A case series of diabetic ketoacidosis associated with SGLT2 inhibitors

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are increasingly initiated as treatment for type 2 diabetes due to favourable cardiorenal characteristics. However, studies have identified an increased risk of diabetic ketoacidosis (DKA). We carried out a retrospective, case-based study at East and North Herts NHS Trust between February 2018 and December 2020. Fifteen cases of SGLT2i associated DKA were identified in people with presumed type 2 diabetes;33.3% were classed as euglycaemic DKA with a blood glucose of <11mmol/L. All cases were associated with a significant precipitating factor including diarrhoea, vomiting, reduced oral intake and sepsis. One case was related to COVID-19. Two people were subsequently found to have raised islet autoantibodies suggesting type 1 diabetes or latent autoimmune diabetes in adults. It is important that awareness of SGLT2i associated DKA is raised among users and health care practitioners, including the recognition of euglycaemic DKA. Sick day rules should be emphasised and reiterated at clinical encounters. Non-specialists in primary care, oncology and in perioperative settings should be empowered to advocate for temporary withdrawal and there should be readier access to blood ketone monitoring when required. When SGLT2i associated DKA occurs, due consideration should be given to evaluate the diabetes classification and investigate the circumstances of the event. Copyright © 2023 John Wiley & Sons.Copyright © 2023 John Wiley & Sons, Ltd.

Anti-SARS-CoV-2 antibodies important in diagnostics of acute hepatitis in children

The most common causes of acute hepatitis in children are hepatitis A and autoimmune hepatitis. Hepatitis in the course of Wilson's disease is sporadically registered in adolescents. An increase of activity of aminotransferases both in the course of multisystem inflammatory syndrome in children (MIS-C) and in the course of COVID-19 has been observed. Hepatitis is common in children with MIS-C and is associated with a more severe presentation and persistent elevation of liver function tests. To date, no cases of acute hepatitis in children due to COVID-19 have been reported. We present 2 cases of acute hepatitis in children where the only cause seems to be a previous asymptomatic SARS-CoV-2 infection.Copyright © 2023 Termedia Publishing House Ltd.. All rights reserved.

Gastrointestinal symptoms and disorders related to COVID-19. Lessons learned from gastroenterologists

COVID-19 is mainly a respiratory illness caused by the SARS-CoV-2 but can also lead to GI symptoms. The primary host receptor which mediates the mechanism as SARS-CoV-2 enters the cell is the ACE2 receptor. Therefore, GI symptoms can be common in COVID-19, and in some cases, they are the first manifestation even before fever and respiratory symptoms. In addition, the liver function tests alteration often is related to a worse prognosis. The exact incidence of GI symptoms is a matter of debate. Moreover, wide variation concerning GI symptoms frequency exists, but the predominant ones seem to be diarrhea, anorexia, nausea, vomiting, and abdominal pain or discomfort.This review summarizes the most relevant findings of COVID-19 on the digestive system, including the liver, biliary tract, pancreas, the most common GI symptoms, and the atypical clinical GI manifestations.Copyright © 2022 Sociedad Medica del Hospital General de Mexico. Published by Permanyer.

IDDF2023-ABS-0156 Poor tolerance of bowel preparation for index colonoscopy decreases surveillance rate in high-risk adenoma removal patients

IDDF-2023-ABS-0156 Table 1Association between Tolerance of BP for index colonoscopy and surveillance rateTolerance of BP for index colonoscopy Surveillance rate% (n/N) Total 67% (127/186) 1. Very intolerable 47% (9/19) 2. Intolerable 48% (10/21) 3. Neither tolerable nor intolerable 76% (55/72) 4. Tolerable 71% (22/31) 5. Very tolerable 72% (31/43) P for trend test 0.04 IDDF2023-ABS-0156 Table 2Risk factors of non-compliance of surveillance colonoscopy by multivariate regression analysis Multivariate OR (95%CI) p value Age,/1-year increase 1.04 (1.03-1.05) 0.001 Male sex 1.13 (0.85-1.52) 0.40 BMI,/1-kg/m2 increase 1.05 (0.96-1.15) 0.28 Family history of CRC 0.93 (0.16-5.25) 0.92 Low education 0.92 (0.39-2.15) 0.90 Comorbidities 1.05 (0.51-2.13) 0.90 Low tolerance of BP for colonoscopy 2.45 (1.11-5.41) 0.006 Absence of primary care physician 4.63 (1.60-13.4) 0.001 BMI: body mass index, CRC: colorectal cancer, BP: bowel preparation IDDF2023-ABS-0156 Table 3The reasons of non-compliance surveillance colonoscopyReasons of non-compliance surveillance colonoscopy n, (%) Total 62 (100%) Not knowing about follow-up intervals 4 (6%) Having no symptoms 15 (24%) Fear of examination Pain during colonoscopy 1 (2%) Embarrassment during colonoscopy 0 (0%) Bowel preparation for colonoscopy 17 (28%) Over sedation during colonoscopy 2 (3%) Old age/severe illness for surveillance 10 (16%) Having no time 10 (16%) Having no money 1 (2%) Fear of Covid-19 infection 2 (3%) IDDF2023-ABS-0156 Figure 1ConclusionsOur findings highlight the need for improvement of the surveillance colonoscopy rate, especially for patients who had poor tolerance to BP on index colonoscopy and no gastroenterology visit. Providing a well-tolerated BP regimen may lead to an increase in surveillance colonoscopy compliance.

