Vijaya L. Rao, MD

A 35-year-old female with a complex psychiatric history and polysubstance use presents to the emergency department following ingestion of three sewing needles. The patient has a long history of multiple suicide attempts and foreign-body ingestions requiring repeated endoscopy. Prior ingestions include, but are not limited to, razor blades, screws, toothbrushes, batteries, plastic cutlery, and shower curtain rings. The patient has had over 50 upper endoscopies within the past year in addition to a laryngoscopy and bronchoscopy for retrieval of foreign bodies. Despite intensive inpatient psychiatric treatment and outpatient behavioral therapy, the patient continues to present with recurrent ingestions, creating frustration among multiple health care providers. Are gastroenterologists obligated to perform repeated endoscopies for recurrent foreign-body ingestions? Is there a point at which it would be medically and ethically appropriate to defer endoscopy in this clinical scenario?

Deliberate foreign-body ingestion (DFBI) is a psychological disorder in which patients swallow nonnutritive objects. The disorder is commonly seen in young female patients with psychiatric disorders.¹ It is also associated with substance abuse, intellectual disabilities, and malingering (such as external motivation to avoid jail). Of those with psychiatric disorders, repeat ingestions are primarily seen in patients with borderline personality disorder (BPD) or part of a syndrome of self-mutilation or attention-seeking behavior.² Patients with BPD are thought to have atrophic changes in the brain causing neurocognitive dysfunction accounting for such behaviors.¹ Self-injurious behavior is also associated with a history of abandonment and childhood abuse.³ Studies show that 85% of patients evaluated for DFBI have a prior psychiatric diagnosis and 84% of these patients have a history of prior ingestions.⁴

One of the fundamental principles of medical ethics is beneficence, supporting the notion that all providers should act in the best interest of the patient. Adults may make poor or self-destructive choices, but that does not preclude our moral obligation to treat them. Patients with substance abuse disorders may repeatedly use emergency room services for acute intoxication and overdose treatment. An emergency department physician would not withhold Narcan from a patient simply because of the frequency of repeated overdoses. A similar rationale could be applied to patients with DFBI – they should undergo endoscopy if they are accepting of the risks/benefits of repeated procedures. Given that this patient’s repeated ingestions are suicide attempts, it could be argued that not removing the object would make a clinician complicit with a patient’s suicide attempt or intent of self-harm.

From an alternative vantage point, patients with repeated DFBI have an increased risk of complications with repeated endoscopy, especially when performed emergently. Patients may have an increased risk of aspiration because of insufficient preoperative fasting, and attempted removal of ingested needles and other sharp objects carries a high risk of penetrating trauma, bleeding, and perforation. The patient’s swallowing history predicts a high likelihood of repeat ingestion which, over time, makes subsequent endoscopies seem futile. Endoscopic treatment does not address the underlying problem and only serves as a temporary fix to bridge the patient to their next ingestion. Furthermore, the utilization of resources is substantial – namely, the repeated emergency use of anesthesia and operating room and endoscopy staff, as well as the psychiatry, surgical, internal medicine, and gastroenterology services. Inevitably, treatment of a patient such as this diverts limited health care resources away from other patients who may have equally or more pressing medical needs.

Despite the seemingly futile nature of these procedures and strain on resources, it would be difficult from a medicolegal perspective to justify withholding endoscopy. In 1986, the Emergency Medical Treatment and Labor Act was enacted that requires anyone presenting to an emergency department to be stabilized and treated.⁷ In this particular patient case, an ethics consultation was obtained and recommended that the patient continue to undergo endoscopy. However, the team also suggested that a multidisciplinary meeting with ethics, the primary and procedural teams, and the hospital’s medicolegal department be held to further elucidate a plan for future admissions and to decide if or when it may be appropriate to withhold invasive procedures. This case was presented at our weekly gastroenterology grand rounds, and procedural guidelines were reviewed. Given the size and nature of most of the objects the patient ingests, we reviewed that it would be safe in the majority of scenarios to wait until the morning for removal if called overnight – providing some relief to those on call while minimizing utilization of emergency anesthesia resources as well as operating room and endoscopy staff.

Caring for these patients is challenging as providers may feel frustrated and angry after repeated admissions. The patient may sense the low morale from providers and feel judged for their actions. It is theorized that this leads to repeated ingestions as a defense mechanism and a means of acting out.¹ Additionally, friction can develop between teams as there is a common perception that psychiatry is not “doing enough” to treat the psychiatric disorder to prevent recurrences.⁸

In conclusion, DFBIs occur in a small number of patients with psychiatric disorders, but account for a large utilization of health care recourses. Gastroenterologists have an ethical and legal obligation to provide treatment including repeat endoscopies as long as the therapeutic benefit of the procedure outweighs risks. A multidisciplinary approach with individualized care plans can help prevent recurrent hospitalizations and procedures which may, in turn, improve outcomes and reduce health care costs.¹ Until the patient and clinicians can successfully mitigate the psychiatric and social factors perpetuating repeated ingestions, gastroenterologists will continue to provide endoscopic management. Individual cases should be discussed with the hospital’s ethics and medicolegal teams for further guidance on deferring endoscopic treatment in cases of medically refractory psychological disease.

Dr. Sims is a gastroenterology fellow in the section of gastroenterology, hepatology, and nutrition, department of internal medicine, University of Chicago Medicine. Dr. Rao is assistant professor in the section of gastroenterology, hepatology, and nutrition, department of internal medicine, University of Chicago Medicine. They had no conflicts of interest to disclose.

