Finding an Answer for an Adolescent with Back Pain

Case report - Introduction: This is the case of an adolescent referred to rheumatology following 5 years of back pain. After years of trying a number of treatments without much success, the cause was found to be a previously undiagnosed urological pathology. The case highlights awareness of non-rheumatological causes and incidental findings which can redirect a patient towards more appropriate treatment and reduce the potential for long-term adverse health issues and anxiety. Case report - Case description: B was referred age 16 to rheumatology with a 5-year history of lower back pain. She had previously seen paediatricians with symptoms initially attributed to constipation due to intermittent straining and hard stool. However, constipation remedies had not relieved the pain which progressed gradually to a more persistent dull ache with impact on daily activities. Various analgesics (including paracetamol and non-steroidal anti-inflammatories), exercises and acupuncture had not helped. There was no history of recurrent urinary tract infections or symptom correlation with fluid intake, menstruation or bowel habit. No inflammatory features or connective tissue disease symptoms were noted and family history was unremarkable Clinical examination was normal apart from mild tenderness in the lumbar region. Rheumatoid factor was borderline positive (15 iu/mL) with the rest of blood tests normal including renal function, inflammatory markers (CRP, ESR), anti CCP and ANA. She had minimal microscopic haematuria without proteinuria. MRI spine in 2015 was normal. In view of her young age and symptoms affecting daily activities, STIR sequence spinal MRI was requested. This excluded any new or old inflammatory changes but incidentally identified a dilated left pelvi-calyceal system. Renal ultrasound confirmed a grossly hydronephrotic left kidney with hydroureter and minimal renal tissue suggesting longstanding obstruction. No calculi were seen. The patient was referred to urologists. Further investigations (including MRI abdomen) confirmed similar findings and a distal ureteric stricture. A MAG 3 renogram showed a normal right kidney but only 12% functioning of the left kidney. Urologists have advised surgery (removal of left kidney and ureter) which may relieve symptoms or a conservative non-surgical approach (continue analgesia, physiotherapy and monitoring). The patient and her family are relieved to have a possible cause identified and are considering the surgical option due to ongoing flank discomfort. Case report - Discussion: This was an interesting finding of hydroureter and hydronephrosis causing longstanding back pain presenting to rheumatologists. Until completion of the spondyloarthropathy protocol MRI (STIR images), aetiology had been unclear. Hydronephrosis and hydroureter has no specific age or racial predilection. Signs and symptoms may depend on whether obstruction is acute/chronic. Chronic cases may be asymptomatic or present as a dull discomfort (like this case). Some cases may only present in adulthood with pain precipitated by fluid intake. Blood tests may show impaired kidney function. Post-mortem studies suggest 50% of people have at least one renal abnormality (e.g., renal cysts, duplex ureters) with autopsy series incidence of hydronephrosis reported as 3.1%. Causes include anatomical abnormalities such as vesico-ureteric reflux, urethral strictures (usually present in childhood), calculi, benign prostatic hyperplasia, or intrapelvic neoplasms, pregnancy and infections (e.g., TB). Sudden onset unilateral renomegaly was reported in one case of primary Sjogren's with lymphocytic interstitial nephritis and positive Sjogren's autoantibodies. Our patient has no clinical or serological evidence of connective tissue disease. Minor pelvi-calyceal distension can occur as a normal finding in wellhydrated patients and pregnancy. However, significant hydronephrosis requires assessment to determine cause as it may affect long term renal function. Imaging via computed tomography, ultrasound and urograms can help guide further management. In this case the preceding cause and duration of pathology is unknown. Sterile, giant hydronephrosis treatment options include observation and ureteric stent or nephrostomy in patients unfit for surgery. Nephrectomy is advised for pain and recurrent infection in a non-functioning kidney. Complications may include bowel perforation, vascular injury and urine leakage. Both open and minimally invasive procedures have good reported outcomes. The COVID-19 pandemic and exams have affected timing of any elective procedures and the patient understands surgery may or may not offer complete symptom resolution. Case report - Key learning points: . Non-inflammatory causes of back pain should always be considered in cases of persistent back pain, particularly in young people to ascertain if there is a treatable cause . Hydronephrosis cases can be asymptomatic or present with vague, intermittent, non-specific abdominal symptoms with normal physical examination with or without haematuria. This can cause diagnostic uncertainty and delay referral to urology and appropriate renal investigations . Assessment of renal function (including MAG 3 renogram) is important to guide further management . Surgical interventions (pyeloplasty/nephrectomy) may ease symptoms long term but there is no guarantee of a successful outcome and operative risks need to be considered too . Left undiagnosed, potentially this patient could have had further disruption to daily activities and both physical and mental well being.

