INCREASED DIAGNOSIS OF HEPATOCELLULAR CARCINOMA IN HOSPITALIZED PATIENTS WITH ALCOHOL RELATED HEPATITIS AFTER THE COVID-19 OUTBREAK: A GLOBAL MULTI-CENTER PROPENSITY MATCHED ANALYSIS

Background The Coronavirus 2019 (COVID-19) pandemic has posed significant challenges in the management of liver disease. Missed or delayed diagnosis of hepatocellular carcinoma (HCC) is anticipated due to discontinuity in standard surveillance protocols during the pandemic, though no large studies have documented the same. We attempted to study the baseline characteristics and outcomes in patients hospitalized with alcohol related hepatitis (AH), before and after the COVID-19 outbreak, and analyze the impact of COVID-19 on outcomes including diagnosis of HCC and inpatient mortality. Methods A federated cloud-based network (TriNetX) data from fifty health care organizations across the globe was analyzed retrospectively. Patients admitted with AH between January 2019 and December 2020 were studied. They were categorized into two groups including post-COVID outbreak (group 1, January 1st, 2020 to December 1st, 2020) and pre-COVID outbreak (group 2, January 1st, 2019 to December 1st, 2019). Patient characteristics and outcomes related to hospitalization were compared between these groups. Results Of 23,201 patients studied, 4,383 patients were included in group 1, and 18,818 in group 2. The two groups had comparable demographic features and occurrence of other comorbid diseases (table 1), none of them had a COVID-19 diagnosis. After propensity matched analysis, we found that group 1 (post-COVID group) had a tendency to have higher total bilirubin levels (p=0.05) during hospitalization. Similarly, the post-COVID group had a higher proportion of patients with underlying cirrhosis (p=0.02). Patients had a similar course during hospitalization among most of the variables compared among the two groups except the occurrence of hepato-renal syndrome (higher in the post-COVID group, p<0.001). Among the outcome variables studied, post-COVID group had an increased occurrence of HCC (Odds Ratio [OR]=1.19, CI=1.08-1.32, p<0.001), however occurrence of ascites (OR= 0.72, CI=0.45-1.17, p=0.18), hepatic encephalopathy (OR=0.74, CI=0.49-1.11, p=0.15), need for steroid use (OR=1.13, CI=0.91-1.41, p=0.24) and inpatient death (OR=0.93, CI= 0.72-1.20, p=0.59) were comparable among both groups. Conclusion Patients hospitalized with AH after the COVID-19 outbreak appear to have a higher occurrence of HCC and hepato-renal syndrome, though the occurrence of ascites, hepatic encephalopathy, need for steroid therapy and overall mortality did not change. This may indicate decreased outpatient diagnosis of HCC, likely from delay or discontinuity in standard HCC surveillance as a result of the COVID-19 outbreak. (Table presented.)

REDUCED ENDOSCOPY UTILIZATION FOR UPPER GASTROINTESTINAL BLEEDING DURING COVID-19 PANDEMIC: A MULTICENTER RESEARCH NETWORK STUDY

Introduction-The Coronavirus Disease-2019 (COVID-19) caused by the novel severe acuterespiratory syndrome coronavirus-2 (SARS-CoV-2) led to significant strain on healthcaresystems worldwide. The decline in UGIB-related hospitalizations is thought to be related tothe fear of contracting the virus and failure of the patients to seek medical care. It is unclearif UGIB-related hospitalizations have been reduced in the US during the pandemic.Methods-We utilized a federated cloud-based network (TriNetX), which provides accessto electronic medical records from 92 healthcare organizations (HCOs) from the US. TheUGIB patients hospitalized from January 1, 2020, to December 1, 2020, were compared toa similar timeline in 2019 from the TriNetX database. Outcomes of the study includemortality rate, utilization rates of esophagogastroduodenoscopy (EGD), colonoscopy, andsigmoidoscopy. The outcomes were measured before and after 1:1 propensity matching ofthe groups based on the baseline demographics and comorbidities.Results-Prevalence of UGIB hospitalizations in 2020 was 27.84% (28,518 UGIB hospitalizationsamong 102,437 total hospitalizations), compared to 34.22% (110,327 UGIB hospitalizationsamong 322,405 total hospitalizations) in 2019. There was a significant decrease (6.4%) in the number of UGIB hospitalizations from pre-pandemic compared to pandemic times(P<0.001). However, the proportion of variceal bleeding and non-variceal bleeding amongthe UGIB population did not change in 2020 compared to 2019 (Table 1). Patients in the2020-group had lower mortality rate (RR 0.45, 95% CI: 0.42–0.47), decreased utilizationof EGD (RR 0.76, 95% CI: 0.74–0.78), colonoscopy (RR 0.71, 95% CI: 0.69–0.74) andsigmoidoscopy (RR 0.67, 95% CI, 0.59 – 0.76) (Table 2).Conclusion-A significant reduction (6.4%) of UGIB hospitalizations with no change in theproportion of variceal and non-variceal bleeding was seen in 2020 compared to 2019.Despite these changes, EGD utilization declined by 25% in 2020 compared to 2019 duringthe same months.AGA s(Figure Presented)Figure 1: Patient's characteristics an comorbidities before and after matching(Figure Presented)Figure 2: Laboratory values and outcomes of the patient admitted with upper gastrointestinal bleed

