FIT and the endoscopy service in Swansea Bay Health Board during the COVID-19 pandemic

Sarmad Tayyab; Elizabeth Rual; Linzi Thomas

doi:10.7861/clinmed.22-4-s74

Introduction

Endoscopy services have been significantly disrupted during the COVID-19 pandemic which led us to look for alternatives for prioritising diagnostic procedures. Faecal immunochemical test (FIT) has been widely used to prioritise endoscopy requests and this study evaluated its reliability in clinical settings.

Methodology

This piece of work was carried out as part of wider quality improvement project to effectively improve the diagnostic yield of endoscopy especially during the COVID-19 pandemic. Retrospective data was collected on all the FITs requested from 17 January to 7 October 2020. A FIT was sent to everyone waiting for a lower GI endoscopy and also to those with anaemia awaiting an upper GI endoscopy as per our local protocol. Patients with visible rectal bleeding were excluded from FIT analysis.

Results

In total, 385 patients were sent a FIT kit during the timeframe out of which six (1.5%) were for oesophago-gastro-duodenoscopy (OGD), 41 (11%) for flexible sigmoidoscopy, 233 (60.5%) for colonoscopy, 102 (26%) for double ended endoscopy while one request was for FIT only. No reason was mentioned in two of the requests.

FIT was positive in 54 (14%) of those patients and negative in 232 (60%), while in 99 (26%) patients it was either not returned or endoscopy was directly booked/cancelled by the referrer.

Out of those patients with a positive FIT, nine (17%) were found to have no abnormality, another nine (17%) were found to have polyp(s) <1 cm, seven (13%) had polyp(s) >1 cm, 10 (18%) had cancer, 12 (22%) showed other abnormality including diverticular disease, haemorrhoids, inflammatory bowel disease, angiodysplasia or upper gastrointestinal ulcer. Five (9%) patients cancelled their appointments for endoscopy while one (2%) was deemed appropriate to have an urgent outpatient appointment and one (2%) was diverted to have computed tomography instead.

Overall, 98 (25%) endoscopies were requested out of a total 385 FIT requests. Out of these, 28 (28.5%) showed no abnormality, 22 (22.5%) showed polyp(s) <1 cm, seven (7%) showed polyp(s) >1 cm, 10 (10%) showed cancer and 31 (32%) showed another abnormality as described above.

Interestingly, all 10 (100%) of cancer outcomes had a positive FIT result as did six out of seven (85.7%) with significant abnormality, ie polyp(s) >1 cm. FIT results in these two categories were anywhere between 12.1 to 400 (10 being upper normal limit and 400 being the highest reported value for FIT).

Conclusion

FIT is an effective way of prioritising endoscopy requests and our study has shown this. A higher FIT result did not correspond to a serious endoscopic outcome in our study. We plan to further develop FIT-related endoscopy prioritisation protocol. Our project led to a business case in the local health board and as a result FIT testing is available to all gastroenterologists, colorectal surgeons and GPs in primary care.