A Single-Centre Experience of Telephone Assessment of Patients Referred to Two Week-Wait Colorectal Surgery Clinics in England

Aim: Despite Covid-19, hospitalsin the England, United Kingdom continued to assess and manage patients referred on two week-wait (2WW) suspected cancer referral pathways. Most index clinic assessments of such patients were conducted viatelephone. We retrospectively evaluated adistrict general hospital experience of managing patients on a 2WW suspected lower gastrointestinal tract (LGIT)cancer referral pathway, initially assessed via telephone Method: Data were obtained using a prospectively maintained database and electronic patient records. LGIT 2WW referrals between 01/06/2020to 31/10/2020 were included. Data were retrospectively collated and analysed using Excel (Microsoft Corporation, USA) Results: A total 757 patients (median age = 70, interquartile range = [59-79], female = 47.2%) were identified. The majority (n = 629,83.1%) were white Caucasian. All patients were initially assessed virtually and only 3 (0.4%) were re-assessed face-to- face for their index appointment. Sixteen (2.1%) missed at least one prior appointment. The most common presenting complaints included change in bowel habit, rectal bleeding, weight loss, anaemia and abdominal pain, and 415 (54.8%), 269 (35.5%) underwent endoscopy and imaging respectively as the first investigation. Forty four (5.8%) patients had malignant pathology with the majority (n = 37,84.1%) being colorectal in origin. Of those diagnosed with a primary colorectal malignancy 25 (67.6%) underwent surgical or endoscopic treatment, 3 (8.1%) were referred to chemoradiotherapy and 8 (21.6%) were referred for palliation. Conclusion(s): Patients referred on the 2WW LGIT pathway continued to be assessed and managed despite Covid-19. Index telephone clinic assessments are perhaps as effective a tool as face-to- face assessments, for patients referred on this pathway. This warrants further investigation.

Utilization of a novel humble inquiry interview approach in assessing implementation barriers to a Nurse Driven Clostridioides difficile infection (CDI) order set

Background. Timely diagnosis and use of contact precautions for Clostridioides difficile infection (CDI) is key to prevent spread in hospital settings. Empowering nursing staff to order stool tests and proactively implement precautions has been shown to reduce hospital acquired CDI. Our institution established a nurse driven CDI order set in 2019, however only 1% of tests were ordered by nurses in the past year. The goal of this quality improvement project was to understand current use of the nurse-driven CDI order set using a novel humble inquiry approach. Methods. We used humble inquiry, an interview approach that poses questions while building relationships with participants through humility, curiosity, and active listening skills to explore barriers to utilization of a nurse driven CDI order set. Two nursing students at a 182-bed Veterans Health Administration (VA) hospital were trained to use humble inquiry and a three-item interview guide. A convenience sample of nurses and nursing assistants were interviewed about a) what they know about the nurse driven CDI order set, b) where there is documentation about the order set and c) barriers to use of the order set (if any). Interviews were conducted from January to April 2022. Demographics were analyzed descriptively. Interview data and the experience of conducting humble inquiry were analyzed using manifest content analysis. Results. Interviews (n=19) with nurses (n=16) and nursing assistants (n=3) revealed the majority (13/19 = 68%) were not aware of the nurse driven CDI order set. Of those aware, most were able to identify the location of information on their unit and where to document in the electronic medical record. The two most common barriers included lack of awareness of the order set and patient reluctance to disclose their bowel habits. Delay in providers reading notes (3/19=16%) and lack of PPE during COVID (1/19= 5%) were also identified as barriers. The nursing students reported the humble inquiry approach allowed participants to be the "experts" and "teachers". Conclusion. The humble inquiry method was valuable in understanding viewpoints and identifying barriers to utilization of a nurse drive CDI order set. Lack of awareness of the order set and patient modesty were identified as barriers and may be targeted for future interventions.