When Characteristics of Clinical Trials Require Per-Protocol as Well as Intention-to-Treat Outcomes to Draw Reliable Conclusions: Three Examples.

Under exceptional circumstances, including high rates of protocol non-compliance, per-protocol (PP) analysis can better indicate the real-world benefits of a medical intervention than intention-to-treat (ITT) analysis. Exemplifying this, the first randomized clinical trial (RCT) considered found that colonoscopy screenings were marginally beneficial, based upon ITT analysis, with only 42% of the intervention group actually undergoing the procedure. However, the study authors themselves concluded that the medical efficacy of that screening was a 50% reduction in colorectal cancer deaths among that 42% PP group. The second RCT found a ten-fold reduction in mortality for a COVID-19 treatment drug vs. placebo by PP analysis, but only a minor benefit by ITT analysis. The third RCT, conducted as an arm of the same platform trial as the second RCT, tested another COVID-19 treatment drug and reported no significant benefit by ITT analysis. Inconsistencies and irregularities in the reporting of protocol compliance for this study required consideration of PP outcomes for deaths and hospitalizations, yet the study coauthors refused to disclose them, instead directing inquiring scientists to a data repository which never held the study's data. These three RCTs illustrate conditions under which PP outcomes may differ significantly from ITT outcomes and the need for data transparency when these reported or indicated discrepancies arise.

Commencing colorectal cancer screening at age 45 years in U.S. racial groups.

Screening for colorectal cancer (CRC) is cost-effective for reducing its mortality among the average-risk population. In the US, CRC incidence and mortality differ among racial/ethnic groups, with non-Hispanic Blacks (NHB) and American Indian/Alaska Natives showing highest incidence and mortality and earlier presentation. Since 2005, some professional societies have recommended CRC screening for NHB to commence at 45 years or earlier; this was not implemented due to lack of recommendation from key groups that influence insurance payment coverage. In 2017 the highly influential U.S. Multi-Society Task Force for Colorectal Cancer recommended screening to commence at 45 years for NHB; this recommendation was supplanted by data showing an increase in early-onset CRCs in non-Hispanic Whites approaching the under-50-year rates observed for NHB. Subsequently the American Cancer Society and the USPSTF recommended that the entire average-risk population move to commence CRC screening at 45 years. Implementing screening in 45-49-year-olds has its challenges as younger groups compared with older groups participate less in preventive care. The US had made extensive progress pre-COVID-19 in closing the disparity gap for CRC screening in NHB above age 50 years; implementing screening at younger ages will take ingenuity, foresight, and creative strategy to reach a broader-aged population while preventing widening the screening disparity gap. Approaches such as navigation for non-invasive and minimally invasive CRC screening tests, removal of financial barriers such as co-pays, and complete follow up to abnormal non-invasive screening tests will need to become the norm for broad implementation and success across all racial/ethnic groups.

Changes in uptake of stool-based colorectal cancer screening during the Covid-19 pandemic.

PURPOSE: Colorectal cancer (CRC) screening is underutilized and endoscopic colon screening includes a number of barriers that were exacerbated by the Covid-19 pandemic. At-home stool-based screening (SBS) increased during the pandemic and potentially reached eligible adults hesitant to be screened by endoscopy. The purpose of this analysis was to examine the change in uptake of SBS during the pandemic among adults not screened within guidelines by endoscopy. METHODS: We used data from the 2019 and 2021 National Health Interview Surveys to estimate uptake of SBS among adults aged 50-75 years, without a previous diagnosis of CRC and without guideline-concordant endoscopic screening. We also examined provider recommendations for screening tests. To examine if changes in uptake differed during the pandemic by demographic and health characteristics, we combined survey years and ran logistic regression models with an interaction term for each factor and survey year. RESULTS: In our study population, SBS increased 74% overall from 2019 to 2021 (8.7% to 15.1%; p < 0.001), with the largest percent increase among those aged 50-52 years (3.5% to 9.9%; p < 0.001). Among those aged 50-52 years, the ratio of endoscopy to SBS changed from 83%/17% in 2019 to 55%/45% in 2021. Cologuard was the only screening test where recommendations by healthcare providers significantly increased from 2019 (10.6% to 16.1%; p = 0.002). CONCLUSIONS: Use and recommendations for SBS increased substantially during the pandemic. Increased awareness among patients could potentially improve future CRC screening rates if uptake of SBS occurs among those unable or unwilling to be screened by endoscopy.

Impacts of COVID-19 on Appropriate Use of Screening Colonoscopy in a Large Integrated Healthcare Delivery System.