References

1. Bangash F et al. Cureus. 2021 Feb;13(2):e13179. doi: 10.7759/cureus.13179

2. Palese C et al. Gastroenterol Hepatol (N Y). 2012 July;8(7):485-6

3. Gitlin GF et al. Psychosomatics, 2007 March;48(2):162-6. doi: 10.1176/appi.psy.48.2.162

4. Palta R et al. Gastrointest Endosc. 2009 March;69(3):426-33. doi: 10.1016/j.gie.2008.05.072

5. Huang BL et al. Clin Gastroenterol Hepatol. 2010 Nov;8(11):941-6. doi: 10.1016/j.cgh.2010.07.013

6. Poynter BA et al. Gen Hosp Psychiatry. 2011 Sep-Oct;33(5):518-24. doi: 10.1016/j.genhosppsych.2011.06.011

7. American College of Emergency Physicians, EMTALA Fact Sheet. https://www.acep.org/life-as-a-physician/ethics--legal/emtala/emtala-fact-sheet/

8. Grzenda A. Carlat Hosp Psych Report. 2021 Jan;1(1 ):5-9

A 35-year-old female with a complex psychiatric history and polysubstance use presents to the emergency department following ingestion of three sewing needles. The patient has a long history of multiple suicide attempts and foreign-body ingestions requiring repeated endoscopy. Prior ingestions include, but are not limited to, razor blades, screws, toothbrushes, batteries, plastic cutlery, and shower curtain rings. The patient has had over 50 upper endoscopies within the past year in addition to a laryngoscopy and bronchoscopy for retrieval of foreign bodies. Despite intensive inpatient psychiatric treatment and outpatient behavioral therapy, the patient continues to present with recurrent ingestions, creating frustration among multiple health care providers. Are gastroenterologists obligated to perform repeated endoscopies for recurrent foreign-body ingestions? Is there a point at which it would be medically and ethically appropriate to defer endoscopy in this clinical scenario?

Deliberate foreign-body ingestion (DFBI) is a psychological disorder in which patients swallow nonnutritive objects. The disorder is commonly seen in young female patients with psychiatric disorders.¹ It is also associated with substance abuse, intellectual disabilities, and malingering (such as external motivation to avoid jail). Of those with psychiatric disorders, repeat ingestions are primarily seen in patients with borderline personality disorder (BPD) or part of a syndrome of self-mutilation or attention-seeking behavior.² Patients with BPD are thought to have atrophic changes in the brain causing neurocognitive dysfunction accounting for such behaviors.¹ Self-injurious behavior is also associated with a history of abandonment and childhood abuse.³ Studies show that 85% of patients evaluated for DFBI have a prior psychiatric diagnosis and 84% of these patients have a history of prior ingestions.⁴

One of the fundamental principles of medical ethics is beneficence, supporting the notion that all providers should act in the best interest of the patient. Adults may make poor or self-destructive choices, but that does not preclude our moral obligation to treat them. Patients with substance abuse disorders may repeatedly use emergency room services for acute intoxication and overdose treatment. An emergency department physician would not withhold Narcan from a patient simply because of the frequency of repeated overdoses. A similar rationale could be applied to patients with DFBI – they should undergo endoscopy if they are accepting of the risks/benefits of repeated procedures. Given that this patient’s repeated ingestions are suicide attempts, it could be argued that not removing the object would make a clinician complicit with a patient’s suicide attempt or intent of self-harm.

From an alternative vantage point, patients with repeated DFBI have an increased risk of complications with repeated endoscopy, especially when performed emergently. Patients may have an increased risk of aspiration because of insufficient preoperative fasting, and attempted removal of ingested needles and other sharp objects carries a high risk of penetrating trauma, bleeding, and perforation. The patient’s swallowing history predicts a high likelihood of repeat ingestion which, over time, makes subsequent endoscopies seem futile. Endoscopic treatment does not address the underlying problem and only serves as a temporary fix to bridge the patient to their next ingestion. Furthermore, the utilization of resources is substantial – namely, the repeated emergency use of anesthesia and operating room and endoscopy staff, as well as the psychiatry, surgical, internal medicine, and gastroenterology services. Inevitably, treatment of a patient such as this diverts limited health care resources away from other patients who may have equally or more pressing medical needs.

Despite the seemingly futile nature of these procedures and strain on resources, it would be difficult from a medicolegal perspective to justify withholding endoscopy. In 1986, the Emergency Medical Treatment and Labor Act was enacted that requires anyone presenting to an emergency department to be stabilized and treated.⁷ In this particular patient case, an ethics consultation was obtained and recommended that the patient continue to undergo endoscopy. However, the team also suggested that a multidisciplinary meeting with ethics, the primary and procedural teams, and the hospital’s medicolegal department be held to further elucidate a plan for future admissions and to decide if or when it may be appropriate to withhold invasive procedures. This case was presented at our weekly gastroenterology grand rounds, and procedural guidelines were reviewed. Given the size and nature of most of the objects the patient ingests, we reviewed that it would be safe in the majority of scenarios to wait until the morning for removal if called overnight – providing some relief to those on call while minimizing utilization of emergency anesthesia resources as well as operating room and endoscopy staff.