Has COVID-19 Pandemic affected the management of patient's with Colorectal cancer?

Introduction: Patients on The Cancer pathway should be investigated on The 2 weeks wait pathway, but COVID-19 pandemic had universal impact on The Healthcare systems. one of The main worries was The impact on Cancer patients due to delayed diagnosis and management. Our study looks at The timeframe of investigations for Colorectal Cancer during The second wave of The pandemic compared to pre COVID time. Method(s): Retrospective study looking at The waiting time to investigate patients with +ve qFIT test during The second wave of pandemic (from November 2020 till March 2021). Result(s): During this period 150 patients had +ve qFIT test, The main presenting symptom was Change in bowel habits. 90 patients were investigated with colonoscopy, only 16 (17%) patients had The colonoscopy done within 2 weeks from The qFIT result. 23 patients had colonoscopy 2-3 weeks from The result. 30 patients (33%) had The colonoscopy between 3-4 weeks, and 21 patients had to wait between 1-6 months to have The colonoscopy. Out of The 150 patients, 60 patients were investigated primarily with CT scan or CT colon. Conclusion(s): During The COVID-19 pandemic, majority of patients in our trust were investigated within one month of +ve qFIT test but yet there was some delay in carrying out The investigations compared to The normal pathway and more patients had CT scans as primary investigations before being referred for colonoscopy.

EVALUATION OF A COLONOSCOPY REFERRAL FORM IN QUEBEC: WHICH INDICATIONS CARRIES A HIGHER RISK OF ADVANCED NEOPLASIA?

Background: Patients referral for colonoscopy in the province of Quebec are organized through a standardized triage sheet that includes all indications categorized in 5 hierarchal scheduling priorities. In the context of a restricted access to colonoscopy, exacerbated by the COVID-19 pandemic, postponed elective endoscopies lead to potential diagnostic and therapeutic delays in patients with colorectal neoplasia. There is currently an important need to evaluate available tools to improve patients prioritization. Aims: This study aims to determine CRC and advanced adenomas (AA) rates associated with indications of priority 3 (P3 fig.1). The secondary objective is to regroup and compare indications with higher and lower rate of CRC and AA. Methods: This retrospective study included all adult patients who underwent a single diagnostic colonoscopy from March 2013 to March 2016 following a single FIT test in a tertiary teaching hospital. A literature review informed the adopted definition of higher-risk of CRC and AA according to P3 colonoscopy indications. These include: Positive FIT test (IN5), hematochezia in ≥ 40 years old patients (IN4), unexplained iron deficiency anemia (IN6) and symptoms suspicious of occult colorectal cancer (IN18). Lower risk P3 indications were defined as: suspicion of IBD (IN3), recent change in bowel habits (IN7), polyp viewed on imaging (IN17), inadequate bowel preparation (IN19), and diverticulitis follow-up (IN20). Higher and lower risk indications findings were analyzed. Results: In our cohort of 2226 patients, indications for colonoscopy referral according to the standardized form were available for 1806 patients (10 P1, 69 P2, 1056 P3, 56 P4 and 615 P5). In our studied group of P3 indications, the mean age was 62.6±11.3 years, 54.1% were female and 173 (16.4%) patients had a significant finding of CRC or AA (table 1). Patients referred for higher risk indications had a significantly increased rate of CRC and AA (19.3% vs 5.1% p≤ 0.01) compared to patients referred for lower risk indications. Conclusions: A standardized colonoscopy referral tool may be adapted to improve prioritization of patients at risk of advanced neoplasia. These findings are especially.

