We appreciate the comments made by Johannah Ruddy and colleagues in response to our Rapid Review,1 the focus of which, in this unprecedented period, was on how to urgently adapt endoscopy in inflammatory bowel disease (IBD) during the COVID-19 pandemic and in the post-pandemic period. As endoscopy services in general have been severely disrupted, the article highlighted priority indications in IBD for endoscopy.
Our current practice has changed dramatically with the incorporation of telemedicine, recognition of risks to patients and staff from unnecessary visits to hospital and undergoing endoscopy, redeployment of staff, and severe curtailment of endoscopy capacity. We proposed practical triaging protocols that can be administered by a range of health-care providers for prioritisation.
The differential diagnosis between IBD and irritable bowel syndrome (IBS) was not the purpose of the algorithm that Ruddy and colleagues highlight. Selecting patients for urgent colonoscopy to investigate who might have a new diagnosis of moderate to severe IBD is one of the four essential indications in IBD for endoscopy during the pandemic.1
Negative emotions such as anxiety and stress increase visceral sensitivity via the brain–gut axis, which is the crucial player in IBS symptoms.2 Emotional state is an important component of triaging patients during the pandemic, with its serious effects on people's emotional state, including stress, anxiety, and depression,3, 4 which might trigger IBS.5 Emotional state and stressful events might be related to health-care seeking behaviour in IBS.6, 7
While anxiety and depression are important in all chronic diseases, including IBS and IBD, this is not an immediate consideration in assessing a patient for a probable new diagnosis of IBD (unlike established IBD). Symptoms of IBS often begin during times of emotional stress.8 We did not propose to evaluate emotional state alone, but also faecal calprotectin, blood test, and clinical symptoms, to decide who should undergo colonoscopy.
Ruling out a diagnosis for the purpose of prioritising colonoscopy is not the same as establishing a diagnosis.9 The term “probable IBS” was included as a triaging decision during this period and eventually the patient will be reviewed in clinic to establish a positive diagnosis and recommend a management plan upon resumption of near-normal service. At this stage we are in full agreement with the comments made by Ruddy and colleagues. Our algorithm does not attribute any pathogenetic interpretation of the emotional state.
Acknowledgments
We declare no competing interests.
References
- 1.Iacucci M, Cannatelli R, Labarile N. Endoscopy in inflammatory bowel diseases during the COVID-19 pandemic and post-pandemic period. Lancet Gastroenterol Hepatol. 2020;5:598–606. doi: 10.1016/S2468-1253(20)30119-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Tanaka Y, Kanazawa M, Fukudo S, Drossman D. Biopsychosocial model of irritable bowel syndrome. J Neurogastroenterol Motil. 2011;17:131–139. doi: 10.5056/jnm.2011.17.2.131. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.McKay D, Yang H, Elhai J, Asmundson G. Anxiety relating to contracting COVID-19 related to interoceptive anxiety sensations: the moderating role of disgust propensity and sensitivity. J Anxiety Disorders. 2020;73 doi: 10.1016/j.janxdis.2020.102233. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Park CL, Russell BS, Fendrich M. Americans' COVID-19 stress, coping, and adherence to CDC guidelines. J Gen Intern Med. 2020 doi: 10.1007/s11606-020-05898-9. published online May 29. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Pellisier S, Bonaz B. The place of stress and emotions in the irritable bowel syndrome. Vitam Horm. 2017;103:327–354. doi: 10.1016/bs.vh.2016.09.005. [DOI] [PubMed] [Google Scholar]
- 6.Choung R, Locke G. Epidemiology of IBS. 3rd Ed. Gastroenterol Clin North Am. 2011;40:1–10. doi: 10.1016/j.gtc.2010.12.006. [DOI] [PubMed] [Google Scholar]
- 7.Muscatello MRA, Bruno A, Mento C. Personality traits and emotional patterns in irritable bowel syndrome. World J Gastroenterol. 2016;22:6402–6415. doi: 10.3748/wjg.v22.i28.6402. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Crohn's and Colitis Foundation IBD vs IBS. https://www.crohnscolitisfoundation.org/what-is-ibd/ibs-vs-ibd
- 9.Spiegel BM, Farid M, Esrailian E, Talley J, Chang L. Is irritable bowel syndrome a diagnosis of exclusion? A survey of primary care providers, gastroenterologists, and IBS experts. Am J Gastroenterol. 2010;105:848–858. doi: 10.1038/ajg.2010.47. [DOI] [PMC free article] [PubMed] [Google Scholar]