over an N95 mask in terms of the reduction of contamination and safe extension of respirator. Therefore, the AGA does not formally recommend this option. Despite these recommendations, it is unclear exactly how long N95 masks can be used and the best procedure for sterilizing them.
The AGA suggests that negative pressure rooms be used over the regular endoscopy rooms when available if performing any GI procedure in patients with known or presumptive COVID-19. This recommendation was based on primarily indirect evidence. A study conducted by Van Doremalen et al found that SARS-CoV-2 could remain viable in aerosol form for up to 3 hours, on copper surfaces for 4 hours, on cardboard surfaces up to 24 hours and on plastic and stainless steel surfaces for up to 72 hours in experimental models5. If negative pressure rooms are not available, portable high-efficiency particular air (HEPA) filters can be considered. The authors acknowledge that the use of negative pressure rooms for endoscopy may be challenging in certain institutions and overall workflow.
Finally within realm of the actual GI procedure, the AGA recommends using standard cleaning, disinfection and reprocessing protocols for all endoscopes regardless of COVID-19 status.
Triaging GI Procedures
Based on recent recommendations by the Surgeon General and American College of Surgeons along with the joint society statement by 4 GI societies to suspend all elective surgeries, determining which procedures to proceed with has become challenging for many6-7.
The AGA recommends that all procedures be reviewed and categorized as time-sensitive or not time-sensitive. Time-sensitive procedures are defined as procedures that if deferred, may negatively affect patient outcomes. Examples of time-sensitive procedures include those for the diagnosis and treatment of cholangitis or GI bleeding, concern for malignancy, new diagnosis of inflammatory bowel disease (IBD) or worsening IBD requiring potential treatment changes. The timeframe for time-sensitive procedures was broad, ranging from within 24 hours to up to 8 weeks. Limiting the number of procedures could lead to better utilization of PPE for HCWs and avoid unnecessary COVID-19 exposure to both patients and HCWs.
Most procedures that are not time-sensitive include those for screening and surveillance colonoscopies. Many physicians may be unclear as to how to proceed with patients who show positive fecal immunochemical test (FIT) or stool DNA tests based on the concern for potentially delaying a diagnosis of colorectal cancer; there is some data to support that delaying colonoscopy in patients with positive FIT testing up to 6 months will not negatively affect patient outcomes8.
Triaging patients for GI procedures during the COVID-19 pandemic will continue to be challenging, a fact which is acknowledged by the AGA authors. Each procedure needs to be evaluated on a case-by-case basis as it is consistently difficult to place all patients with the same indication into discrete categories. Some institutions are developing committees to review each endoscopic procedure and determine if it can be delayed.
Although the AGA recommendations do not specifically mention documentation, it is vital that the risks and benefits of either deferring or proceeding with the GI procedures are discussed with the patient and documented in the patient’s chart. Utilization of telehealth has been increasingly helpful in assisting with these discussions.
1. Pan L, Mu M, Ren HG, et al. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional multicenter study. Preprint. Am J Gastroenterol. Published online March 18, 2020.
2. Sultan S, Lim JK, Altayar O, et al. AGA Institute rapid recommendations for gastrointestinal procedures during the COVID-19 pandemic [published online April 1, 2020]. Gastroenterology. doi:10.1053/ j.gastro.2020.03.072
3. Offeddu V, Yung CF, Low M, Tam C. Effectiveness of masks and respirators against respiratory infections in healthcare workers: a systematic review and meta-analysis. Clin Infect Dis. 2017;65(11):1934-1942.
4. Tran K, Cimon K, Severn M, et al. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One. 2012;7(4):e35797.
5. Doremalen N, Morris D, Holbrook M, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1 [published online March 17, 2020]. N Engl J Med. doi:10.1056/NEJMc2004973
6. American College of Surgeons. COVID-19: recommendations for management of elective surgical procedures. Published online March 13, 2020. Accessed April 8, 2020.
7. American College of Gastroenterology. COVID-19 Clinical Insights for Our Community of Gastroenterologists and Gastroenterology Care Providers. Published online March 15, 2020. Accessed April 8, 2020.
8. Corley D, Jensen C, Quinn, et al. Association between time to colonoscopy after a positive fecal test result and risk of colorectal cancer and cancer stage at diagnosis. JAMA. 2017;317(16):1631-1641.