Initiating Home Parenteral Nutrition Therapy in a Patient at High Risk of Refeeding Syndrome After COVID-19 Infection

Background: An emerging finding about COVID-19 is its effect on nutrition and weight loss. The COVID-19 symptoms of fatigue, altered taste or smell, and lack of appetite are well known. But COVID-19 may have a more profound effect on clinical nutrition status. Two recent studies have identified that approximately one-third of ambulatory COVID-19 patients are at risk of experiencing weight loss >= 5% (Anker, et al;di Filippo, et al). The case study presented here discusses home start total parenteral nutrition (TPN) in a patient recently diagnosed with COVID-19 at high risk for refeeding syndrome. Method(s): N/A Results: Case Study: A 92-year-old patient was diagnosed with COVID-19 on June 8, 2022. Over the next week, she was hospitalized twice to manage symptoms of acute mental status changes, lethargy, aphasia, hypotension, and loss of appetite. The patient received nirmatrelvir/ritonavir, remdesivir, and bebtelovimab to treat COVID-19 at different times between June 9, 2022, and June 18, 2022. She remained COVID positive and continued to deteriorate clinically. On June 20, 2022, the patient began receiving 24/7 homecare, including intravenous (IV) fluids of dextrose 5% in normal saline (D5NS) 1000 mL daily for three days. She continued to experience loss of appetite and had no bowel movement for 3 days. On June 23, 2022, she was referred to this specialty infusion provider to initiate TPN therapy in the home setting. The patient's BMI was 18.2 kg/m2. Lab results revealed potassium 3.0 mmol/L, phosphate 1.6 mg/dL, and magnesium 1.6 mg/dL. High risk of refeeding syndrome was identified by the level of hypophosphatemia and hypokalemia. The specialty infusion provider's registered dietitian recommended to discontinue D5NS and begin NS with added potassium, phosphate, and magnesium. Thiamine 200mg daily was added to prevent Wernicke's encephalopathy. The patient's clinical status and lab values were monitored closely each day until her electrolyte levels stabilized (Table 1). Home TPN therapy was initiated on June 28, 2022, with <10% dextrose and 50% calorie requirement with 85% protein and 1.0 g/kg lipids. Three-day calorie count and nutrition education were performed four days post TPN initiation. Oral intake met only 25% of estimated needs. Over several days, theTPN formula was gradually increased to goal calories and the infusion cycle was slowly decreased. The following week, the patient's oral intake improved to 60%-75% of estimated needs. Her constipation resolved, and she showed improvement in functional status and mobility. Her appetite drastically improved when the TPN was cycled. Another three-day calorie count was performed when TPN calories reached goals. Oral intake demonstrated 100% estimated calorie and protein needs. TPN therapy was ultimately discontinued on July 14, 2022. As of September 30, 2022, the patient has stabilized at her pre-COVID weight of 45 kg with full recovery of appetite, function, and cognition. Discussion(s): The ASPEN Consensus Recommendations for Refeeding Syndrome (da Silva, et al) describe the repletion of electrolyte levels before introducing calories to prevent end-organ damage associated with refeeding syndrome (respiratory muscle dysfunction, decreased cardiac contractility, cardiac arrhythmias, and encephalopathy). Conclusion(s): This case study highlights the successful initiation of home TPN therapy in a patient at high risk of refeeding syndrome post COVID-19 infection. Although home start TPN and the risk of refeeding syndrome are not new concepts, they must be considered in the setting of COVID-19. Given the effects COVID-19 has on taste, smell, and appetite and the recent finding that one-third of patients with COVID infection may experience weight loss of >= 5%, nutrition support and patient education are vital components of overall patient care. (Figure Presented).

