Figure 4: Proposed flowchart for cholangitis and jaundice in patients with
IBD and PSC

- This diagnosis is very severe and needs immediate care as it can lead to even worse issues with the patient
- As always, ruling out a COVID-19 diagnosis is the first step, but even if COVID-19 is present, it must be treated first and then non COVID-19 infected steps must also be taken
- The full outline of this is available in Figure 4


Ohio State University, Columbus

- This paper details updated endoscopic protocol for the diagnosis and management of inflammatory bowel disease (IBD) 
- This paper described how endoscopy is now considered a potential route of infection due to the nature of the procedure 
- In this paper, they describe 4 different scenarios which would warrant endoscopic procedures; including, new diagnosis of moderate-to-severe IBD, severe acute flare-up of ulcerative colitis, sub-acute obstruction in patients with IBD, and worsening cholangitis and jaundice in patients with IBD and PSC
- Additionally, this paper provides a small section discussing the risks of postponing endoscopy in patients with IBD
- Lastly, this paper does also contain some guidelines for PPE, however, these are very similar to PPE guidelines found in other papers like this one


Endoscopy in inflammatory bowel diseases during the COVID-19 pandemic and post-pandemic period

Iacucci, M., Cannatelli, R., Labarile, N., Mao, R., Panaccione, R., Danese, S., Kochhar, G. S., Ghosh, S., & Shen, B. (2020). Endoscopy in inflammatory bowel diseases during the COVID-19 pandemic and post-pandemic period. The lancet. Gastroenterology & hepatology, 5(6), 598–606. https://doi.org/10.1016/S2468-1253(20)30119-9

URL:  https://www.sciencedirect.com/science/article/pii/S2468125320301199?casa_token=uUsUnFt82AYAAAAA:9Xhnaknc6S5TrM7D7o0pc2xJ2wzRMLiahT-979Zlm2Mj5OhvrtJZ8JO1u-NH5m55kI3h600


- One new thing to keep in mind is gastrointestinal manifestations of COVID-19 and the symptoms it creates as some are similar to that of IBD
- After ruling out COVID-19 as a possible issue, stool samples should be taken to rule out pathogen-based illness
- Stressors should also be taken into consideration as stress can mimic symptoms of IBD
- After following these initial ruling steps, patients may be able to move onto possible endoscopic procedures as most other diseases have been eliminated
- Additionally, Figure 1 can be used as a visual representation of the steps which and decision making up until endoscopy


New Diagnosis of Moderate-to-Severe IBD

- When attempting to diagnose a sever acute ulcerative colitis flare up, the first thing that must be ruled out is COVID-19 symptom related digestive distress
- If COVID-19 infection is likely ruled out, standard stool sample tests should be performed for digestive infections
- Once flare-up has become the most likely diagnosis, patient should receive a baseline endoscopy and colonoscopy status will determine whether additional treatment is needed
- This has been outlined in a visual format in Figure 2


Severe Acute Flare-Up of Ulcerative Colitis

- Gastric or intestinal obstructions are significant are could lead to possible cancers, these should be delt with as soon as possible and cannot be postponed
- These patients are on high priority for colonoscopy with minimal preparation of diagnosis by colonoscopy and biopsies
- Once COVID-19 diagnosis has been ruled out for these patients, they should be put into immediate care for obstructions
- All procedures for this scenario are available in Figure 3


Sub-Acute Obstruction in Patients with IBD

Worsening Cholangitis and Jaundice in Patients with IBD and PSC

- Prolonged period without endoscopy could have long term implications as many patients with this condition are prone to relapsing
- Delayed colonoscopies could increase risk profile in patients for colorectal cancer
- Additionally those who have already been diagnosed with low-grade or high-grade dysplasia who need endoscopic removal may all become high risk with postponing of procedures


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