Caring for these patients is challenging as providers may feel frustrated and angry after repeated admissions. The patient may sense the low morale from providers and feel judged for their actions. It is theorized that this leads to repeated ingestions as a defense mechanism and a means of acting out.¹ Additionally, friction can develop between teams as there is a common perception that psychiatry is not “doing enough” to treat the psychiatric disorder to prevent recurrences.⁸

In conclusion, DFBIs occur in a small number of patients with psychiatric disorders, but account for a large utilization of health care recourses. Gastroenterologists have an ethical and legal obligation to provide treatment including repeat endoscopies as long as the therapeutic benefit of the procedure outweighs risks. A multidisciplinary approach with individualized care plans can help prevent recurrent hospitalizations and procedures which may, in turn, improve outcomes and reduce health care costs.¹ Until the patient and clinicians can successfully mitigate the psychiatric and social factors perpetuating repeated ingestions, gastroenterologists will continue to provide endoscopic management. Individual cases should be discussed with the hospital’s ethics and medicolegal teams for further guidance on deferring endoscopic treatment in cases of medically refractory psychological disease.

Dr. Sims is a gastroenterology fellow in the section of gastroenterology, hepatology, and nutrition, department of internal medicine, University of Chicago Medicine. Dr. Rao is assistant professor in the section of gastroenterology, hepatology, and nutrition, department of internal medicine, University of Chicago Medicine. They had no conflicts of interest to disclose.

References

1. Bangash F et al. Cureus. 2021 Feb;13(2):e13179. doi: 10.7759/cureus.13179

2. Palese C et al. Gastroenterol Hepatol (N Y). 2012 July;8(7):485-6

3. Gitlin GF et al. Psychosomatics, 2007 March;48(2):162-6. doi: 10.1176/appi.psy.48.2.162

4. Palta R et al. Gastrointest Endosc. 2009 March;69(3):426-33. doi: 10.1016/j.gie.2008.05.072

5. Huang BL et al. Clin Gastroenterol Hepatol. 2010 Nov;8(11):941-6. doi: 10.1016/j.cgh.2010.07.013

6. Poynter BA et al. Gen Hosp Psychiatry. 2011 Sep-Oct;33(5):518-24. doi: 10.1016/j.genhosppsych.2011.06.011

7. American College of Emergency Physicians, EMTALA Fact Sheet. https://www.acep.org/life-as-a-physician/ethics--legal/emtala/emtala-fact-sheet/

8. Grzenda A. Carlat Hosp Psych Report. 2021 Jan;1(1 ):5-9

A 35-year-old female with a complex psychiatric history and polysubstance use presents to the emergency department following ingestion of three sewing needles. The patient has a long history of multiple suicide attempts and foreign-body ingestions requiring repeated endoscopy. Prior ingestions include, but are not limited to, razor blades, screws, toothbrushes, batteries, plastic cutlery, and shower curtain rings. The patient has had over 50 upper endoscopies within the past year in addition to a laryngoscopy and bronchoscopy for retrieval of foreign bodies. Despite intensive inpatient psychiatric treatment and outpatient behavioral therapy, the patient continues to present with recurrent ingestions, creating frustration among multiple health care providers. Are gastroenterologists obligated to perform repeated endoscopies for recurrent foreign-body ingestions? Is there a point at which it would be medically and ethically appropriate to defer endoscopy in this clinical scenario?

Deliberate foreign-body ingestion (DFBI) is a psychological disorder in which patients swallow nonnutritive objects. The disorder is commonly seen in young female patients with psychiatric disorders.¹ It is also associated with substance abuse, intellectual disabilities, and malingering (such as external motivation to avoid jail). Of those with psychiatric disorders, repeat ingestions are primarily seen in patients with borderline personality disorder (BPD) or part of a syndrome of self-mutilation or attention-seeking behavior.² Patients with BPD are thought to have atrophic changes in the brain causing neurocognitive dysfunction accounting for such behaviors.¹ Self-injurious behavior is also associated with a history of abandonment and childhood abuse.³ Studies show that 85% of patients evaluated for DFBI have a prior psychiatric diagnosis and 84% of these patients have a history of prior ingestions.⁴

One of the fundamental principles of medical ethics is beneficence, supporting the notion that all providers should act in the best interest of the patient. Adults may make poor or self-destructive choices, but that does not preclude our moral obligation to treat them. Patients with substance abuse disorders may repeatedly use emergency room services for acute intoxication and overdose treatment. An emergency department physician would not withhold Narcan from a patient simply because of the frequency of repeated overdoses. A similar rationale could be applied to patients with DFBI – they should undergo endoscopy if they are accepting of the risks/benefits of repeated procedures. Given that this patient’s repeated ingestions are suicide attempts, it could be argued that not removing the object would make a clinician complicit with a patient’s suicide attempt or intent of self-harm.

From an alternative vantage point, patients with repeated DFBI have an increased risk of complications with repeated endoscopy, especially when performed emergently. Patients may have an increased risk of aspiration because of insufficient preoperative fasting, and attempted removal of ingested needles and other sharp objects carries a high risk of penetrating trauma, bleeding, and perforation. The patient’s swallowing history predicts a high likelihood of repeat ingestion which, over time, makes subsequent endoscopies seem futile. Endoscopic treatment does not address the underlying problem and only serves as a temporary fix to bridge the patient to their next ingestion. Furthermore, the utilization of resources is substantial – namely, the repeated emergency use of anesthesia and operating room and endoscopy staff, as well as the psychiatry, surgical, internal medicine, and gastroenterology services. Inevitably, treatment of a patient such as this diverts limited health care resources away from other patients who may have equally or more pressing medical needs.