PATIENTS REFERRED TO ANORECTAL MANOMETRY BEFORE AND DURING THE COVID PANDEMIC: ARE THEY DIFFERENT?

Background and aim: The SARS-CoV 2 pandemic has provoked drastic lifestyle changes and distracted the attention of doctors and patients towards “urgent” diseases. Consequently, it could have influenced also the features of the patients referred to a “nonurgent” diagnostic test such as anorectal manometry (ARM). The aim of this study was to evaluate possible differences in the features of patients undergoing ARM before and during the pandemic. Materials and methods: Demographic and clinical information was collected in 388 patients (m 99, f 289;mean age:53 ± 16.4 years) undergoing ARM according to the London Protocol from July to December 2019 (154 pts.), 2020 (101 pts.), 2021 (133 pts.). Information was collected using also dedicated scales: HADS, PACSYM, ODS, SF-12 and Wexner. Results: The indications for ARM were chronic constipation, fecal incontinence, chronic anal pain, evaluation after rehabilitation or before surgery. No difference was detected regarding indications and demographic features in the three different periods apart from the following: - duration of symptoms: in 2019, there was a lower prevalence of long-lasting symptomatology (>10 years) compared to 2020 and 2021 (p = 0.029). - ODS score (constipated patients): mean ODS score was lower in 2020 (11.22 ± 4.37) and in 2021 (10.89 ± 4.64) than in 2019 (14.82 ± 5.09) (p < 0.01). - HADS score mean values were always below the cutoff for diagnosing anxiety or depression. However, the mean score of depression was lower in 2020 (6.64 ± 3.24) and 2021 (5.16 ± 4.62) than in 2019 (7.58 ± 4.84) (p < 0.05). Manometric diagnostic conclusions were not significantly different in the three periods. Conclusions: The features of patients referred to a manometric evaluation were quite similar before and after the pandemic. The pandemic could have partially selected the patients with a long-lasting symptomatology, more prevalent in 2020 and in 2021. The slight differences we detected in the ODS and HADS scores may be related to lifestyle changes imposed by the forced lockdown, which resulted in changes in bowel habits. Our results are different from those reported in the literature regarding a worsening of functional disorders during pandemic. ARM is a niche exam and cannot be considered a mirror of functional disorders because they are very prevalent in the general population, while there are very few patients who undergo ARM. A multicenter study that can validate our conclusions is desirable.