Gastrointestinal bleeding risk and endoscopy utilization in covid-19 patients on therapeutic anticoagulation: A multicentric study

Introduction: Patients affected with coronavirus disease 2019 (COVID-19) can lead to severe hypercoagulability. Many of these patients receive therapeutic anticoagulation because of a very high risk of thromboembolism. However, data about the risk of gastrointestinal bleeding (GIB) in these patients on therapeutic anticoagulation is scarce. Additionally, endoscopy utilization among these GIB patients need further studies. This study aims to evaluate the rates of GIB bleeding in COVID-19 patients and the endoscopy utilization for the same from a national research network database. Methods: We used a federated cloud-based network database named TriNetX, comprising of 50 healthcare organizations (HCOs) across the US to identify all adults patients who were on therapeutic anticoagulation (warfarin, therapeutic dose-heparin [enoxaparin, unfractionated heparin], direct thrombin inhibitors, direct-acting factor Xa inhibitors 3-months prior to COVID-19 diagnosis. Patients with the use of anticoagulants for thromboprophylaxis were excluded. Patients with the above characteristics were studied from January 1, 2020, to June 15, 2021, were divided into the anticoagulation (COVID with AC) and without anticoagulation (COVID w/o AC) groups. The primary outcomes were rates of GIB (melena/hematemesis), inpatient hospitalizations, endoscopy (EGD/colonoscopy) utilization, number of packed red blood cell (PRBC) transfusions, and 30-day all-cause mortality. The outcomes were measured after 1:1 propensity matching of the groups based on the baseline demographics and comorbidities. Results: A total of 104,946 patients in COVID with AC and 591,273 patients in COVID w/o AC groups were compared. The patient comorbidities at presentation, laboratory findings, and clinical outcomes are noted in Table 1. After matching, COVID with AC patients had a higher risk of GIB (risk ratio [RR]-1.62 (CI-1.45 -1.82)), inpatient hospitalization rates (RR-4.53 (CI-4.42 -4.65)), PRBC transfusions (RR 3.67 (CI-3.35 -4.02)), overall mortality (RR 3.93 (3.75 -4.12)). Despite the increased presence of GIB, endoscopy utilization was lower (RR-0.85 (0.78 -0.93)). Conclusion: Rates of GIB, inpatient hospitalization, and overall mortality increased in COVID-19 patients on therapeutic anticoagulation. However, endoscopy utilization remained low, probably due to fear of infection transmission. If the increased mortality is related to the underlying severity of COVID-19 or unidentified comorbidities need to be further evaluated.