Despite the seemingly futile nature of these procedures and strain on resources, it would be difficult from a medicolegal perspective to justify withholding endoscopy. In 1986, the Emergency Medical Treatment and Labor Act was enacted that requires anyone presenting to an emergency department to be stabilized and treated.⁷ In this particular patient case, an ethics consultation was obtained and recommended that the patient continue to undergo endoscopy. However, the team also suggested that a multidisciplinary meeting with ethics, the primary and procedural teams, and the hospital’s medicolegal department be held to further elucidate a plan for future admissions and to decide if or when it may be appropriate to withhold invasive procedures. This case was presented at our weekly gastroenterology grand rounds, and procedural guidelines were reviewed. Given the size and nature of most of the objects the patient ingests, we reviewed that it would be safe in the majority of scenarios to wait until the morning for removal if called overnight – providing some relief to those on call while minimizing utilization of emergency anesthesia resources as well as operating room and endoscopy staff.

Caring for these patients is challenging as providers may feel frustrated and angry after repeated admissions. The patient may sense the low morale from providers and feel judged for their actions. It is theorized that this leads to repeated ingestions as a defense mechanism and a means of acting out.¹ Additionally, friction can develop between teams as there is a common perception that psychiatry is not “doing enough” to treat the psychiatric disorder to prevent recurrences.⁸

In conclusion, DFBIs occur in a small number of patients with psychiatric disorders, but account for a large utilization of health care recourses. Gastroenterologists have an ethical and legal obligation to provide treatment including repeat endoscopies as long as the therapeutic benefit of the procedure outweighs risks. A multidisciplinary approach with individualized care plans can help prevent recurrent hospitalizations and procedures which may, in turn, improve outcomes and reduce health care costs.¹ Until the patient and clinicians can successfully mitigate the psychiatric and social factors perpetuating repeated ingestions, gastroenterologists will continue to provide endoscopic management. Individual cases should be discussed with the hospital’s ethics and medicolegal teams for further guidance on deferring endoscopic treatment in cases of medically refractory psychological disease.

Dr. Sims is a gastroenterology fellow in the section of gastroenterology, hepatology, and nutrition, department of internal medicine, University of Chicago Medicine. Dr. Rao is assistant professor in the section of gastroenterology, hepatology, and nutrition, department of internal medicine, University of Chicago Medicine. They had no conflicts of interest to disclose.

References

1. Bangash F et al. Cureus. 2021 Feb;13(2):e13179. doi: 10.7759/cureus.13179

2. Palese C et al. Gastroenterol Hepatol (N Y). 2012 July;8(7):485-6

3. Gitlin GF et al. Psychosomatics, 2007 March;48(2):162-6. doi: 10.1176/appi.psy.48.2.162

4. Palta R et al. Gastrointest Endosc. 2009 March;69(3):426-33. doi: 10.1016/j.gie.2008.05.072

5. Huang BL et al. Clin Gastroenterol Hepatol. 2010 Nov;8(11):941-6. doi: 10.1016/j.cgh.2010.07.013

6. Poynter BA et al. Gen Hosp Psychiatry. 2011 Sep-Oct;33(5):518-24. doi: 10.1016/j.genhosppsych.2011.06.011

7. American College of Emergency Physicians, EMTALA Fact Sheet. https://www.acep.org/life-as-a-physician/ethics--legal/emtala/emtala-fact-sheet/

8. Grzenda A. Carlat Hosp Psych Report. 2021 Jan;1(1 ):5-9

What is coronavirus disease 2019 (COVID-19)?

COVID-19 is a viral respiratory illness that can be potentially life-threatening and is caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-COV-2). The constellation of symptoms varies in severity but most often includes fever, fatigue, myalgias, cough, and dyspnea. Digestive symptoms such as anorexia, nausea, and diarrhea have also been reported.¹ The incubation period of the virus appears to range from 1 to 14 days, most commonly between 3 and 7 days.² The virus is characterized by its efficient person-to-person transmission, with each case leading to 1.4-3.9 additional infected individuals on average, which has led to a global pandemic and one of the most significant public health crises in modern history.

What are the most vulnerable patient populations within a typical gastroenterology practice?

While the virus can affect anyone, and there are increasing reports of young individuals requiring intensive care, older patients are thought to be at the highest risk for severe disease – particularly those older than age 60 years. Those who developed disease requiring admission to an ICU in Wuhan, China, had a median age of 66 years with comorbid conditions including hypertension, diabetes, and cardiovascular and cerebrovascular disease.³ In addition to these, the Centers for Disease Control and Prevention identifies those who live in a nursing home or long-term care facility to be at high risk, and patients with chronic lung disease, severe obesity, renal failure, or liver disease also may be at increased risk.⁴ There is often a question if patients on immunosuppression, such as those with inflammatory bowel disease, are at increased risk for the development of infection. At the time of writing, there are not available data that demonstrate this association. Regarding pregnant and lactating women, limited studies done on pregnant patients with COVID-19 revealed that the virus was not transmitted to the fetus in later stages of pregnancy or into breast milk.⁵ As there is much that has yet to be clearly elucidated, it is prudent to recommend that all patients adhere to social distancing guidelines (including working from home when possible) as well as frequent and thorough hand washing, avoidance of touching one’s face, and avoidance of sick contacts.
 

Can COVID-19 present with gastrointestinal symptoms?