Early Enteral Feeding With Prebiotic-Containing Formula in Critically Ill Mechanically Ventilated Covid-19 Patients

Background: Optimal supportive care which includes adequate nutrient delivery remains the cornerstone in managing critically ill patients with COVID-19. Nutrition guiding principles for critically ill patients with COVID-19 strongly recommend providing early enteral nutrition (EEN) within 24-36 hours of admission to the intensive care unit (ICU) or within 12 hours of placement on mechanical ventilation (MV). Moreover, data show critically ill COVID-19 patients have negative alterations in their gut microbiome which is attributed to many factors including insufficient EN and fiber provision. The success and tolerance of EEN with a prebiotic formula in patients with COVID 19 is unknown. Here we aimed to assess, before and after implementation of an enteral feeding protocol, the achievement of EEN, estimated energy goals, and tolerance of a prebiotic formula in MV patients with COVID-19. Method(s): Data were collected and analyzed retrospectively from June 2020-May 2021 and prospectively from June 2021-January 2022. A protocol to promote EEN and improve nutrition delivery with a prebiotic-containing formula to patients within the seven days of ICU admission was created and implemented in June 2021 in the Medical ICU. Time to start EEN following invasive MV was assessed. Feeding adequacy over the first seven days of ICU admission was calculated by dividing the mean total calories of formula infused over the first seven ICU days by the estimated goal calories/day. The average number of bowel movements (BM) over the first seven ICU days was used to evaluate feeding tolerance. To determine the impact of inflammation and co-morbid conditions on feeding adequacy and tolerance, admission C-reactive protein (CRP) and Charlson Comorbidity Index (CCI) were trended with feeding adequacy. The Institutional Review Board approved the study. Result(s): A total of 343 patient records were analyzed with 203 patients in retrospective (R) and 140 patients in prospective groups (P). The post- MV feeding initiation time was shorter after implementing the feeding protocol (Mean 45.2 vs 33.8 hrs, and Interquartile Range (IQR) of Median (hrs) (18, 51) vs (16, 43) for the R and P groups, respectively (p = 0.04). Achievement of feeding goal rates were similar between groups (30.0 % vs 29.5%) (p >0.05). A prebiotic-containing formula was received in 36.2 % of patients in the R group versus 43.4 % in the P group. Providing a prebiotic formula had no impact on achieving goal nutrition in either period. In the R group, patients receiving the non-prebiotic formula had a higher total 7-days BM occurrence compared to the prebiotic formula group (8 vs 5.9 BMs/7 days, p = 0.03). In the P group there were no differences in the number of BMs between non-prebiotic and prebiotic formula groups (5.3 vs 5.0 BMs/7 days, p >0.05). Higher admission CRP and CCI values trended with higher incidence of inadequate feeding. Mean CCI was 4.42 and 4.17 for patients who received less than 25% goal feeding compared to those who received >80% of their goal feeds, respectively. Mean CRP was 12.3 and 11.4 for patients who received < 25% goal feeds compared to those who received >80% of goal feeds, respectively (p > 0.05). There were no differences in overall ICU length of stay between the R (11.7 days) and P (11.1 days) groups. (p = 0.34) Conclusion(s): EEN protocol implementation decreased time to EEN initiation in mechanically ventilated COVID-19 patients but did not affect patients in achieving goal nutrition in the first week of their ICU stay. Furthermore, COVID-19 patients tolerated EEN with prebiotic containing formulas. Further research is warranted to determine the impact of EEN with a prebiotic formula on the gut microbiome in critically ill MV patients with COVID-19.

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).

Patient pathway in a tertiary referral pelvic floor unit: Telephone triage assessment clinic.

