We congratulate Marietta Iacucci and colleagues on their recent Rapid Review1 of recommendations to triage endoscopy during COVID-19. We would like to highlight several points with regard to their algorithm for a suspected new diagnosis of inflammatory bowel disease (IBD).
The authors state that “negative emotions…can cause symptoms that mimic IBD” and that emotional state must be assessed to help rule out irritable bowel syndrome (IBS). We argue that the inclusion of “negative emotions” in this context is potentially deleterious to patient care. To the public, IBS is already a highly stigmatised condition with the misconception that the illness might not be real.2 Stigmatisation arises from medical providers, friends, and family members and can perpetuate feelings of shame and helplessness, leading to delayed management and its long-term consequences.3
In the authors' diagnostic algorithm, an abnormal emotional state, along with normal blood tests and faecal calprotectin leads to “probably IBS”. Poor emotional health is common in IBS and IBD and does not serve to discriminate between the two conditions.4 Moreover, this might be exacerbated by the psychosocial shock precipitated by the COVID-19 pandemic. The dichotomised outcome of emotional state as normal versus abnormal is ambiguous and fails to capture the complexities of psychological health; it is also pejorative and risks further stigmatisation of IBS.
Third, the step in the algorithm to “rule out IBS” after a negative stool test for infection does not follow the globally accepted diagnostic protocol for IBS. This fuels the commonly held misunderstanding among health-care professionals that IBS is a diagnosis of exclusion.4 Instead, this diagnosis can be made on clinical grounds using the Rome IV criteria, which has high specificity (97%) for IBS.5 Clinicians should not need to rule IBS out, but rather, should use clear evidence-based guidelines to make a diagnosis if patients meet criteria.6
We hope that the authors will consider a revision of their algorithm in figure 1 and the supporting text. We welcome a revision that eliminates the assessment of emotional state as part of the diagnostic algorithm or for differentiating IBS from IBD. We also recommend for the algorithm to be adapted to include the assessment of IBS using Rome IV criteria, which would lead to a positive diagnosis of IBS once criteria are met.
Acknowledgments
We declare no competing interests.
References
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