BACKGROUND: Decreasing low-value colonoscopy is critical to optimizing access for high-need patients, particularly in resource-constrained environments such as those created by the COVID-19 pandemic. We hypothesized that rates of screening colonoscopy overuse would decline during COVID compared to pre-COVID due to enhanced procedural scrutiny and prioritization in the setting of constrained access. OBJECTIVE: To characterize impacts of COVID-19 on screening colonoscopy overuse DESIGN: Retrospective national cohort study using Veterans Health Administration administrative data PARTICIPANTS: Veterans undergoing screening colonoscopy in Q4 2019 (pre-COVID) and Q4 2020 (COVID) at 109 endoscopy facilities MAIN MEASURES: Rates of screening colonoscopy overuse KEY RESULTS: 18,376 screening colonoscopies were performed pre-COVID, 19% (3,641) of which met overuse criteria. While only 9,360 screening colonoscopies were performed in Q4 2020, 25% met overuse criteria. Overall change in median facility-level overuse during COVID compared to pre-COVID was 6% (95%CI 5%-7%), with significant variability across facilities (IQR: 2%-11%). Of colonoscopies meeting overuse criteria, the top reason for overuse in both periods was screening colonoscopy performed <9 years after previous screening procedure (55% pre-COVID, 49% during COVID). The largest shifts in overuse category were in screening procedures performed <9 years after prior screening colonoscopy (-6% decline COVID vs. pre-COVID) and screening procedures performed in patients below average-risk screening age (i.e., age <40 (5% increase COVID compared to pre-COVID), age 40-44 (4% increase COVID vs. pre-COVID)). Within facility performance was stable over time; 83/109 facilities changed their performance by <=1 quartile during COVID compared to pre-COVID. CONCLUSIONS: Despite pandemic-related resource constraints and enhanced procedural scrutiny and prioritization in the setting of COVID-related backlogs, screening colonoscopy overuse rates remained roughly stable during COVID compared to pre-COVID, with continued variability across facilities. These data highlight the need for systematic and concerted efforts to address overuse, even in the face of strong external motivating factors.

Recurrent Liver Abscess in a Non-Toxic Patient

Introduction: Liver abscesses are caused by direct spread from peritonitis, biliary tract infection or via hematogenous seeding from a distant source. Most are polymicrobial, however Escherichia coli and Klebsiella pneumoniae are the most common offending pathogens. Patients usually present with pain, fever, and clinical signs of infection. We describe a case of spontaneous liver abscess in a non-toxic patient that recurred 10 years after a previous abscess. Case Description/Methods: A 73-year-old-man with a history of type 2 diabetes mellitus, hypertension, CAD status post CABG and PCI 3 years ago, and abdominal aortic aneurysm status post endovascular aneurysm repair presented with 2 weeks of dark urine. After receiving his COVID-19 booster and influenza vaccinations, he developed flu-like symptoms with a self-resolving fever of 101.8degreeF. He had dark amber urine without dysuria or hematuria. Later, he experienced generalized weakness and decreased oral intake. Outpatient labs showed elevated liver function tests, and he was told to present to the ED. On arrival, he was afebrile with stable vitals. Physical exam was unremarkable. Laboratory evaluation showed a hemoglobin of 11.7 g/dL, sodium of 133 mEq/L, creatinine of 1.4 mg/dL, aspartate aminotransferase of 117 U/L, alanine aminotransferase of 212 U/L, alkaline phosphatase of 825 U/L, total bilirubin of 4.1 mg/dL, and direct bilirubin of 2.1 mg/dL. Triple-phase CT showed a 2.8 cm mass in the right liver lobe with linear enhancement. Ultrasound showed mixed echogenicity measuring 3.6 x 2.9 x 3.3 cm in segment 8 of the liver. On further evaluation, patient had an E. coli abscess diagnosed 10 years prior, managed with antibiotics and drainage. At that time, the abscess was within the right inferior liver lobe, similar to his current abscess. LFTs downtrended. Abscess was aspirated, with culture growing oxidase negative, gramnegative rods, likely E. coli. Patient started on ceftriaxone and metronidazole, to undergo colonoscopy as an outpatient and rule out colonic bacterial translocation. Discussion(s): Pyogenic liver abscess can result in significant morbidity and mortality because of worsening infection and sepsis. Abscesses occur because of spread from adjacent infection or after recent surgeries. Recurrence is very rare. Here, we describe a very unusual case of a pyogenic liver abscess growing E. coli in a non-toxic patient, with the same location and causative organism as an abscess managed 10 years prior. (Figure Presented).

