Digestive endoscopy during Covid-19 outbreak in Italy: a tertiary referral center experience

We read the letter by Zhang et al. on stepping up infection control measures in digestive endoscopy [1], which provided many interesting suggestions to minimize Covid-19 infection. We would like to offer some additional suggestions and advice derived from our Italian experience in a high-volume Covid-19 hospital and based on risk assessment by in-hospital and international infection control experts [2].

First, endoscopic procedures have been stratified into upper gastrointestinal (esophagogastroduodenoscopy, endoscopic retrograde cholangiopancreatography [ERCP], and endoscopic ultrasound), lower gastrointestinal (colonoscopy), and ambulatory visits in order to optimize resource use ([Fig. 1]). Currently, we are only performing urgent endoscopies and bedside visits, according to the availability of endoscopist experience. We also perform urgent endoscopies in high-risk patients (fever > 37.5 °C not related to other causes, respiratory symptoms); ambulatory visits for high-risk patients are generally postponed.

Fig. 1 Risk stratification for digestive endoscopy during the Covid-19 epidemic. FFP, filtering facepiece; GI, gastrointestinal.

For upper gastrointestinal endoscopies, the highest level of protection is provided because these procedures generate, coughing, sneezing, sputum, and subsequent droplets: double gloves, surgical gown, protective glasses, surgical cap, and filtering facepiece 2/3 (FFP-2/3) mask. Second operators (if needed) have a moderate level of protection because they are not in direct contact with the patient: standard gloves, single-use water-repellent gown, protective glasses, surgical cap, and FFP-2/3 mask.

For lower gastrointestinal endoscopies, a moderate level of protection is provided because of potential fecal-oral transmission (and viral presence in stools) [3]: standard gloves, single-use water-repellent gown, protective glasses, surgical cap, and FFP-1 mask. If the patient has a high risk (fever > 37.5 °C not related to other causes, respiratory symptoms), an FFP-2/3 mask is always used.

For ambulatory visits, a low level of protection is used, as shown in [Fig. 1].

For Covid-19 patients, endoscopies are preferably performed at the bedside, especially in our Emergency Department or in a dedicated double room setting as shown in [Fig. 2]. It is important to remember that sedation for endoscopy in Covid-19 patients requires special attention.

Fig. 2 Double-room setting to minimize Covid-19 spread during digestive endoscopy for positive patients. a The double room setting. b Dressing room with clean and unclean areas. c Endoscopy room.

Endoscopists alone could manage patients with 97 % oxygen saturation, respiratory rate of < 25 breaths/min, and PaO₂/FiO₂ > 300, while also remembering that respiratory depression can be caused by midazolam and meperidine.

For patients with < 97 % oxygen saturation, respiratory rate of > 25 breaths/min, PaO₂/FiO₂ < 300, and the presence of other risk factors (i. e. obesity, chronic obstructive pulmonary disease, age > 70 years), anesthesiologist assistance is required because these patients have a higher risk of acute respiratory failure. Anesthesiologist assistance is also important to reduce cough and sputum emissions; for this purpose, orotracheal intubation can be evaluated. The prone position (as in intensive care management) can improve the ventilation/perfusion ratio (Va/Q) and should be preferred in order to improve tissue oxygenation, especially for ERCP.

Following the precautions described above, between 22 February and 3 April, we performed 924 endoscopies (six Covid-19-positive patients) and no members of our digestive endoscopy team have reported symptoms.

Publication History

Article published online:
24 June 2020

• References

• 1 Zhang Y, Zhang X, Liu L. et al. Suggestions for infection prevention and control in digestive endoscopy during current 2019-nCoV pneumonia outbreak in Wuhan, Hubei province, China. Endoscopy 2020; 52: 312-314
• 2 Ang TL. Gastrointestinal endoscopy during COVID-19 pandemic. J Gastroenterol Hepatol 2020;
• 3 Gu J, Han B, Wang J. COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology 2020;