Endoscopy During the COVID-19 Lockdown

The Problem

What do you do when you feel unwell and need an endoscopy? A patient contacted me today. She has been suffering with upper abdominal pain, with burning in her chest, regurgitation of food and central abdominal discomfort but also with pale stools and diarrhoea. Not surprisingly she has lost 3kg in weight in a month.  Her GP prescribed omeprazole but this has not helped. She has been to accident and emergency (A/E) twice already.

What Should She Do?

In normal times, she would have had an endoscopy and indeed her GP has referred her to her local NHS hospital for this. But unfortunately, this severity of symptoms is not currently deemed adequate to require endoscopy. Why? Because the risk of developing COVID-19 from coming to hospital is currently quite high. But also because of the current lack of personal protective equipment (PPE). PPE needs to be conserved for the highest risk environments. Endoscopy is an ‘aerosol generating procedure’ and as such, all medical staff present in the room need to wear full PPE for even the simplest procedure. It is commonly reported in the news just how stretched PPE supplies are at present, so it is no surprise that we are now very careful about doing procedures that we would normally do without thinking twice.

What Should I Do?

So what can I do for this poor woman? Well the first thing is to take a very careful history so that I can try and work out the most likely problem.  Luckily for me she has already had an abdominal ultrasound scan and I know that gallstones are not the cause of her problems. Her blood tests from A/E suggest that she doesn’t have severe infection. The story is made little easier because she is only in her thirties. This makes cancer very unlikely.

What Will I Do?

So I’m going to rely on some simple rules of thumb. Firstly, the dose of omeprazole that she has been given is amongst the lowest possible at 20 milligrams once daily. She was also prescribed lansoprazole 15 milligrams once daily to take instead.  There is really no difference between either of these two medicines at these doses. The big problem is that they only work for about 12 hours to stop acid production in the stomach. If she has acid reflux, or a stomach ulcer , she might need a higher dose of medicine. Rather than taking 40 milligrams of omeprazole once a day, she would be better off taking 20 milligrams twice daily. That would suppress stomach acid production both day and night.

But she has being feeling ill for weeks and so I’m going to give her 40mg omeprazole twice daily for two weeks to try and give her an immediate symptom relief.  She can then reduce to 20 milligrams twice daily and if she is lucky she will have her endoscopy within the next 4 weeks or so.

Remember, there may be more than one thing going on…

I have one other concern and that is the diarrhoea. Perhaps she has inflammation in the bowel. Mesalazine works as an anti-inflammatory which has direct impact on the bowel wall. Maybe this will help if she has inflammatory bowel disease.

I do hope these simple approaches make her feel somewhat better.  She needs a diagnosis and I really hope that the current lockdown in endoscopy will be relaxed quickly so that she can get clarity on what is going on . This will ensure she gets the right medicine so that she can have a speedy recovery.

In the mean time best advice still remains to keep away from hospitals which turned out to be quite dangerous places at the moment. Stay at home and be assured that as soon as the lockdown is released we will be back doing endoscopies to clear the ever growing backlog as quickly as possible.