Patient Navigator Pilot to Improve Completion of FIT Testing in Primary Care

Introduction: Colorectal cancer (CRC) screening is a critical preventative service and part of routine patient care. CRC is the second leading cause of cancer death in the US, and yet a third of the eligible population does not undergo routine screening. Endoscopy centers have been stretched thin by both COVID-19 and the recent drop in screening initiation age to 45. Fecal immunochemical testing (FIT), a sensitive and specific CRC screening modality, may be used to reach and risk-stratify more patients to increase the yield for detecting advanced neoplasia and cancer, reducing pressure on colonoscopy centers. Unfortunately, FIT is often suboptimal as patients inconsistently complete and return the test for analysis. Method(s): We performed a retrospective analysis of 5211 individuals at a single internal medicine clinic who had FIT ordered as part of USPSTF recommended care from 01/2017 through 12/2021. Starting in 01/2021 we instituted a dedicated patient navigator to support patients in completing FIT. Chi-square, Fisher exact test, and Student's t-tests were performed for descriptive analyses. Multivariable logistic regression was used to compare FIT kit drop off rates pre- and post-intervention, with the model adjusted by age, gender, race, ethnicity, language, and insurance status. Analysis was performed in SAS version 9.4. (Table) Results: The post-intervention period included 1181 (22.7%) patients. The predominant reasons cited for failure to complete testing were forgot (25%), too busy (13%), and lost kit (11%). Our intervention improved drop off rates from 46.4% to 51.3% at 2 weeks (OR 1.19, 95%CI 1.01-1.41), 56.7% to 73.7% at 1 month (2.14 [1.78-2.58]), 64.7% to 89.7% at 3 months (4.73 [3.66-6.12]), and 78.9% to 98.2% at 1 year (14.39 [8.25-25.12]). Overall, our intervention improved FIT kit drop off rates by 53.4% (1.53 [1.30-1.81]). FIT was positive in 4.9% (p=0.0529). (Figure) Conclusion(s): FIT can increase CRC screening rates, particularly in resource-limited settings, and may decrease the burden on endoscopy centers nationwide by improving the efficiency of colonoscopy in the average risk screening population. The addition of a dedicated patient navigator is a simple intervention that, by providing culturally competent care and personalized attention, improves completion rates and return time, allowing FIT to be a reliable method of screening. The ability to increase screening rates and prioritize patients for diagnostic colonoscopies will ultimately lead to earlier detection and treatment of CRC.

Marginal Artery of Drummond Pseudoaneurysm Masquerading as Fistulous Tract Resulting in Recurrent Lower Gastrointestinal Bleeding

Introduction: The mortality rate of patients hospitalized with a lower gastrointestinal bleed has been reported at 1.1% in the United States from 2005 to 2014. Pseudoaneurysms, typically associated with pancreatitis, have been described in case reports as a rare condition with a small subset presenting as gastrointestinal bleeding. Our study describes a rare case of recurrent lower gastrointestinal bleeding diagnosed as a pseudoaneurysm by endoscopy and angiography. Case Description/Methods: A 38-year-old male presented to our facility from a long-term care facility with hematochezia and blood clots per gastrostomy-jejunostomy. He had recently been hospitalized for severe coronavirus disease 2019 with a complicated hospital course in the intensive care unit including necrotizing pancreatitis with an abdominal drain, multiple secondary infections, tracheostomy, and percutaneous endoscopic gastrostomy-jejunostomy. On previous hospitalization, he was found to have a small pseudoaneurysm of the gastroduodenal artery and received embolization of the gastroduodenal and gastroepiploic arteries at that time. During transport to our hospital, he was noted to have tachycardia, hypotension requiring norepinephrine, and was transfused one unit of red blood cells. Hemoglobin at this time was 7.5 g/dl after transfusion. Esophagogastroduodenoscopy was completed and showed a gastrojejunostomy tube in the expected location but was noted to be tight to the mucosa, which was pale in appearance. Flexible sigmoidoscopy revealed localized areas of edematous and erythematous mucosa with some associated oozing throughout the sigmoid colon. Repeat evaluation was completed one week later due to recurrent hematochezia. Colonoscopy was performed with identification of an apparent fistulous tract in the sigmoid colon located at 35 cm. Computed tomography angiography localized a pseudoaneurysm arising from the marginal artery of Drummond just proximal to its anastomosis with the ascending branch of the left colic artery and was successfully embolized. Discussion(s): Pseudoaneurysms, such as the one described in this case, have been shown to be associated with pancreatitis and can result if a pseudocyst involves adjacent vasculature. Gastrointestinal bleeding is a rare presentation of this condition. However, this case highlights the importance of repeat colonoscopy and angiography in the setting of a lower gastrointestinal bleed of unknown etiology.

Utilization of Patient-Centered Digital Tools to Improve Adherence Rates for Outpatient Screening Colonoscopies in a Metropolitan Hospital