BACKGROUND: To meet the increasing demands for colorectal pelvic floor services, a dedicated telephone triage assessment clinic (TTAC) was set up to establish a more efficient pathway, and reduce waiting times and patient's visits to the hospital. The primary aim of this study was to review TTAC in patients suffering from pelvic floor dysfunction and assess its feasibility. Secondary aims include measurement of waiting times for TTAC, main presenting complaints, and main treatment outcomes, including the need for review by a consultant surgeon. METHODS: Review of data collected retrospectively in a single tertiary referral center collected from an institutional database. KEY RESULTS: Between January 2016 and October 2017, 1192 patients referred to our pelvic floor unit were suitable for TTAC. Of these, 694 patients had complete records. There were 66 without follow-up after the initial TTAC, leaving 628 patients for analysis. In all, 86% were females and 14% were males, with a mean age of 52 years (range: 18-89). The median waiting time for TTAC was 31 days (range: 0-184). The main presenting complaint during the TTAC was obstructive defecation in 69.4%, fecal incontinence in 28.5%, and rectal prolapse in 2.1%. In our study, 611 patients had conservative management (97.3%), with a median of three sessions per patient (range: 1-16), while 82 patients (13.1%) needed a surgical intervention. Only 223 patients (35.5%) were reviewed by a consultant at some stage during the study period. CONCLUSIONS AND INFERENCES: To optimize resources, an adequate triage system allowed us to streamline the pathway for each individual patient with pelvic floor dysfunction according to their symptoms and/or test results with the aim of reducing waiting times and expediting treatment.

Management of Extremely Complex Constipation Patients in a Nurse-Led Clinic with Health Play Specialist Involvement

Introduction Children with idiopathic chronic constipation are extremely challenging to manage. Before review by tertiary specialist teams, Children have suffered for years with constipation, which leads to significant behaviour related issues around toileting, despite adequate medical treatment. The involvement of the health play specialist (HPS) in the nurseled constipation clinic is to address behaviours around toileting. Aims To demonstrate involvement of HPS in the clinic led to improved outcomes for children and families. This will be identified through the use of parental satisfaction questionnaires and four case studies. Case Studies We demonstrate four extremely complex constipation cases referred to clinic and successfully managed by HPS with unique individualised approach with support and plans for parents and school. 9-year-old boy with history of sexual abuse, with soiling and wetting accidents. 5 sessions with the HPS, focusing on toileting behaviours. Sessions involved desensitizing play around the body, use of toilet related games/activities, videos and mobile apps. All issues resolved. 5-year-old boy: Stool with-holding, will only pass stools in a nappy and soiling. 8 sessions with HPS - Intense toilet training for 2-4 days with hourly sits. Reward charts to compliment interests, targets adjusted when goal reached, prizes given. Desensitization play around toileting behaviours. Using analogies to improve behaviour, he loved dustbin lorries - body empties the waste (poo) just like the bin men collecting the rubbish to get rid of it from home. No more accidents, independent toileting achieved 5-year-old girl Issues with constipation, soiling and toilet refusal. All bowel movements in knickers. Complete HPS treatment virtually, secondary to COVID restrictions. 6 Video call sessions- individualised plan of regular sits to relax, with no pressure to perform. To do an activity whilst on the toilet. Visual pictures/videos explaining how the body works and the plan was adjusted on the video. Rewards when child reached the target, and prize sent in post. Outcome -no fear of the toilet, bowels open on the toilet, no accidents. 8 year old boy premature 33 + 5 weeks. Constipation with overflow since birth. Referred to surgeons for rectal biopsies and botox injections at the age of 3 but no improvement. Age 4 admitted to the ward for 1 week for observation, transit marker study and toilet training was unsuccessful. Referred to another unit for second opinion at parental request. Started to refuse medications. ACE surgery discussed. Diagnosed with Autism at 7 years. Invited for a week of intense toileting with HPS, hourly sits and desensitization activities on medication taking, toileting, with-holding, signs and signals of body. Reward system in place, when reached expectations, reward given by hospital. Outcome bowels open daily in the toilet, wears pants all the time. Satisfaction questionnaires were given to parents and feedback was extremely positive. Conclusion The health play specialist involvement in the nurse led constipation clinic allows for individualised intervention guided by the child's needs. Pharmacological interventions alone may be unsuccessful without addressing behavioural needs.

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.