While initial reports did not describe this as a common presentation, a subsequent multicenter study out of the Hubei province in China reported that nearly half of all patients in the study with COVID-19 had one or more digestive symptoms as their chief complaint. Of note, the study cited the most common digestive complaint as anorexia, which is not necessarily specific to the gastrointestinal tract. Twenty percent of the patients in their cohort did report either abdominal pain, vomiting, or diarrhea.^1,6 The majority had concomitant respiratory symptoms, though a small minority (7%) had digestive symptoms only. In patients reporting diarrhea, it was not described as high volume or clinically severe, but the digestive symptoms worsened with severity of the overall disease. Interestingly, the first patient with COVID-19 in the United States presented with nausea, vomiting, and diarrhea; ultimately, stool and respiratory specimens tested positive for the virus. This has led to the question of fecal-oral transmission in addition to, or in lieu of, aerosolization, which has been thought to be the primary mode of transmission.⁷ There have also been increasing reports of ageusia and anosmia, sometimes as the presenting complaint.⁸ More data are certainly needed; however, the possibility of gastrointestinal symptoms as a manifestation of COVID-19 and of fecal-oral transmission should be kept in mind when evaluating patients and performing procedures.
 

What kind of personal protective equipment (PPE) should I wear while performing endoscopy?

An early publication from Italy suggested a risk-stratification system in order to dictate the type of PPE to wear for endoscopy; however, official recommendations from the American Gastroenterological Association (AGA) have since emerged.^9,10 For both upper and lower endoscopic procedures, regardless of COVID-19 status, it is recommended to wear a respirator mask, which is specifically designed to block aerosols (N95, N99, or powered air purifying respirator). Given that upper endoscopic procedures are aerosol-generating procedures and there is a theoretic risk to aerosolization during colonoscopy (especially during insertion of instruments through the biopsy channel), respirator masks will provide the most protection to the endoscopist. In addition, the presence of SARS-CoV-2 RNA in fecal samples, although of unclear clinical significance at this time, led to the recommended use of respirators for lower endoscopic procedures as well.

Furthermore, endoscopists should double-glove for all endoscopic procedures in order to reduce viral transmission from contaminated PPE to hands or clothing. Also, in known or presumptive COVID-19 positive patients, negative pressure rooms for endoscopy should be utilized when available.¹⁰

If I have been exposed or if I develop symptoms suspicious for COVID-19, what should I do?

First and foremost, a health care provider should reach out to their physician as well as department leadership if in either situation. The CDC recommends immediate self-quarantine if there is any suspicion you may have COVID-19 to minimize further person-to-person transmission.¹¹ This means staying home from work, avoiding public places, and if possible, separating yourself from others in your home. The decision for testing may be individualized based on regional availability of tests, nature of exposure, or severity of symptoms. Many institutions have a sick health care worker triage number in place to advise further. Be cognizant of your symptoms, particularly your respiratory status, and if your condition appears to be worsening seek prompt medical attention and, if possible, call ahead to facilitate being triaged appropriately upon arrival.
 

As a trainee, how can I minimize my risk while continuing medical education?

Most institutions are implementing ways to minimize exposure of trainees to patients. Ways of doing so include limiting the number of individuals on bedside rounds, providing consultative care and recommendations remotely, conducting team discussions of patients remotely, avoiding workrooms or common areas, and practicing social distancing at the hospital. Some institutions are also consolidating inpatient fellows/services in order to limit fellow time in the hospital, recommending against fellow participation in endoscopy and in-person ambulatory care in order to protect fellows as well as preserve PPE. The reduction in in-person clinical care should be tempered by continuing to prioritize medical education during this time. Fellows can still be involved in an outpatient clinic setting by conducting virtual visits and engaging in telehealth, as many specialties are instituting. Furthermore, clinical conferences, board reviews, and journal club can still be conducted through digital platforms and remain interactive. Trainees can also wisely utilize this unexpected period away from the hospital to complete research projects, case reports, and review articles, thereby strengthening resumes for upcoming job searches or advanced fellowship applications.


To engage in more discussion on how to navigate educational activities in fellowship at this time, visit the AGA community.

To learn more about COVID-19 and its implications for gastroenterologists, visit the AGA university site which features helpful educational modules.

Lastly, the Joint GI Society message on COVID-19 can be found here.


 

References

1. Pan L et al. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional, multicenter study. Am J Gastro. 2020. doi: 10.14309/ajg.0000000000000620.

2. Huang C et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497-506.

3. Wang D et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. JAMA. 2020 Feb 7;323(11):1061-9.

4. Centers for Disease Control and Prevention. Information for Healthcare Professionals: COVID-19 and Underlying Conditions. Accessed March 22, 2020.

5. Schwartz DA. An analysis of 38 pregnant women with COVID-19, their newborn infants, and maternal-fetal transmission of SARS-CoV-2: Maternal coronavirus infections and pregnancy outcomes. Arch Pathol Lab Med. 2020. doi: 10.5858/arpa.2020-0901-SA.

6. Guan W et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020 Feb 28. doi: 10.1056/NEJMoa2002032.

7. Gu J et al. COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology. 2020 Mar 3. doi: 10.1053/j.gastro.2020.02.054.

8. The New York Times. Roni Caryn Rabin, “Lost Sense of Smell May Be a Clue to Coronavirus Infection.” Accessed March 24, 2020.

9. Repici A et al. Coronavirus (COVID-19) outbreak: What the department of endoscopy should know. Gastrointest Endosc. 2020 Mar 14. doi: 10.1016/j.gie.2020.03.019.

10. Sultan S et al. AGA Institute rapid recommendations for gastrointestinal procedures during the COVID-19 pandemic. Gastroenterology. 2020 Mar 31. doi: 10.1053/j.gastro.2020.03.072.