RARE CASE OF ILEOCOLIC MESENTERY PRIMARY MELANOMA WITH LIVER METASTASIS

Purpose/Background: Although GI melanoma is commonly a metastatic disease, it is very unusual to see the mesenteric mass of the cecum and terminal ileum as the primary origin of melanoma. Hypothesis/Aim: This is a case report and presentation showing a rare occasion of primary melanoma in the cecum and the terminal ileum mesentery along the ileocolic pedicle causing cecal complete bowel obstruction. Methods/Interventions: The reported case is a rare occasion of large bowel obstruction near the cecum resulted from primary mesenteric melanoma invading into the wall of the descending colon. Primary melanoma of the GI tract is still controversial and only a limited of cases have been reported in the literature. We added a review of the other published case reports to this case report using Endnote. Results/Outcome(s): This is a 68-year-old female who was seen in the outpatient setting with increasing abdominal girth in addition to nausea and vomiting and obstipation. The patient had alternating bowel habits for over 2 months which she felt this was related to Covid as she was tested Covid positive and diagnosed with Covid pneumonia at the same time. She was directly admitted from the office to the inpatient and she had a CAT scan of the abdomen pelvis that demonstrated cecal obstruction related to possibly cecal mass/mesenteric mass with multiple liver metastatic diseases. She underwent exploratory laparotomy which resulted in Right extended hemicolectomy en bloc with a loop of jejunum and part of the terminal ileum. We tested later serum S100 the protein and it was elevated to 18,000, she had serum negative alpha-fetoprotein and negative CEA. This is a 68-year-old female who was seen in the outpatient setting with increasing abdominal girth in addition to nausea and vomiting and obstipation. The patient had alternating bowel habits for over 2 months which she felt was related to Covid as she was tested Covid positive and diagnosed with Covid pneumonia at the same time. She was directly admitted from the office to the inpatient service and she had a CAT scan of the abdomen pelvis that demonstrated cecal obstruction related to possibly cecal mass/ mesenteric mass with multiple liver metastatic diseases. She underwent exploratory laparotomy which resulted in Right extended hemicolectomy en bloc with a loop of jejunum and part of the terminal ileum. She had also intraoperative liver biopsy that demonstrated metastasis of the melanoma to the liver. We tested later serum S100 the protein and it was elevated to 18,000, she had serum negative alpha-fetoprotein and negative CEA. Limitations: Case report study with reported cases reviewed. Conclusions/Discussion: Large bowel obstruction could be related to unusual diagnoses like melanoma of the bowel mesentery. Although, primary GI melanoma is rare this showed the possibility of such diagnosis. (Figure Presented).

Drive By Flu-FIT: A novel way to mitigate the decrease in colorectal cancer screening during the COVID-19 pandemic

Background: During the height of the COVID-19 pandemic, screening colonoscopy rates decreased by 90%. The decreased screening rates will increase the burden of colorectal cancer (CRC) in communities. The pandemic has created a need for novel models for safely engaging and screening community members for CRC. Methods: We implemented NCI's Screen to Save CRC screening campaign using a socially-distanced, Drive By Flu-FIT protocol and report the results of the FIT component of the program. In partnership with the leadership of Enon Tabernacle Church, the largest Baptist church in the Philadelphia region, we invited community members at average risk for CRC and between the ages of 45-75 to register for one of three Drive by Flu-FIT events held between Oct-Nov, 2020. Interested participants also completed eligibility, registration, and demographic questionnaires administered electronically via REDCap. Upon completion of these questionnaires, participants watched a 8-minute CRC screening educational video and pre- and post- CRC knowledge and intentions questionnaires. Participants who attended one of the three events received a Flu vaccine and/or FIT test and instructions to return the completed FIT to a medical collection box at Enon Tabernacle Church. This research was approved by the University of Pennsylvania's Institutional Review Board. Results: Of the 335 participants that registered for the event, 80 (23.9%) did not show, 63 (18.8%) were ineligible and 192 attended the event and received a FIT (57.3%). Reasons for ineligibility were: age outside of the recommended age for screening (n=40);having had a recent colonoscopy (n=13);symptoms/signs of CRC including change in your bowel habits, rectal bleeding, abdominal pain, iron deficiency anemia, unexplained weight loss (n=10);a possible family history or possible Lynch syndrome (n=1). Patients with symptoms/signs and family history of CRC were referred to colonoscopy. The 192 participants that comprised this analytic had a mean (s.d.) age of 58.9 (9.5) years, 60.4% were female, 93.8% self-identified as Black, and 1.6% as Hispanic. The pre-and post-knowledge scores showed an increase after the video intervention (p=0.0006) as did the intention to screen scores (p=0.007). To date, of the 192 participants who received a FIT, 38 (19.7%) did not return the FIT, 141 (73.4%) had a negative FIT result and 13 (6.7%) had a positive FIT result and were referred to colonoscopy. The results of colonoscopy are pending. Conclusions This research shows that a socially-distanced Drive By Flu-FIT program is feasible, acceptable and effective in engaging the community in CRC education and screening during the COVID-19 pandemic. Novel programs such as this can help mitigate the significant decline in screening for CRC that has occurred as a result of the COVID-19 pandemic and, thus, can help reduce the burden of CRC in our diverse communities.