Pharmacist Optimization of Bowel Preparations in the Critically Ill: The Poopy Study

INTRODUCTION: Critically ill patients undergo stressful states while in the intensive care unit (ICU) and thus have alterations in bowel habits, including constipation in 20- 83% and diarrhea in 3.3-78%. Patients frequently receive opioid analgesics to assist with sedation and pain control. Appropriate bowel management is essential to prevent further complications during the ICU stay. The purpose of this study is to examine the various bowel preparations (BP) used in ICU patients, time to first bowel movement after initiation or escalation of a BP, and reason for BP discontinuation. METHOD(S): This multi-center, multi-ICU, retrospective observational review evaluated tele-critical care pharmacist interventions documenting initiation or change in BP from January 2, 2021 to June 30, 2021. Interventions were excluded if the BP was renewed, duplicate therapy and/or change in formulation. Descriptive statistics were used to describe the data. RESULT(S): One hundred ninety-six unique patients had at least one BP intervention. Baseline characteristics include 55% male, average age of 64 years, a BMI of 32.9, and 66% COVID-19 positive. One hundred seventy-four unique patients had a BP initiated or added on to current therapy, while 62 unique patients had current therapy escalated. The median days to first bowel movement after initiation or addition of a BP was 5.4 days (range 0-19). Ninety-eight percent of patients received an opioid, either continuous infusion or oral, and 90% received enteral nutrition. Docusate and senna were the primary BPs added when a regimen was initiated. Then, polyethylene glycol was added as the next BP. Lactulose and bisacodyl suppositories were added as 4th line treatment if the patient had not experienced a bowel movement. Methylnaltrexone was used in 1 patient. Fifty-two unique patients had one or more medications from their current bowel regimen discontinued due increased stool output, diarrhea, multiple bowel movements within last 24 hours, or the patient refusing the medication. CONCLUSION(S): Initiation of BPs in critically ill patients, especially if receiving an opiate, may be delayed. Bowel regimen initiation should be considered when the patient is placed on opiate therapy. If the patient continues to have a delayed response to therapy, prompt escalation of therapy may be warranted.

Comprehensive, longitudinal wastewater surveillance for SARS-CoV-2 across a university campus, demonstrates low levels of SARS-CoV-2 activity relative to the surrounding community

Background. Universities are interactive communities where frequent contacts between individuals occur, increasing the risk of outbreaks of COVID-19. We embarked upon a real-time wastewater (WW) monitoring program across the University of Calgary (UofC) campus measuring WW SARS-CoV-2 burden relative to levels of disease in the broader surrounding community. Figure 1 The colour scheme shows 6 sewer sub-catchments at the University of Calgary. Auto samplers were deployed at 4 sampling nodes within sub-catchments CR and YA (both residence halls), and UCE and UCS (catchments that include several campus buildings). Figure 2 Log10-transformed abundance (i.e., copies per mL) of nucleocapsid gene (i.e., N1) for SARS-CoV-2 for each sampling location during October 2021 - April 2022. Locations denoted by the same letters (A, B, or C) show no statistical difference (p > 0.05) according to the Wilcoxon rank-sum test. The WWTP sample corresponds to a catchment area covering most of Calgary including the university campus, for which sampling locations CR, UCE, UCS, and UCW are defined in Fig. 1. Methods. From October 2021 - April 2022, WW was collected thrice weekly across UofC campus through 4 individual sewer sampling nodes (Fig. 1) using autosamplers (C.E.C. Analytics, CA). Results from these 4 nodes were compared with community monitoring at Calgary's largest WW treatment plant (WWTP), which received WW from surrounding neighborhoods, and also from UofC. Nucleic acid was extracted from WW for RTqPCR quantification of the N1 nucleocapside gene from SARS-CoV-2 genomic RNA. Qualitative (positive samples defined if cycle threshold < 40) and quantitative statistical analyses were performed using R. Results. Levels of SARS-CoV-2 in WW were significantly lower at all campus monitoring sites relative to the WWTP (Wilcoxon rank-sum test p < 0.05;Fig. 2). The proportion of WW samples that were positive for SARS-CoV-2 was significantly higher for WWTP than at least two campus locations (p < 0.05 for Crowsnest Hall and UCE - University way and campus drive) according to Fischer's exact 2-sided test. The proportion of WW samples with positive WW signals were still higher for WWTP than the other two locations, but statistically not significant (p = 0.216). Among campus locations, the buildings in UCE catchment showed much lower N1 signals than other catchments, likely owing to buildings in this catchment primarily being administration and classroom environments, with lower human-to-human contact and less defecation compared to the other 3 catchments, which include residence hall, a dining area, and/or laboratory spaces. Conclusion. Our results show that SARS-CoV-2 RNA shedding in WW at the U of C is significantly lower than the city-wide signal associated with surrounding neighborhoods. Furthermore, we demonstrate that WW testing at well-defined nodes is a sampling strategy for potentially locating specific places where high transmission of infectious disease occurs.