Introduction: Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States. Screening through stool testing or colonoscopy is the standard of care for all ages 50 to 75 years, but national rates of procedures remain sub-optimal. Digital applications i.e., frequent automated text-based reminders and assess through personal healthcare apps on smartphones, can be effective tools to overcome barriers to screening colonoscopy adherence thus improving the outcomes. Method(s): We performed a retrospective study on a prospectively maintained database on CRC screening adherence rates from July 2019 to March 2022 in outpatient settings of a metropolitan hospital. Only screening colonoscopies (SC) scheduled during the study time period were included. Demographics and health-care resources utilization were reviewed. Primary comparison was between SC performance rates, prior to and after implementation of: a digital navigation program (DNP) developed by a private company that consisted of generating automated messages containing bowel-prep instructions, appointment reminders, driving instructions, short informative procedure videos;and EPIC EMR generated personal health app called MyChart. All participants were offered access to DNP through a digital platform and MyChart app set up on their smartphones. Result(s): Total of 3584 SC were scheduled during the study period. Overall age was 6069.6 years and majority were males at 55%;Hispanics were 49% with Not Hispanics at 24%. Pre-intervention period (n51057), 48% of SC performed and 52% cancelled;and in post-intervention period (n52527), 85% SC performed with 15% cancelled (p< .001) with a percent change of 74% increase in procedures. In postintervention group< DNP enrolled 930 patients of which 87% presented for procedure. Patients who did not present, received additional reminders. Bowel prep between groups showed no significant difference in quality (Table). Conclusion(s): Our study highlights a significant increase in performance rates of scheduled screening colonoscopies with a 74% increase after implementation of a DNP and MyChart app utilization. Usefulness of digital applications in improving screening colonoscopy adherence and reducing no show rates, has been well studied in literature with promising results, but implementation on a larger scale is lacking. Especially after COVID-19 pandemic, use of technology to increase adherence to CRC screening and surveillance seems more warranted.

The 'Tic'king Bleeder: A Rare Case of Bleeding Dieulafoy's Lesion in a Jejunal Diverticulum

Introduction: Dieulafoy lesion (DL) is a relatively rare and arguably under-recognized condition, accounting for 1-2% of acute GI bleeding. Most bleeding DLs occur in the stomach, followed by the small intestine, with less than 1% occurring in the jejunum. Bleeding DL on a jejunal diverticulum is even more rare, with a handful cases described in the literature. Here we present a rare case of a bleeding DL in a jejunal diverticulum with its endoscopic management. Case Description/Methods: A 65-year-old female with history of COVID-19 infection one month prior to presentation treated with steroids and therapeutic anticoagulation presented to the ED after having multiple episodes of coffee-ground emesis and two episodes of syncope at home. Last dose of Apixaban was 12 hours prior to admission. Physical exam revealed BP of 90/60 on Norepinephrine infusion, HR of 96, abdominal exam was soft and nontender, DRE revealed melena. Hemoglobin/hematocrit was significantly decreased at 3.6/12.8. Patient was appropriately resuscitated with blood products and fluids, and she was scheduled for an EGD. Initial EGD did not identify a clear source of her bleeding, and she was scheduled for colonoscopy. Colonoscopy with deep cannulation of the terminal ileum up to 40cm revealed significant amounts of fresh blood all throughout the colon and terminal ileum. Decision was made for push enteroscopy, which revealed a jejunal diverticulum containing a Dieulafoy lesion with an overlying clot (Image A). The lesion was first injected with epinephrine at 2 sites followed by a clot removal overlying the lesion using 13-0 circular snare. A clear stigma of recent bleeding was noticed from the lesion after clot removal (Image B), after which 2 metallic clips were placed over the lesion to achieve hemostasis (Image C). The patient had no further episodes of bleeding and was follow up in clinic eventually, recovering well. Discussion(s): Because of the life-threatening nature of Dieulafoy lesions, identification is of paramount importance for treatment purposes. Jejunal DLs are a rare entity but should be considered in cases with negative bidirectional endoscopies. In our case, push enteroscopy helped identify the bleeding lesion. DL in a diverticulum can pose a challenge to the endoscopist due to difficulty of access to the lesion. Epinephrine injection followed by mechanical clipping showed a positive outcome in our case which can be considered while approaching bleeding DLs in a diverticulum. (Figure Presented).

Utilizing a Decentralized Clinical Study Approach for Expedited and Diverse Recruitment for Clinical Validation of a Novel Non-invasive Multitargeted Stool-based RNA Test

Introduction: Traditional clinical trials that utilize fixed sites often fail to recruit participants that are representative of the intended use population. Participants, particularly those from minority groups, cite geographical constraints, mistrust, miscommunication, and discrimination as barriers to successful recruitment. A decentralized clinical trial enrollment strategy offers reduced cost, reduced time requirements, and circumvents barriers associated with the recent pandemic outbreak. Method(s): After the mt-sRNA test system entered design-lock, a decentralized clinical trial (CRC-PREVENT) was launched through a digital campaign (https://www.colonscreeningstudy.com/;NCT04739722). Online advertisements were published on multiple social media sites, and engagement with materials directed patients to an online screener. Participants who completed the screener were eligible for enrollment if they met CRC-PREVENT inclusion and exclusion criteria and were willing to complete all clinical trial components, including providing a stool sample before an optical colonoscopy. Result(s): After 12 months of active enrollment, 276,400 individuals engaged with digital advertisements and completed pre-screener surveys to determine eligibility for the clinical trial. In total, 14,264 individuals consented to participate in the CRC-PREVENT clinical trial. Of these individuals, 58% were female (42% were male), and 65% were over 50. Regarding race and ethnicity, eligible individuals directly represented the intended use population: 16% were Black or African American, 0.2% were Native Hawaiian, Pacific Islander, American Indian, or Alaskan Native, and 7% were Hispanic or Latinx. Regarding socioeconomic status, the decentralized approach permitted access to individuals with healthcare inequities: 25% of participants had income under $29,999, 5% of participants were from rural areas (defined as a city center , 10,000 people), and 36.7% of participants were on public insurance. Individuals were derived from 7,644 unique zip codes across all 48 continental United States. (Table) Conclusion(s): A decentralized recruitment strategy permits highly successful enrollment in the face of screening burdens heightened by COVID-19 pandemic. This approach also offered a significantly more diverse population and could mitigate selection bias and attrition bias associated with the cohorts observed in traditional clinical studies.