GUT-BRAIN AXIS AND IRRITABLE BOWEL SYNDROME DURING SARS COV-2 PANDEMIC. A SURVEY BASED STUDY

INTRODUCTION: Irritable bowel syndrome (IBS) is a functional disorder with high prevalenceimpacting on patient’s quality of life. IBS is considered a multifactorial entity, in whichsocioemotional factors and social stress might play a central role in the generation andworsening of symptoms. The mandatory lockdown in response to SARS CoV-2 pandemic,represents a unique scenario of reduced social interaction and complexity, potentially impactingthe IBS-patients’ symptoms evolution. OBJECTIVE: To evaluate the impact of the mandatorylockdown due to the SARS CoV-2 pandemic on the brain-gut axis symptomatology inIBS patients. MATERIAL AND METHODS: All IBS-diarrhea and mixed bowel habits patternsubtype patients, from an existing Rome IV-defined cohort database, were invited to participate(n = 129, mean age 54 [+/-16], 78% female). Patients were assessed via an onlinesurvey or phone interview. The survey included Irritable Bowel Syndrome Severity Scale(IBS-SS), Likert scale, as well as measures of Bristol scale, anxiety and depression andsomatization. Further, patients were asked about comorbidities (pyrosis and/or regurgitation,dyspepsia, chronic fatigue, fibromyalgia, non-migraine headache, weight and eating habits).Most of this data was compared with pre-pandemic existing data. RESULTS: During lockdown,there was a significant decrease in severe IBS patients’ proportion (50.39 % vs 30%, p=0.000) compared to the pre pandemic state. Before pandemic, this cohort of patientshad a mean IBS-SS of 278.54 (+/- 88.64) compared to 212.36 (+/-117.50) during lockdown(difference -65.9 [95% CI: -89.4 to – 42.4];p = 0.000). Likewise, there was a decrease ofone average point on the Likert Scale on global IBS symptoms, pain, and distension, as wellas an improvement in stool consistency (2-point average decrease on Bristol Scale). Similarly,anxiety and somatization scores were improved and there was a significant decrease infibromyalgia and chronic fatigue symptoms during lockdown (in comparison with prepandemictimes). Conversely, headache and pyrosis and/or regurgitation symptoms increasedsignificantly. These effects remained when adjusted for confounders (age, sex, anxiety, anddepression), evidencing that the mandatory lockdown represented an independent protectivefactor for severe IBS-symptoms (OR 0.39, 95% CI 0.18-0.87;p=0.02). CONCLUSION: Incomparison with a pre-pandemic period, there was a significant improvement in IBS-severitysymptoms, anxiety and somatization during the SARS CoV-2 pandemic and mandatorylockdown. Lesser exposure to external stress burden during lockdown could have beeninvolved in a better control of affecting gut-brain axis factors.(Table Presented)(Image Presented)

STRATIFYING THE IMPACT OF COVID-19 PANDEMIC ON THE EMOTIONAL AND PHYSICAL WELL-BEING OF PATIENTS WITH INFLAMMATORY BOWEL DISEASE