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.

Successful Outcome of AKI in a Patient With Leptospirosis and COVID-19 Infection

Introduction: Severe leptospirosis manifests as pulmonary edema leading to ARDS. Superimposed Covid-19 increases the risk ARDS and AKI. Cytokine storm is the main incriminating factor in both. High-dose steroids have been used to facilitate the effects of covid-19 and leptospirosis. Case Description: A 31-year-old male farmer was admitted to ER on Nov 10, 2020. According to PMH, the diseases presented on Nov 3 with chills, fever, abdominal pain, diarrhea. On admission he had decreased urine output, edema, fever, abdominal pain, diarrhea. Laboratory tests were significant for uremia, abnormal liver enzymes, thrombocytopenia, leukocytosis, elevated LDH. Leptospirosis serology test was positive. Doxycycline 200mg added. Hemodialysis was started. Oxygen saturation fell to 74% on room air. Nasopharyngeal swab tested positive for COVID-19. Methylprednisolone 500mg i/v for three consecutive days, followed by 32mg. Chest CT showed bilateral ground-glass opacities Fig.1. From Nov 23 his clinical condition improved: urine output increased, oxygen saturation became 98% on room air, bowel movements one time per day. He was discharged. In December serum creatinine dropped to basic levels (89 mcmol/L). CT scan of the lungs showed almost complete resolution of the opacities Fig.2. Discussion(s): Our case demonstrates successful resolution of the severe ARDS, AKI, with complete restoration of the kidney function under steroid therapy. Further trials are needed to elaborate recommendations on steroid therapy during co-existing covid-19 and leptospirosis.

Functional Gastrointestinal Disorders in Children Following Sars-Cov-2 Infection Resemble Other Post-Viral Syndromes