Pseudomembranous colitis in patients with COVID-19 (review)

AIM: to estimate the features of pseudomembranous colitis in patients with COVID-19, diagnostics, conservative treatment and surgery for complications. PATIENTS AND METHODS: a retrospective analysis of 396 patients with pseudomembranous colitis (PMC) in patients with new coronavirus infection was carried out for the period from March 2020 to November 2021. Among them there were 156 (39.3%) males, females - 240 (60.6%), moderate and severe forms of COVID-19 occurred in 97.48%. The diagnosis of PMC was established due to clinical picture, laboratory, instrumental methods (feces on Cl. difficile, colonoscopy, CT, US, laparoscopy). RESULT(S): the PMC rate in COVID-19 was 1.17%. All patients received antibiotics, 2 or 3 antibiotics - 44.6%, glu-cocorticoids were received by all patients. At 82.8%, PMC developed during the peak of COVID-19. To clarify the PMC, CT was performed in 33.8% of patients, colonoscopy - 33.08%, laparoscopy - in 37.1% (to exclude bowel perforation, peritonitis). Conservative treatment was effective in 88.8%, 76 (19.1%) patients had indications for surgery (perforation, peritonitis, toxic megacolon). Most often, with peritonitis without clear intraoperative confir-mation of perforation, laparoscopic lavage of the abdominal cavity was performed (60 patients - 78.9%, mortality - 15.0%), colon resection (n = 6 (7.9%), mortality - 66.6%), ileo-or colostomy (n = 8 (10.5%), mortality - 37.5%), colectomy (n = 2 (2.6%), mortality - 50.0%). The overall postoperative mortality rate was 22.4%, the incidence of surgical complications was 43.4%. In addition, in the postoperative period, pneumonia was in 76.3%, thrombosis and pulmonary embolism in 22.3% of patients. In general, the overall mortality in our patients with PMC was 11.4%, with conservative treatment - 8.8%. CONCLUSION(S): pseudomembranous colitis is a severe, life-threatening complication of COVID-19. In the overwhelm-ing majority of patients, conservative therapy was effective, but almost 1/5 of patients developed indications for surgery, the latter being accompanied by high mortality and a high morbidity rate. Progress in the treatment of PMC, apparently, is associated with early diagnosis, intensive conservative therapy, and in the case of indications for surgery, their implementation before decompensation of the patient's condition and the development of severe intra-abdominal complications and sepsis.Copyright © 2022, Association of Coloproctologists of Russia. All rights reserved.

A Rare Etiology for Ulcerative Colitis Flare

Introduction: Prior to colonoscopy, it is well understood that patients must undergo bowel cleansing. Based on the type of laxative, colonoscopy preparations fall into two categories - polymer-based formulas (PEG) and saline-based formulas (NaP). Both types of bowel preparations are deemed to be relatively safe and part of routine practice. However, we describe the rare case of an ulcerative colitis (UC) flare due to the bowel preparation formula. Case Description/Methods: A 29-year-old female with diagnosis of UC, presently in clinical and biochemical remission on oral mesalamine, contracted COVID-19 and had reactivation of UC symptoms. After being on budesonide tablets and rectal foam for two months, patient achieved clinical remission, and a surveillance colonoscopy was performed which revealed normal colon and terminal ileum except mild congestion in the cecum (Figure A). Pathology revealed unremarkable mucosa in the entire colon except for chronic active colitis in the cecum. Immediately following this colonoscopy, the patient started to experience another severe UC flare requiring hospitalization. The patient's laboratory work-up was normal except for an elevated fecal calprotectin (1710). Stool infectious work-up was negative and the patient denied any NSAID or antibiotic use. The patient underwent a repeat colonoscopy which revealed severe Mayo 3 pancolitis (Figure B) in comparison to a stable colonoscopy a few weeks prior. It was revealed that for her initial colonoscopy, she had used SUPREP bowel prep kit. On prior colonoscopies she had used MiraLAX bowel prep with no adverse effects. During hospitalization, the patient was started on biologic therapy with good effect. Discussion(s): There are no clear guidelines on appropriate bowel preparation formula for the inflammatory bowel disease (IBD) population. Sufficient literature exists to confirm that NaP can irritate the intestinal mucosal wall. Moreover, numerous animal experiments have employed dextran sodium sulfate for chemical induction of intestinal inflammation to mimic UC flares in humans [1]. Thus, it can be surmised that because SUPREP ingredients contain sodium sulfate, the potential for UC flare is higher. It is pertinent for practitioners to be aware of the possible rare adverse effects of saline-based formulas, especially when treating the IBD population.