Background and Aims: Psychological stress is a known risk factor for relapse and worsening symptoms for patients with Inflammatory bowel disease (IBD) and could negatively affect the disease course. The COVID-19 pandemic has created ongoing distress since it started at the end of 2019. In this study, we utilized the Pandemic Emotional Impact Scale (PEIS) to stratify patients with IBD who have been impacted in terms of their well-being and IBD management.Methods: In a multi-center survey study, a 75-item questionnaire, that incorporated the PEIS, was administered to patients with IBD from June 26 to September 19, 2020. The PEIS was developed during the COVID-19 pandemic and consists of 16 questions that assess the emotional impact of the pandemic. Each of 16 items are scored on a 0-4 scale (0=“Not at all”, 1=“A little bit”, 2=“Moderately”, 3=“A lot” and 4=“Extremely”) with the total PEIS score ranging between 0 to 64. Wilcoxon rank sum test and Kruskal-Wallis test were used to examine the association between the PEIS and measures of emotional well-being (sleep patterns, stress level, and vulnerability), changes in IBD symptoms, and the likelihood of IBD patients to visit medical facilities after the reopening. Results: Most of the patients chose to answer “Not at all”, “A little bit”, and “moderately” and were less likely to choose “A lot” and “Extremely” in most of the categories (Figure 1). The mean PEIS score for the entire population was 21.16 (95% CI 19.98_22.36). Female patients, patients with anxiety, and patients with depression were noted to have a significantly higher PEIS score than other patients. Using nonparametric testing, high PEIS was significantly associated with poor sleep, feeling more stressed, feeling more vulnerable, and worsening GI symptoms (abdominal pain and bowel habits). Additionally, PEIS score was significantly higher in patients who reported that they would avoid or be less likely to schedule visits to the GI clinic, GI procedures, or imaging studies after the reopening (Figure 2).Conclusion: Increasing PEIS score was associated with substandard emotional and physical outcomes in patients with IBD. Utilizing the PEIS score as a screening tool could help better tailor outreach and follow-up to support patients with IBD who have been impacted the most.(Table Presented)(Table Presented)

FAECAL IMMUNOCHEMICAL TEST (FIT) FOR TRIAGING SYMPTOMATIC PATIENTS – PUTTING UK NICE GUIDELINES INTO PRACTICE

Introduction: Endoscopy Capacity Has Been Under Pressure During The Covid19 Crisis. Fit Affords The Opportunity To Identify A High Risk Group In Whom Urgent Colonoscopy Can Be Justified To Exclude Colorectal Cancer (Crc). It Allows Identifying Patients In The Low Risk Group In Whom Any Endoscopy Avoided. We Describe Our Experience Of Using Quantitative Fit To Guide Referral For Crc From Primary Care Using The Uk Nice Guidance Criteria. Methodology: Over A Six Month Period All Patients Were Assessed During Consultation In Primary Care To Determine If They Met The Criteria Of Nice Ng12 Or The Dg30 Guidelines. Fit Was Requested At The Time Of This Assessment. The Ng12 Guideline States That Patients Over 40 Years With Unexplained Weight Loss And Abdominal Pain, Patients Over 50 With Unexplained Rectal Bleeding And Patients Over 60 With Iron Deficiency Anaemia And Change In Bowel Habit Should All Be Referred For Suspicion Of Crc On The High Risk Pathway. The Dg30 Guideline Advises Patients To Be Referred On The Low Risk Pathway If Patients Is Aged 50 And Over With Unexplained Abdominal Pain Or Weight Loss, Patients Aged 60 And Under With Change In Bowel Habits Or Iron Deficiency Anaemia. All Patients On The High Risk Pathway (Ng12) Were Referred Into Secondary Care For Assessment / Investigations While Patients On The Low Risk Pathway (Dg30) Were Referred Only If They Met The Fit Threshold Of 10 Μg Hb/G Or Had New Iron Deficiency Anaemia. In Secondary Care, Clinical Judgement Was Applied Regarding The Need For Any Further Investigations. Results: 535 Patients Fulfilled The Criteria For The Low Risk Pathway And 364 Were On The High Risk Pathway. Only 19% (N = 101) Of The Patients On The Low Risk Pathway Met The Criteria For Secondary Care Referral Based On The Results Of The Fit Or Iron Deficiency. For The Patients On The High Risk Pathway, 133 Patients Were Downgraded In Priority As The Fit Test Were < 10 Μg Hb/G, 168 Patients Had Fit Test Between 10 And 99 Μg Hb/G And 28 Patients Had Results > 100 Μg Hb/G. The Median Age On Referral Was 73 With 11% Of All Patients Aged Below 50 Years. A Total Of 14 Cancers Were Diagnosed In This Group With 9 Crc And 5 Extra Colonic Cancers. All The Patients With Crc Had Fit > 100 Μg Hb/G (Pick Up Rate Of 22%). No Crc Were Diagnosed In Patients In The Intermediate Or Low Range Fit Test. Conclusion: Fit Is Likely To Be A Clinically Effective And Cost-Effective Strategy For Triaging People Who Are Presenting, In Primary Care Settings, With Lower Abdominal Symptoms And Who Are At Low Risk For Crc When Using The Dg30 And Ng12 Nice Criteria. References: Nice. Suspected Cancer: Recognition And Referral. National Institute For Health And Care Excellence, 2015. Nice. Quantitative Faecal Immunochemical Tests To Guide Referral For Crc In Primary Care. National Institute For Health And Care Excellence, 2017.

