• health services research
• ethics

In the first week of the UK lock-down, a 2-year-old boy was referred to be evaluated for very-early-onset inflammatory bowel disease (IBD) at the Department of Paediatric Gastroenterology at a tertiary care hospital in the UK. At the same time, gearing up for the COVID-19 pandemic, the NHS was in the process of steering towards an ‘essential treatments only’ national healthcare provision pathway. To optimise capacity in anticipation of the expected wave of Sars-Cov-2 emergencies, physicians were asked to postpone all non-urgent clinical activities including face-to-face outpatient visits, diagnostic procedures and hospital-based therapies.

This strategy has rapidly become a reality: in the first week of April 2020 alone, two children at our institution have received the clinical/presumptive diagnosis of Crohn’s disease and were subsequently started on treatment without the diagnostic certainty of endoscopy or MRI.

The 2-year-old boy was discussed in a virtual multidisciplinary team meeting, where—as an exception—the decision was made to list the child for diagnostic gastrointestinal endoscopy on the only paediatric emergency theatre list. Surprisingly, oesophagogastroduodenoscopy and colonoscopy revealed a single juvenile rectal polyp that was endoscopically removed. The remainder of the procedure was normal, and the boy was discharged without further medical treatment.

What if we had not urged for the boy to be placed on one of the few emergency lists? An erroneous ‘clinical diagnosis’ of IBD would have entailed significant sequelae including pharmacological immunosuppression with the potential side effects and continued bleeding of the still undiagnosed polyp.

This case represents a crucial aspect that goes missing in the …