Impact of pandemic on epidemiology and management of acute colonic pseudo obstruction: Nationwide clinical data research network

Introduction: Acute colonic pseudo-obstruction (ACPO), also known as Ogilvie's syndrome, is characterized by massive acute dilatation of the large intestine without a mechanical cause. Early recognition to identify serious adverse events such as ischemia/ perforation is critical to reducing mortality rates. COVID-19 pandemic led to a significant shift of resources for the treatment of patients with reduced utilization of endoscopy and imaging, which could have impacted outcomes in patients with ACPO. In this study, we aim to identify the change in the clinical outcomes in ACPO patients in 2020. Methods: All adult patients with a new diagnosis of intestinal obstruction without mechanical cause were identified using ICD-10 codes (K59.8, K56.69). Patients diagnosed with megacolon (K59.3) were excluded. Patients were included from TriNetX, a federated cloud-based network that comprises 92 healthcare organizations across the entire US. The primary outcomes were rates of pharmacological therapy (neostigmine use), lower GI endoscopic decompression (Colonoscopy/sigmoidoscopy), surgery (laparotomy), and overall 30 day- mortality. The outcomes were measured after 1:1 propensity matching of the groups based on the baseline demographics and comorbidities. Results: A total of 24,310 patients were diagnosed with ACPO in 2020 compared to 95,014 with a reduced incidence of 74.5%. Comorbidities of these patients at presentation and clinical outcomes are noted in Table 1. Patients with behavioral/neurodevelopmental disorders, obesity, opioid use and laxative were significantly higher in ACPO patients. After matching, rates of neostigmine use (risk ratio [RR]- 0.71 (CI- 0.41 - 1.23)), imaging (CT/MRI) (RR- 0.86 (CI- 0.72 - 1.03)), surgery ((RR- 0.93 (CI- 0.83 - 1.03)) did not differ between the groups. Endoscopic utilization reduced significantly in 2020 (RR- 0.86 (CI- 0.78 - 0.95)). Furthermore, mortality was low in 2020 group (RR- 0.74 (CI- 0.65 - 0.84)). Conclusion: The rates of ACPO diagnosis in 2020 reduced by 74.5% compared to 2019. Although the neostigmine use, cross-sectional imaging use, and surgery rates did not change, endoscopic utilization was reduced by 15%. This was noted despite a need for urgent endoscopic decompression needed in these patients. Interestingly, the mortality was also reduced by 26% in 2020-ACPO groups even after lower utilization rates of endoscopy. (Table Presented).

The pancreas and COVID-19: A clinical conundrum

With the progression of the COVID-19 pandemic, the classic manifestations of COVID-19 (e.g., persistent fever, dry cough, pneumonia, and acute respiratory distress syndrome in the severe disease) have expanded to include less common complications of the extrapulmonary organs. Recent evidence has shown that COVID-19 patients with concomitant presence of GI symptoms are at higher risk of developing severe disease and have poor clinical outcomes. Recently, multiple SARS-CoV-2-induced acute pancreatitis (AP) cases have been reported. This literature review aims to provide an insight into SARS-CoV-2-directed invasion of the pancreas. We will also review the currently available literature on the clinical effects of SARS-CoV-2, including AP and mild elevation of lipase levels in patients with COVID-19. In addition, we will discuss plausible mechanisms that underly SARS-CoV-2-induced pancreatitis.

Inflammatory bowel disease amid the covid-19 pandemic: Impacmanagement strategies, and lessons learned

The current outbreak of COVID-19 pandemic caused by SARS-CoV-2 has affected nearly 188 countries. Patients with severe COVID-19 are more commonly elderly and suffer from comorbidities such as hypertension, diabetes mellitus, coronary artery disease, chronic pulmonary disease, obesity, and cancer. Inflammatory bowel disease (IBD) affects as many as 6.8 million people globally, and a significant proportion of them are treated with immunosuppressants. Hence, there is an ongoing concern over the impact of COVID-19 on IBD patients and their susceptibility to it. So far, there are about 1439 IBD patients in the Surveillance Epidemiology of Coronavirus under Research Exclusion (SECURE-IBD) registry reported to be infected with SARS-CoV-2. There are many unique challenges and dilemmas that need to be taken into account when managing an IBD patient with COVID-19. The management of each patient should be individualized. The IBD societies and experts have strongly recommended that patients should not discontinue their IBD medications. If the patients have symptoms of COVID-19 or IBD flare-up, they are recommended to call their IBD physician first to discuss their medication. In addition, IBD patients are urged to practice social distancing strictly to minimize the chances of infection. As COVID-19 is rapidly evolving, our experience and understanding of its impact on the IBD population may potentially change in the near future. © 2020, Hellenic Society of Gastroenterology. All rights reserved.