Emotional state should not be used to differentiate IBD from IBS – Authors' reply
Authors: Marietta Iacucci, Rosanna Cannatelli, Nunzia Labarile, Subrata Ghosh
Journal: The Lancet. Gastroenterology & hepatology (2020)

We appreciate the comments made by Johannah Ruddy and colleagues in response to our Rapid Review,1Iacucci M Cannatelli R Labarile N et al.Endoscopy in inflammatory bowel diseases during the COVID-19 pandemic and post-pandemic period.Lancet Gastroenterol Hepatol. 2020; 5: 598-606Summary Full Text Full Text PDF PubMed Scopus (65) Google Scholar 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.1Iacucci M Cannatelli R Labarile N et al.Endoscopy in inflammatory bowel diseases during the COVID-19 pandemic and post-pandemic period.Lancet Gastroenterol Hepatol. 2020; 5: 598-606Summary Full Text Full Text PDF PubMed Scopus (65) Google Scholar Negative emotions such as anxiety and stress increase visceral sensitivity via the brain–gut axis, which is the crucial player in IBS symptoms.2Tanaka Y Kanazawa M Fukudo S Drossman D Biopsychosocial model of irritable bowel syndrome.J Neurogastroenterol Motil. 2011; 17: 131-139Crossref PubMed Scopus (193) Google Scholar 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,3McKay 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; 73102233Crossref Scopus (100) Google Scholar, 4Park CL Russell BS Fendrich M et al.Americans' COVID-19 stress, coping, and adherence to CDC guidelines.J Gen Intern Med. 2020; (published online May 29.)DOI:10.1007/s11606-020-05898-9Crossref Scopus (516) Google Scholar which might trigger IBS.5Pellisier S Bonaz B The place of stress and emotions in the irritable bowel syndrome.Vitam Horm. 2017; 103: 327-354Crossref Scopus (60) Google Scholar Emotional state and stressful events might be related to health-care seeking behaviour in IBS.6Choung R Locke G Epidemiology of IBS. 3rd Ed.Gastroenterol Clin North Am. 2011; 40: 1-10Summary Full Text Full Text PDF PubMed Scopus (140) Google Scholar, 7Muscatello MRA Bruno A Mento C et al.Personality traits and emotional patterns in irritable bowel syndrome.World J Gastroenterol. 2016; 22: 6402-6415Crossref PubMed Scopus (52) Google Scholar 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.8Crohn's and Colitis FoundationIBD vs IBS.https://www.crohnscolitisfoundation.org/what-is-ibd/ibs-vs-ibdDate accessed: June 4, 2020Google Scholar 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.9Spiegel 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: 848-858Crossref PubMed Scopus (148) Google Scholar 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. We declare no competing interests. Endoscopy in inflammatory bowel diseases during the COVID-19 pandemic and post-pandemic periodThe coronavirus disease 2019 (COVID-19) pandemic is changing the management of many chronic diseases, including that of patients with inflammatory bowel diseases (IBD). In particular, the performance of routine endoscopy is temporarily suspended, and only emergency endoscopy is allowed in many countries where severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread. We highlight different scenarios in which endoscopy should still be performed urgently in patients with IBD, as well as recommendations regarding the use of personal protective equipment. Full-Text PDF Emotional state should not be used to differentiate IBD from IBSWe 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). Full-Text PDF