11. Centers for Disease Control and Prevention. COVID-19: What to do if you are sick. Accessed March 22, 2020.

Dr. V.L. Rao is assistant professor of medicine, section of gastroenterology, hepatology, nutrition, department of internal medicine, University of Chicago Medicine; Dr. K. Rao is assistant professor, division of infectious diseases, department of internal medicine, University of Michigan Medical School, Ann Arbor.

What is coronavirus disease 2019 (COVID-19)?

COVID-19 is a viral respiratory illness that can be potentially life-threatening and is caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-COV-2). The constellation of symptoms varies in severity but most often includes fever, fatigue, myalgias, cough, and dyspnea. Digestive symptoms such as anorexia, nausea, and diarrhea have also been reported.¹ The incubation period of the virus appears to range from 1 to 14 days, most commonly between 3 and 7 days.² The virus is characterized by its efficient person-to-person transmission, with each case leading to 1.4-3.9 additional infected individuals on average, which has led to a global pandemic and one of the most significant public health crises in modern history.

What are the most vulnerable patient populations within a typical gastroenterology practice?

While the virus can affect anyone, and there are increasing reports of young individuals requiring intensive care, older patients are thought to be at the highest risk for severe disease – particularly those older than age 60 years. Those who developed disease requiring admission to an ICU in Wuhan, China, had a median age of 66 years with comorbid conditions including hypertension, diabetes, and cardiovascular and cerebrovascular disease.³ In addition to these, the Centers for Disease Control and Prevention identifies those who live in a nursing home or long-term care facility to be at high risk, and patients with chronic lung disease, severe obesity, renal failure, or liver disease also may be at increased risk.⁴ There is often a question if patients on immunosuppression, such as those with inflammatory bowel disease, are at increased risk for the development of infection. At the time of writing, there are not available data that demonstrate this association. Regarding pregnant and lactating women, limited studies done on pregnant patients with COVID-19 revealed that the virus was not transmitted to the fetus in later stages of pregnancy or into breast milk.⁵ As there is much that has yet to be clearly elucidated, it is prudent to recommend that all patients adhere to social distancing guidelines (including working from home when possible) as well as frequent and thorough hand washing, avoidance of touching one’s face, and avoidance of sick contacts.
 

Can COVID-19 present with gastrointestinal symptoms?

While initial reports did not describe this as a common presentation, a subsequent multicenter study out of the Hubei province in China reported that nearly half of all patients in the study with COVID-19 had one or more digestive symptoms as their chief complaint. Of note, the study cited the most common digestive complaint as anorexia, which is not necessarily specific to the gastrointestinal tract. Twenty percent of the patients in their cohort did report either abdominal pain, vomiting, or diarrhea.^1,6 The majority had concomitant respiratory symptoms, though a small minority (7%) had digestive symptoms only. In patients reporting diarrhea, it was not described as high volume or clinically severe, but the digestive symptoms worsened with severity of the overall disease. Interestingly, the first patient with COVID-19 in the United States presented with nausea, vomiting, and diarrhea; ultimately, stool and respiratory specimens tested positive for the virus. This has led to the question of fecal-oral transmission in addition to, or in lieu of, aerosolization, which has been thought to be the primary mode of transmission.⁷ There have also been increasing reports of ageusia and anosmia, sometimes as the presenting complaint.⁸ More data are certainly needed; however, the possibility of gastrointestinal symptoms as a manifestation of COVID-19 and of fecal-oral transmission should be kept in mind when evaluating patients and performing procedures.
 

What kind of personal protective equipment (PPE) should I wear while performing endoscopy?

An early publication from Italy suggested a risk-stratification system in order to dictate the type of PPE to wear for endoscopy; however, official recommendations from the American Gastroenterological Association (AGA) have since emerged.^9,10 For both upper and lower endoscopic procedures, regardless of COVID-19 status, it is recommended to wear a respirator mask, which is specifically designed to block aerosols (N95, N99, or powered air purifying respirator). Given that upper endoscopic procedures are aerosol-generating procedures and there is a theoretic risk to aerosolization during colonoscopy (especially during insertion of instruments through the biopsy channel), respirator masks will provide the most protection to the endoscopist. In addition, the presence of SARS-CoV-2 RNA in fecal samples, although of unclear clinical significance at this time, led to the recommended use of respirators for lower endoscopic procedures as well.

Furthermore, endoscopists should double-glove for all endoscopic procedures in order to reduce viral transmission from contaminated PPE to hands or clothing. Also, in known or presumptive COVID-19 positive patients, negative pressure rooms for endoscopy should be utilized when available.¹⁰

If I have been exposed or if I develop symptoms suspicious for COVID-19, what should I do?

First and foremost, a health care provider should reach out to their physician as well as department leadership if in either situation. The CDC recommends immediate self-quarantine if there is any suspicion you may have COVID-19 to minimize further person-to-person transmission.¹¹ This means staying home from work, avoiding public places, and if possible, separating yourself from others in your home. The decision for testing may be individualized based on regional availability of tests, nature of exposure, or severity of symptoms. Many institutions have a sick health care worker triage number in place to advise further. Be cognizant of your symptoms, particularly your respiratory status, and if your condition appears to be worsening seek prompt medical attention and, if possible, call ahead to facilitate being triaged appropriately upon arrival.
 

As a trainee, how can I minimize my risk while continuing medical education?