BACKGROUND: Post-infectious functional gastrointestinal disorders (PI-FGID) involve a broad group of well-recognized conditions such as Irritable Bowel Syndrome (IBS) and Functional Dyspepsia (FD) that follow an infectious illness involving the GI tract. Post-infectious IBS (PI-IBS) is the most well-known entity occurring in ~10% of patients following acute gastroenteritis due to bacteria or enteropathic viruses, and can last for several months. The SARS-CoV-2 (COVID-19) virus appears to infect the GI system as well as the respiratory tract. While respiratory signs and symptoms are generally the most prominent and life-threatening aspects of COVID-19 infection, nearly half of COVID-19 cases present with digestive symptoms such as diarrhea, anorexia, vomiting, nausea, and abdominal pain. COVID-19 infection has also been associated with autonomic dysregulation, manifesting as fatigue or dizziness. In addition, COVID-19 may infect the brain and lead to MRI changes which may alter emotions and somatic perception. The goal of this study was to determine the impact of COVID-19 on PI-FGID symptoms in children and adolescents. METHODS Recruitment: An electronic medical record (EMR) search was carried out to find all patients 8 years of age or older who were COVID-19 tested at the Ann and Robert H. Lurie Children's Hospital of Chicago between November 2020 and October 2021. Questionnaires: A COVID-19 Phenotype survey was administered to identify COVID-19 symptoms, severity, and duration in the 7 days prior to the COVID-19 test. The following questionnaires were distributed to the parent or guardian of the COVID-19 tested child with instructions to refer to the 3 months following the test (1) COMPASS-31 - assesses presence of symptoms of dysautonomia;(2) PEESS v2.0 - assesses frequency and severity of symptoms of esophageal dysfunction;(3) QPGSIV - assesses presence of functional nausea/vomiting, defecation, and pain disorders;(4) Nausea Profile (NP) - assesses severity of somatic, gastrointestinal and emotional symptoms associated with nausea;(5) Dyspepsia Symptom Survey (DSS) - novel survey to assess frequency and severity of symptoms related to gastric or duodenal dysfunction;(6) Nausea Severity Profile - assess severity of nausea (7) PedsQL General Well-Being Survey - assesses overall quality of life. An email was sent in July 2021 to patients tested November 2020-March 2021, and an email was sent in December 2021 to patients tested April-October 2021. Consent was obtained by patients agreeing to complete the surveys, and data were collected to a RedCAP database. Data analysis: A comparison of survey results was carried out for the following subgroups: COVID-19 positive, COVID-19 negative without symptoms at time of viral testing, and COVID-19 negative with symptoms at time of viral testing. Due to the small size of the COVID-19 positive group relative to the COVID-19 negative groups, a Mann-Whitney U was utilized to compare the COVID-19 positive group with the COVID-19 negative asymptomatic group and COVID-19 negative symptomatic group separately, along with the COVID-19 negative asymptomatic group versus the COVID-19 negative symptomatic group. Categorical data were compared via Fischer's Exact Test. RESULT(S): A total of 771 patients/parent(s)/guardian(s) completed the required questionnaires. The demographics for each of the comparative subpopulations were well-matched. The COVID-19 negative patients with symptoms present prior to the COVID test had significantly increased composite scores on all surveys compared to the COVID-19 negative asymptomatic group (p-values=0.014-0.0001). The COVID-19 positive group had no significant differences in composite scores compared to the COVID-19 negative symptomatic group with the exception of the NP somatic score (p-value=0.02). The COVID-19 positive group had significantly increased composite scores compared to the COVID-19 negative asymptomatic group on the DSS frequency composite and NP somatic, gastrointestinal, and emotional scores (p-value=0.03-0.0001). The COVID-19 negative symptomatic group had a significant increase in FGID prevalence detected by the QPGSIV (p-value <0.05) compared to the COVID-19 negative asymptomatic group, while the COVID-19 positive group showed no difference. CONCLUSION(S): We found an increased frequency of functional dyspepsia and nausea symptoms compared to a control population, although no differences were seen compared to a population with presumptive non-COVID-19 infection. Further, we found a significant increase in somatic and emotional symptoms in COVID-19 positive patients compared to a control population underscoring the need for a comprehensive biopsychosocial approach. Thus, Long-COVID GI disease likely exists in children. However, its manifestations do not appear worse than those following any other viral infection.