PREVALENCE AND BURDEN OF ILLNESS OF ROME IV IRRITABLE BOWEL SYNDROME IN THE U.S

Introduction: Rome IV irritable bowel syndrome (IBS) is characterized by abdominal pain and altered bowel habits, and meta-analysis reveals a global prevalence of 3.8%. Using data from the “National GI Survey II”—a nationwide audit of gastrointestinal (GI) symptoms in nearly 90,000 adult Americans—we aimed to determine the prevalence, burden of illness, and healthcare seeking behavior of those who met Rome IV IBS criteria. Methods: We conducted the National GI Survey II from 5/3-6/24/20, a period coinciding with the peak of the initial COVID-19 wave in the U.S. A representative adult sample based on U.S. Census age, sex, and region data was recruited. The self-administered survey guided participants through the Rome IV IBS questionnaire, NIH GI PROMIS symptom scales, and questions on comorbidities and demographics. A primary outcome was prevalence of IBS based on Rome IV criteria;we also determined the presence and severity of non-cardinal IBS symptoms and healthcare seeking for abdominal pain, constipation, or diarrhea in those with IBS. We used multivariable logistic regression to adjust for confounding variables. Results: Of the 88,969 individuals who completed the survey, 6,543 (7.4%) met Rome IV IBS criteria: mixed IBS (IBS-M), 34.0%;IBS with constipation (IBS-C), 32.1%;IBS with diarrhea (IBS-D), 29.6%;unsubtyped IBS, 4.4%. Females, non-Hispanic Whites, and those 30-49yo and with comorbidities (e.g., prior gastroenteritis, fibromyalgia, inflammatory bowel disease) had statistically higher odds for meeting Rome IV IBS criteria (all p<.001). Differences in pain severity, as measured by PROMIS, were not evident among the subtypes (p>.05). Table 1 presents the presence and severity of symptoms beyond the cardinal IBS symptoms;those with IBS-D or IBS-M were more likely to report excess gas, heartburn, regurgitation, nausea/vomiting, pelvic pain, or bowel incontinence vs. those with IBS-C, but symptom severity scores were largely similar among groups. Those with IBS reported the following healthcare seeking behaviors for their cardinal IBS symptoms: ever sought care, 73.8%;ever sought care via telehealth, 19.4%;sought care in past 12 months, 59.7%. Table 2 presents the healthcare seeking data stratified by subtype;those with IBS-D and IBS-M were less likely to have sought care vs. those with IBS-C. Discussion: In this nationwide U.S. survey, we found that Rome IV-positive IBS is more prevalent (7.4%) vs. prior estimates. Additional research is needed to understand if this higher prevalence is in part due to the COVID-19 pandemic, as social distancing may have levied a psychological toll on many individuals, leading to alterations in the gut-brain axis and a propensity to develop IBS or gain greater awareness of symptoms. We also noted that people with IBS commonly experience other symptoms on top of their cardinal IBS symptoms.(Table presented) (Table presented)