Appropriateness and Completion of Multitarget Stool DNA Testing in Primary and Subspecialty Care

Introduction: Colorectal cancer (CRC) is the third most prevalent cancer in the United States, with a 4% lifetime incidence. While more clinicians have begun ordering multitarget stool DNA (mt-sDNA) testing due to the COVID-19 pandemic, adherence to guidelines on mt-sDNA and rates of subsequent follow-up testing has not been well studied. We assessed the appropriateness of mt-sDNA orders and rate of high-quality colonoscopy completion following a positive result in a large academic medical center. Method(s): We identified patients ordered for mt-sDNA in primary care and gastroenterology clinics at our institution between April 2020 and July 2021. For each case, we reviewed the appropriateness of mtsDNA testing, documentation of shared decision making, result of testing, and subsequent follow-up. Appropriateness was defined in accordance to the most recent American College of Gastroenterology guidelines on mt-sDNA use for CRC screening. Result(s): Of the 797 patients in our study, 685 (86%) met all appropriateness criteria for mt-sDNA testing (Table). Shared decision making was documented in 488 (62%) cases, and the most common reason for ordering mt-SDNA was hesitancy for colonoscopy. 483 patients (61%) completed mt-sDNA testing, of which 74 cases (15%) were positive. Rates of positivity were higher in cases of inappropriate (28%) rather than appropriate (13.7%) orders (p = 0.01). Colonoscopy was ordered in 73 cases (99%) and completed by 59 patients (80%). Of the 56 patients who underwent colonoscopy at our institution, most had documentation of a high-quality colonoscopy, defined as adequate prep (84%), cecal intubation (93%), visualization of the appendiceal orifice and ileocecal valve (94%), and right colon retroflexion (83%). Sixteen patients (29%) were found with advanced adenomas and 19 (34%) had other adenomas or sessile polyps. Among the 409 patients with negative tests, a 3-year follow-up recommendation was documented for 369 patients (90%). Conclusion(s): Most clinicians at our institution identified appropriate patients for mt-sDNA testing and provided appropriate follow-up< and the majority of patients who underwent colonoscopy had documentation of a high-quality colonoscopy. In contrast, there were suboptimal rates of mt-sDNA completion and documentation of shared decision making. Further studies are needed to identify barriers to documentation of shared-decision making and to completion of high-quality colonoscopies in patients being screened with mt-sDNA.

IgM Multiple Myeloma Presenting With Diarrhea

Introduction: IgM Multiple Myeloma (MM) is a rare subtype of MM consisting of <1% cases of MM. It is distinguished from Waldenstrom Macroglobinemia, which also produces IgM, by the absence of somatic mutation MYD88. We present a patient with a chief complaint of diarrhea which unknowingly led to his hematological diagnosis Case Description/Methods: A 64 year old male with RA-SLE overlap syndrome on steroids, and recent COVID19 pneumonia, had presented with 5 episodes of watery diarrhea every day and 40 Ib weight loss within 2 months. CT revealed small bowel enteritis and stool studies, including C. diff, cultures, ova and parasites were negative. Diarrhea persisted despite antibiotics, therefore an EGD and Colonoscopy were performed which showed duodenal lymphangiectasia and a normal colon. Duodenal biopsy revealed eosinophilic deposits in the villous lamina propria which stained for IgM and stained negative under congo red ruling out amyloidosis. SPEP and a bone marrow biopsy revealed monoclonal IgMspikes and plasma cells in the bone marrow suggesting MMalong with a co-existing population of CLL. Next-generation sequencing was negative forMYD88, supporting IgM MM instead of Waldenstrom. He developed a protein-losing enteropathy with dramatic hypoalbuminemia (albumin 0.9) and lower extremity edema and DVTs. He was started on chemotherapy and frequent albumin infusions. His diarrhea completely resolved, however not in time, as his other medical comorbidities lagged behind and he developed anasarca and continued to deteriorate. Discussion(s): Plasma cell dyscrasias such as IgM MM or more commonly Waldenstrom have rarely been reported to cause GI symptoms. GI involvement can include direct GI infiltration of plasma cells, IgM deposition, or the finding of a plasmacytoma. It has been speculated that IgM deposits can lead to interstitial viscosity and obstructive lymphangiectasia leading to diarrhea and a protein-losing enteropathy as in our patient. Protein loss has led him to have hypoalbuminemia and possibly loss of antithrombotic proteins that have caused DVTs. Few case reports have suggested that treating the underlying cause with chemotherapy stops diarrhea entirely. Although our patient's diarrhea ceased, we believe that it was not in time for him to entirely recover from the later complications of the disease. We hope that this case can help clinicians to attempt prompt treatment of patients when they find GI specimens showing IgM deposits and they suspect a plasma cell dyscrasia.

