GASTROENTEROLOGY
Efficiencies in digestive disease diagnostics
The COVID-19 pandemic has brought many challenges for clinicians and supporting services that have driven the need to manage patients differently. Amanda Appleton and Emma Isom explain how the increased use of novel diagnostic solutions has helped to address capacity issues in gastroenterology, while enabling safe, remote care for vulnerable patients.
The onset of the pandemic caused widespread disruption to many clinical diagnostic pathways. Already overburdened endoscopy services faced considerable reductions, resulting in fewer procedures and, consequently, fewer diagnoses of colorectal cancer (CRC) and significant bowel disease. CRC is highly treatable if detected in its early stages1
and long-term quality of life is much improved following successful treatment. However, the waiting times for endoscopy have resulted, and still are resulting, in concerning delays to diagnosis.2
Therefore,
a supporting pathway is a necessary pre- requisite to alleviate pressure on the service and prioritise those with the most severe symptoms, for further investigation. In April 2020, the British Society of Gastroenterology (BSG) published guidance on endoscopy activity during COVID-19. It recommended that all endoscopy, except emergency and essential procedures, should be ceased immediately.3
In the first month of
the lockdown period in the UK, endoscopy activity had reduced to only 5% of normal activity.4 Rutter et al published data from the National Endoscopy Database which showed that ‘pre-COVID’ an average of 394 colorectal cancers were detected by colonoscopy and flexible sigmoidoscopy per week, whereas during COVID this decreased to an average of 112 cases per week.4 With these changes in the availability of endoscopy and the simultaneous limit on laboratory testing resources due to staff reallocations, steps were implemented to change the way in which patients were being investigated for colorectal cancer. New solutions had to be developed as those referred for CRC investigation faced increasing
Figure 1
waiting times. It became necessary to triage these patients to allocate resources more effectively.
Faecal Immunochemical Test In June 2020, an article in The Lancet for the BSG Endoscopy COVID working group,5 described how the faecal immunochemical test (FIT) could be used as a triage tool to guide the prioritisation of investigations. This would help in the management of the limited capacity of endoscopy departments during COVID-19. Prior to the pandemic, the role of FIT, in addition to screening for bowel
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cancer, was for the symptomatic assessment of primary care patients, as guided by NICE DG30.
However, with the reduction in services, FIT is now also being utilised for triaging patients on existing secondary care waiting lists and patients being referred under two- week-wait (2WW) pathways from primary care. Uptake for this has varied nationally with some areas of the UK seeing a large increase in FIT requests as the test becomes included in more pathways.
The faecal haemoglobin concentration detected by FIT is proportional to the risk
AUGUST 2021
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