Most institutions are implementing ways to minimize exposure of trainees to patients. Ways of doing so include limiting the number of individuals on bedside rounds, providing consultative care and recommendations remotely, conducting team discussions of patients remotely, avoiding workrooms or common areas, and practicing social distancing at the hospital. Some institutions are also consolidating inpatient fellows/services in order to limit fellow time in the hospital, recommending against fellow participation in endoscopy and in-person ambulatory care in order to protect fellows as well as preserve PPE. The reduction in in-person clinical care should be tempered by continuing to prioritize medical education during this time. Fellows can still be involved in an outpatient clinic setting by conducting virtual visits and engaging in telehealth, as many specialties are instituting. Furthermore, clinical conferences, board reviews, and journal club can still be conducted through digital platforms and remain interactive. Trainees can also wisely utilize this unexpected period away from the hospital to complete research projects, case reports, and review articles, thereby strengthening resumes for upcoming job searches or advanced fellowship applications.


To engage in more discussion on how to navigate educational activities in fellowship at this time, visit the AGA community.

To learn more about COVID-19 and its implications for gastroenterologists, visit the AGA university site which features helpful educational modules.

Lastly, the Joint GI Society message on COVID-19 can be found here.


 

References

1. Pan L et al. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional, multicenter study. Am J Gastro. 2020. doi: 10.14309/ajg.0000000000000620.

2. Huang C et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497-506.

3. Wang D et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. JAMA. 2020 Feb 7;323(11):1061-9.

4. Centers for Disease Control and Prevention. Information for Healthcare Professionals: COVID-19 and Underlying Conditions. Accessed March 22, 2020.

5. Schwartz DA. An analysis of 38 pregnant women with COVID-19, their newborn infants, and maternal-fetal transmission of SARS-CoV-2: Maternal coronavirus infections and pregnancy outcomes. Arch Pathol Lab Med. 2020. doi: 10.5858/arpa.2020-0901-SA.

6. Guan W et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020 Feb 28. doi: 10.1056/NEJMoa2002032.

7. Gu J et al. COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology. 2020 Mar 3. doi: 10.1053/j.gastro.2020.02.054.

8. The New York Times. Roni Caryn Rabin, “Lost Sense of Smell May Be a Clue to Coronavirus Infection.” Accessed March 24, 2020.

9. Repici A et al. Coronavirus (COVID-19) outbreak: What the department of endoscopy should know. Gastrointest Endosc. 2020 Mar 14. doi: 10.1016/j.gie.2020.03.019.

10. Sultan S et al. AGA Institute rapid recommendations for gastrointestinal procedures during the COVID-19 pandemic. Gastroenterology. 2020 Mar 31. doi: 10.1053/j.gastro.2020.03.072.

11. Centers for Disease Control and Prevention. COVID-19: What to do if you are sick. Accessed March 22, 2020.

Dr. V.L. Rao is assistant professor of medicine, section of gastroenterology, hepatology, nutrition, department of internal medicine, University of Chicago Medicine; Dr. K. Rao is assistant professor, division of infectious diseases, department of internal medicine, University of Michigan Medical School, Ann Arbor.

What is coronavirus disease 2019 (COVID-19)?

COVID-19 is a viral respiratory illness that can be potentially life-threatening and is caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-COV-2). The constellation of symptoms varies in severity but most often includes fever, fatigue, myalgias, cough, and dyspnea. Digestive symptoms such as anorexia, nausea, and diarrhea have also been reported.¹ The incubation period of the virus appears to range from 1 to 14 days, most commonly between 3 and 7 days.² The virus is characterized by its efficient person-to-person transmission, with each case leading to 1.4-3.9 additional infected individuals on average, which has led to a global pandemic and one of the most significant public health crises in modern history.

What are the most vulnerable patient populations within a typical gastroenterology practice?

While the virus can affect anyone, and there are increasing reports of young individuals requiring intensive care, older patients are thought to be at the highest risk for severe disease – particularly those older than age 60 years. Those who developed disease requiring admission to an ICU in Wuhan, China, had a median age of 66 years with comorbid conditions including hypertension, diabetes, and cardiovascular and cerebrovascular disease.³ In addition to these, the Centers for Disease Control and Prevention identifies those who live in a nursing home or long-term care facility to be at high risk, and patients with chronic lung disease, severe obesity, renal failure, or liver disease also may be at increased risk.⁴ There is often a question if patients on immunosuppression, such as those with inflammatory bowel disease, are at increased risk for the development of infection. At the time of writing, there are not available data that demonstrate this association. Regarding pregnant and lactating women, limited studies done on pregnant patients with COVID-19 revealed that the virus was not transmitted to the fetus in later stages of pregnancy or into breast milk.⁵ As there is much that has yet to be clearly elucidated, it is prudent to recommend that all patients adhere to social distancing guidelines (including working from home when possible) as well as frequent and thorough hand washing, avoidance of touching one’s face, and avoidance of sick contacts.
 

Can COVID-19 present with gastrointestinal symptoms?

While initial reports did not describe this as a common presentation, a subsequent multicenter study out of the Hubei province in China reported that nearly half of all patients in the study with COVID-19 had one or more digestive symptoms as their chief complaint. Of note, the study cited the most common digestive complaint as anorexia, which is not necessarily specific to the gastrointestinal tract. Twenty percent of the patients in their cohort did report either abdominal pain, vomiting, or diarrhea.^1,6 The majority had concomitant respiratory symptoms, though a small minority (7%) had digestive symptoms only. In patients reporting diarrhea, it was not described as high volume or clinically severe, but the digestive symptoms worsened with severity of the overall disease. Interestingly, the first patient with COVID-19 in the United States presented with nausea, vomiting, and diarrhea; ultimately, stool and respiratory specimens tested positive for the virus. This has led to the question of fecal-oral transmission in addition to, or in lieu of, aerosolization, which has been thought to be the primary mode of transmission.⁷ There have also been increasing reports of ageusia and anosmia, sometimes as the presenting complaint.⁸ More data are certainly needed; however, the possibility of gastrointestinal symptoms as a manifestation of COVID-19 and of fecal-oral transmission should be kept in mind when evaluating patients and performing procedures.
 