Frequency and Predictors of Emergency Department Visits Following Colonoscopy: An Assessment of Procedure Safety

Introduction: Colonoscopy is the most commonly performed colorectal cancer screening test in the US, and is associated with known adverse events (AE), including gastrointestinal bleeding (GIB), bowel perforation, abdominal pain, and others. Despite this, post-colonoscopy AEs are rarely monitored by current colonoscopy quality programs. This study investigated the frequency of ED visits in the two weeks following an outpatient colonoscopy at a multi-site academic center. Method(s): We conducted a retrospective cohort study including all adults aged >= 40 who underwent an outpatient colonoscopy at a single academic center between 2016-2019. Data from 2020 were excluded given unpredicTable effects of the COVID-19 pandemic on healthcare utilization. Patients were identified using procedural codes and administrative claims records were used to identify persons who had a subsequent ED visit up to 14 days after their procedure date. For those with ED visits, patient charts were reviewed to data including details of ED presentation. Descriptive statistics were used to characterize the sample. Result(s): There were 187 patients who had an ED visit within two weeks of their colonoscopy, among 34,222 total colonoscopies during the same 4 year time period (0.44%). 46.1% of the ED visits reviewed were either definitely or possibly related to post-colonoscopy AEs. The mean age of the population sample was 61 years. The most common presenting symptoms to the ED post-colonoscopy included abdominal pain (47%), GI bleeding (27.7%), and nausea/vomiting (20.6%). The most common ED diagnosis included GI bleed (26.2%), dehydration (6.4%), and obstruction (3.6%). Nearly half of patients presenting to the ED were admitted (47.2%). In terms of clinical details of the colonoscopies of those who presented to the ED, polypectomy was performed in 67.4% of patients and polypectomy of a large (>=10mm) polyp was performed in 22.7% of patients. Hot snare/biopsy was used in 36.9% of patients and periprocedural use of anti-thrombotics occurred in 36.9% of patients. (Table) Conclusion(s): ED visits occurred in roughly 4 out of 1000 patients within two weeks of a colonoscopy at our center, and nearly half of these patients were admitted. A high proportion of ED visits were for GI symptoms. Furthermore, over 1/3rd of patients with ED visits following a colonoscopy had polyps removed with electrosurgical techniques. These data suggest that regular monitoring of post-colonoscopy ED visits may be valuable for quality improvement purposes.

Mucosa-Associated Lymphoid Tissue Lymphoma of the Rectum Incidentally Found in a Patient with Ulcerative Colitis

Introduction: Mucosa-associated lymphoid tissue (MALT) lymphomas are extra-nodal marginal zone B-cell lymphomas, most commonly found in the stomach, associated with Helicobacter pylori infections, and generally not linked with inflammatory bowel disease. Rectal MALT lymphoma is very uncommon and often associated with painful defecation, change in bowel habits, or rectal pressure/prolapse. Here, we present a rare case of an asymptomatic female with ulcerative colitis (UC) found to have benign-appearing rectal polyps during a routine screening colonoscopy. Case Description/Methods: The patient is a 56-year-old female with a history of left-sided UC, diagnosed in 1993, with one flare after receiving the 2nd dose of the Moderna COVID-19 vaccine, taking oral Olsalazine 500 mg twice daily, low-dose Prednisone, and mesalamine suppositories as needed presenting for screening colonoscopy. The patient was asymptomatic, citing regular non-bloody bowel movements and normal stool consistency. Colonoscopy revealed two 7 mm sessile, non-bleeding rectal polyps, surrounded by congested, erythematous, friable, and ulcerated mucosa in the rectosigmoid colon. Cold forceps biopsies were taken. Hematopathology evaluation of the routine colon biopsy samples revealed chronic nonspecific colitis while pathology of the rectal polyps showed marked lymphoplasmacytic infiltrate and extra-nodal marginal zone lymphoma of MALT. Ancillary studies, immunohistochemistry, and molecular studies for B-cell gene rearrangement confirmed extra-nodal marginal zone lymphoma of MALT with prominent plasmacytic differentiation. The patient was informed and close follow-up in Gastroenterology clinic was arranged. (Figure) Discussion: Rectal MALT lymphoma is rare with unclear management options. Treatments of UC include watchful waiting, surgical resection, endoscopic mucosal resection, radiation, and/or chemotherapy. Helicobacter pylori infections, though strongly linked with gastric MALT lymphoma, have not been shown to be strongly correlated with rectal MALT lymphoma. Given that patients with UC have chronic UCassociated colonic inflammation, lymphoma is often difficult to distinguish visually during colonoscopy, frequently masked by ulcerations and pseudo-polyps. In cases like these, more definitive treatments such as surgical resection could therefore be warranted. Long-term follow-up data is sparse and definitive management remains a clinical conundrum, thus these patients require reliable long-term multidisciplinary close follow-up. (Figure Presented).