A 73-year-old female presented at the outpatient department with a 2-day history of upper abdominal pain after a meal. She has no pre-existing conditions or major past medical history. Before admission, she went through the mandatory pre-screening assessment (Figure 1), which has been implemented at our hospital through the COVID-19 outbreak, including inquiry of potential contact history (whether contacted with a suspected or laboratory-confirmed COVID-19 patient in the last 2 weeks); patient's symptom check (body temperature >=37.3 C, coughing or shortness of breath and/or other symptoms of acute respiratory symptom are highly suspected); laboratory test (a nasopharyngeal swab specimen for COVID-19 RNA test and serological tests for COVID-19 antibody); and a chest computed tomography (CT) scan (a typical "ground glass opacity" image is highly suspected), respectively.
The patient was categorized as having a "low risk" of COVID-19 infection and was subsequently admitted to the GI unit. During routine physical examination, her vital signs were stable, whereas moderate rebound tenderness appeared at the upper abdominal region. The blood chemistry panel showed prominently elevated amylase (5,082 IU/L) and lipase (>3,000 IU/L) levels, suggesting pancreatitis. Bilirubin level and the lipid profile were normal, with the mild increase of gamma-glutamyl transpeptidase (GGT, 59 U/L), alamine amino transferase (ALT, 95U/L), and aspartate amino transferase (AST, 95U/L), respectively. In addition, complete blood count showed severe inflammation with increased white blood cell (20.5 x 109/L) and neutrophil (19.1 x 109/L) counts. An abdominal CT scan indicated inflammation and swelling of the pancreas, a mildly enlarged gallbladder, as well as a slightly dilated common biliary duct (CBD) (Figure 2A). Notably a diverticular pouch was present at the junction of second and third with no obvious stone identified at that time portions of duodenum. To further rule out the possible biliary or extrabiliary obstructive pathology, the patient was referred to MR cholangiopancreaticography (MRCP) examination. MRCP coronal haste thin slice image confirmed the presence of duodenal diverticular partially compressing the distal end of CBD and resulting in dilation of its proximal part (Figure 2B). The maximal diameter of the diverticula was 2.67 cm. An ERCP may be sufficient to identify the presence of small stones (and subsequently remove them) or, alternatively, to place a stent inside the duct to restore bile flow.
The patient was informed of management options and agreed to endoscopic interventions. She was also acknowledged to have potential exposure risks to COVID-19 in the hospital environment. Surgical mask and gloves were provided to the patient and the relative who was responsible for transfer her to the ERCP unit. In addition, the patient was also provided with a disposable medical hair net and gown. They were further advised to minimize movement while waiting for the procedure to minimize the risk of contamination.
Prior to the ERCP procedure, the patient's status of COVID-19 was verified among the ERCP team. To limit the exposure risk for HCW, general anesthesia with tracheal intubation or deep sedation, which normally requires the anesthesia personnel to stay in the procedure room, was not applied in the current setting. Pre-ERCP screening was therefore critical to assess the patient's suitability to undergo conscious sedation. With regards to this, the patient had no cardio-pulmonary disease, no difficulties related to the airway, no morbid obesity, and, furthermore, no significant gastroesophageal reflux disease (GERD), which will probably cause an increased risk of developing complications during and after the ERCP procedure. Ten minutes before the procedure, intravenous administration of diazepam (5 mg) and dezocine (2.5 mg) was used to generate effects of anesthesia for the patient. In addition, antispasmodic (phloroglucinol, 20 mg) was given to reduce duodenal motility for the procedure. The vital parameters [heart rate (HR), blood pressure (BP), and respiration rate, (SpO2)] were monitored throughout the procedure.
Although performing endoscopic procedures in a negative-pressure room during the COVID-19 outbreak was recommended among several gastroenterological endoscopy societies, this is not available in most endoscopy facilities around the world. We equipped an operative room with a negative-pressure system in a separate unit to be used for all patients with respiratory symptoms. Given that the current patient was categorized as being at a low risk of infection, she was not transferred to the negative-pressure room.
All HCW at the hospital have received appropriate training on hand hygiene and use of PPE prior to procedures. The endoscopists and assistance wore PPE by reviewing the Asian Pacific Society for Digestive Endoscopy (APSDE) guidelines, American Society for Gastrointestinal Endoscopy (ASGE) guidelines, and CDC recommendations for ERCP. Washing hands with soap and water or alcohol-based hand rub were mandatory before and after patient interaction, contact with potentially infectious sources, and before putting on and removing PPE. The step-by-step approach for wearing PPE is as follows (Figures 3A-C): wear a respirator [either N95, the US standards for respirator masks, or NK95, the Chinese standards for respirator masks, or the equivalent, which are rated to capture 95% of tiny particles (0.3 micron particles, to be exact)]; wear an impermeable gown; wear the first pair of gloves so they cover the impermeable gown, which cover the wrist; wear lead aprons, thyroid shields, and dosimeters; wear boot covers; wear goggles and a face shield; wear a disposable isolation gown; wear a second pair of gloves over the isolation gown so they cover the wrist.
At ERCP, JPDD was observed, and a duodenoscopy identified the papilla located on the edge of diverticular fundus (Figure 2C). ERCP was performed in the usual fashion with selective biliary cannulation and injection of contrast material into common bile. A small stone was visualized in the distal CBD where it was juxtaposed against the diverticulum. To remove the stone, the endoscopist performed a small sphincterotomy in conjunction with balloon dilation, and subsequent removal of the stone was achieved with balloon extraction (Figure 2D). A 6F endoscopic nasobiliary drainage (ENBD) tube was placed to drain remnant stone. After the procedure, the patient's respiratory and cardiac signs were carefully monitored in the GI ward. Physical distancing was emphasized; we permitted only one relative or guardian per patient, and they were given masks and a separate room to other patients. All the nurses and healthcare providers were tested for COVID-19 and had to show negative results prior to returning work; we had mandatory education and training on infection measures, including hand hygiene and use of PPE. A total of 2 days later, the patient's amylase and lipase levels returned to normal, and the EBD tube was thus withdrawn. In addition, a sample of bile collected during ERCP procedure was tested for COVID-19 serology; it showed negative results. The possible ERCP-related complications, including pancreatitis, infection of the bile ducts or gallbladder, hemorrhage, and perforation in the bile or pancreatic ducts, were not observed. The patient was discharged afterwards and followed up 2 weeks later to assess whether she developed any respiratory symptoms and to further assess her progress after the procedure. A total of 2 months later, she was further followed up at an outpatient department. There was no retaining stone detected in CBD by CT scan, and no evidence of post-ERCP pancreatitis or other ERCP-related complications developed during the follow-up.