Is emergency endoscopic retrograde cholangiopancreatography safe in COVID-19 pandemic?

Abstract

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 is now a pandemic worldwide and clinicians have many questions about the safety of interventional procedures, even in an emergency [1]. Here, we will present an endoscopic retrograde cholangiopancreatography (ERCP) case safely performed in emergency situations in a case known to be COVID-19 positive. An 81-year-old male patient was admitted to the emergency department with right upper quadrant pain, jaundice and fever of the last 2 days. In his evaluation, obstructive jaundice due to cholelithiasis and cholangitis was determined. ERCP was performed by duodenoscope (Olympus, TJF-150) with needle-knife sphincterotomy (Microtech) and precut. The procedure was completed without acute complications, after ERCP his bilirubin levels and complaints improved. On the fourth day of ERCP, he had an acute coronary syndrome, coronary angiography was performed and a coronary stent was inserted. Due to stent insertion, 600 mg clopidogrel, 300 mg acetylsalicylic acid, and 6000 IU enoxaparin were given to the patient. On the fifth day of ERCP, he had melena, with a 2 g/dl decrease in hemoglobin levels. Because he was having a 38.5°C of fever and cough, COVID-19 rapid blood test (OVIOSR) determining the serology of Corona virus-19 was performed which was positive. We performed ERCP again, with maximum protection using appropriate equipment (Fig. 1). On the sphincterotomy line, there were blood cloths and they were cleaned with serum physiologic. Coagulation was achieved with the tapered tip sphincterotome (Microtech), choledoch was selectively cannulated, and 10F 10 cm plastic stent (10F, 10 cm; Microtech) was inserted. Two hemoclips (Sureclip, MicroTech) were inserted, and at the end of the procedure, there was no bleeding. After ERCP, because COVID-19 rapid blood test was positive, the real-time PCR test for nucleic acid determination in respiratory samples for COVID-19 was sent to the laboratory which was positive and thorax computerized tomography was performed which revealed bilateral ground-glass opacities in basal parts of the lungs. Instantly, COVID-19 treatment including hydroxychloroquine (2 × 400 mg loading and 2 × 200 mg maintenance) and azitromycine (1 × 500 mg loading and 1 × 250 mg maintenance) started [2]. On follow-ups, his hemoglobin levels did not decrease and his vital signs were stable. After 7 days of treatment for Coronavirus-19 in ICU, his real-time PCR test for nucleic acid determination in respiratory samples (NCOV-19) was negative and he was discharged. Due to the contact history, rapid test results and PCR in healthcare workers in this team were negative, and no COVID symptom was observed during the 14-day follow-up. In conclusion, if adequate precautions are taken, emergency ERCP procedures can be performed safely without any harm to the healthcare workers and patients.