What kind of personal protective equipment (PPE) should I wear while performing endoscopy?

An early publication from Italy suggested a risk-stratification system in order to dictate the type of PPE to wear for endoscopy; however, official recommendations from the American Gastroenterological Association (AGA) have since emerged.^9,10 For both upper and lower endoscopic procedures, regardless of COVID-19 status, it is recommended to wear a respirator mask, which is specifically designed to block aerosols (N95, N99, or powered air purifying respirator). Given that upper endoscopic procedures are aerosol-generating procedures and there is a theoretic risk to aerosolization during colonoscopy (especially during insertion of instruments through the biopsy channel), respirator masks will provide the most protection to the endoscopist. In addition, the presence of SARS-CoV-2 RNA in fecal samples, although of unclear clinical significance at this time, led to the recommended use of respirators for lower endoscopic procedures as well.

Furthermore, endoscopists should double-glove for all endoscopic procedures in order to reduce viral transmission from contaminated PPE to hands or clothing. Also, in known or presumptive COVID-19 positive patients, negative pressure rooms for endoscopy should be utilized when available.¹⁰

If I have been exposed or if I develop symptoms suspicious for COVID-19, what should I do?

First and foremost, a health care provider should reach out to their physician as well as department leadership if in either situation. The CDC recommends immediate self-quarantine if there is any suspicion you may have COVID-19 to minimize further person-to-person transmission.¹¹ This means staying home from work, avoiding public places, and if possible, separating yourself from others in your home. The decision for testing may be individualized based on regional availability of tests, nature of exposure, or severity of symptoms. Many institutions have a sick health care worker triage number in place to advise further. Be cognizant of your symptoms, particularly your respiratory status, and if your condition appears to be worsening seek prompt medical attention and, if possible, call ahead to facilitate being triaged appropriately upon arrival.
 

As a trainee, how can I minimize my risk while continuing medical education?

Most institutions are implementing ways to minimize exposure of trainees to patients. Ways of doing so include limiting the number of individuals on bedside rounds, providing consultative care and recommendations remotely, conducting team discussions of patients remotely, avoiding workrooms or common areas, and practicing social distancing at the hospital. Some institutions are also consolidating inpatient fellows/services in order to limit fellow time in the hospital, recommending against fellow participation in endoscopy and in-person ambulatory care in order to protect fellows as well as preserve PPE. The reduction in in-person clinical care should be tempered by continuing to prioritize medical education during this time. Fellows can still be involved in an outpatient clinic setting by conducting virtual visits and engaging in telehealth, as many specialties are instituting. Furthermore, clinical conferences, board reviews, and journal club can still be conducted through digital platforms and remain interactive. Trainees can also wisely utilize this unexpected period away from the hospital to complete research projects, case reports, and review articles, thereby strengthening resumes for upcoming job searches or advanced fellowship applications.


To engage in more discussion on how to navigate educational activities in fellowship at this time, visit the AGA community.

To learn more about COVID-19 and its implications for gastroenterologists, visit the AGA university site which features helpful educational modules.

Lastly, the Joint GI Society message on COVID-19 can be found here.


 

References

1. Pan L et al. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional, multicenter study. Am J Gastro. 2020. doi: 10.14309/ajg.0000000000000620.

2. Huang C et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497-506.

3. Wang D et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. JAMA. 2020 Feb 7;323(11):1061-9.

4. Centers for Disease Control and Prevention. Information for Healthcare Professionals: COVID-19 and Underlying Conditions. Accessed March 22, 2020.

5. Schwartz DA. An analysis of 38 pregnant women with COVID-19, their newborn infants, and maternal-fetal transmission of SARS-CoV-2: Maternal coronavirus infections and pregnancy outcomes. Arch Pathol Lab Med. 2020. doi: 10.5858/arpa.2020-0901-SA.

6. Guan W et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020 Feb 28. doi: 10.1056/NEJMoa2002032.

7. Gu J et al. COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology. 2020 Mar 3. doi: 10.1053/j.gastro.2020.02.054.

8. The New York Times. Roni Caryn Rabin, “Lost Sense of Smell May Be a Clue to Coronavirus Infection.” Accessed March 24, 2020.

9. Repici A et al. Coronavirus (COVID-19) outbreak: What the department of endoscopy should know. Gastrointest Endosc. 2020 Mar 14. doi: 10.1016/j.gie.2020.03.019.

10. Sultan S et al. AGA Institute rapid recommendations for gastrointestinal procedures during the COVID-19 pandemic. Gastroenterology. 2020 Mar 31. doi: 10.1053/j.gastro.2020.03.072.

11. Centers for Disease Control and Prevention. COVID-19: What to do if you are sick. Accessed March 22, 2020.

Dr. V.L. Rao is assistant professor of medicine, section of gastroenterology, hepatology, nutrition, department of internal medicine, University of Chicago Medicine; Dr. K. Rao is assistant professor, division of infectious diseases, department of internal medicine, University of Michigan Medical School, Ann Arbor.