Aida Analysis of Swachh Bharat Abhiyan: Role of Behavioral Antecedents

The aim of advertising is to encourage consumers to buy or use what the company is offering. AIDA theory of advertising describes the effect of advertising media. According to AIDA model, a potential consumer goes through 4 phases when deciding whether to buy a product and these correlate to the 4 phases of the AIDA model. AIDA theory of advertising describes the effect of advertising media. The acronym AIDA stands for Attention/Awareness, Interest, Desire and action. The effectiveness of any advertising campaign can be easily judged through the four stages of AIDA theory. In the first phase, the attention of consumers is captured. Once the consumer is aware that the product or service exists, the business should work on increasing the potential’s customer’s interest level. In the third phase, an emotional connection is established moving consumer’s mindset from “I like it” to “I want it”. In the last stage, the focus is on achieving ultimate goal which is to drive the receiver of the marketing campaign to initiate action and purchase the product or service. India accounts for about 90% of the population in South Asia and 59% of the 1.3 billion people still defecate in open, making it the single largest contributor to open defecation in the world. India loses atleast 1000 children a day to diarrhoeal deaths due to open defecation and lack of proper sanitation facilities. Due to the increment of awareness of environmental issues, health issues and also economic issues, Swachh Bharat campaign has been established. On launching Swachh Bharat Abhiya, PM Narendra Modi had said “the pursuit of cleanliness can be an economic activity contributing to GDP growth, reduction in health care costs and a source of employment. Mahatma Gandhi wished to see a "Clean India" where people work hand in hand to make the country clean. To work seriously towards this vision of Gandhi Ji, Prime Minister Shri Narendra Modi launched the Swachh Bharat Abhiyaan on October 2, 2014 and asked people from all walks of life to help in successful implementation of this mission. He invited all the Indians to devote 100 hours to clean their surroundings. In order to bring out behaviour change, extensive awareness generation initiatives would need to be undertaken with regards to the negative healthcare issues related to open defecation. The campaign has been described as "beyond politics" and "inspired by patriotism". Post COVID the need for social distancing and personal hygiene is going to bring about several structural changes right from how people stand in a queue or get a haircut to flying or watching movies. The new institutional practices are likely to remain in place for a longer period of time, with some becoming a permanent feature of public life. The present paper seeks to study the Swachh Bharat Abhiyan (SBA) through the lens of AIDA model. The study investigates the perception of people towards SBA through behavioural antecedents viz. attitude towards SBA, role of social media & subjective norms. This study is carried out to explore consumers’ demographic variables and their significant influence on the 4 variables of AIDA theory. Research Methodology: This quantitative study employed the exploratory research design. Data was collected from 335 respondents from all over India which covered North region, South-East, South-West, East, West, North-East, North-West and central region with the help of a structured questionnaire and focus groups. Percentage analyses, one way ANOVA and multiple regression are the statistical tools adopted for testing the hypotheses using SPSS. Findings and Implications: The statistically significant results revealed that category influences interest, desire & action of individuals. Education also positively impacts desire & action of individuals. Service class people were found to show more interest in SBA. Females were found to show more desire and action towards SBA activities. Single respondents show more desire in SBA. Religion was also found to affect SBA activities. People from Eastern egion are more attentive to SBA activities while people from South West region were found to show interest in SBA activities. North West people have desire to actively participate in SBA while respondents from South East are the most action-oriented people as far as SBA activities are concerned.

EFFECTS OF SACRAL PHOTOBIOMODULATION ON THE AUTONOMIC NERVOUS SYSTEM IN PATIENTS WITH COLONIC DYSMOTILITY

Background: Patients with chronic refractory constipation show colon dysmotility, including impaired coordination of descending colon-sigmoid colon-rectum-anal sphincter motor functions;this may involve slow colonic transit and colo-anal dyssynergia. Impaired neuronal communication between the sacral defecation center and the distal colon may be causative. In addition, patients with lumbosacral neurological conditions (with lower back pain) may not be able to evoke an effective defecation reflex. Aims: To evaluate if a single therapeutic session of sacral low-level laser therapy (LLLT) would affect the autonomic activity in patients with chronic constipation as revealed by changes in heart rate variability, and to report a multi-session treatment case study. Methods: In 41 patients with chronic constipation, one session of LLLT was executed, using red LED light at a wavelength of 660 nm for 10 minutes and infrared LED light at wavelength of 840 nm for 10 minutes followed by infrared laser light with wavelength of 825 nm for 20 minutes, while measuring the electrocardiogram. One patient received this treatment 8x over 3 weeks. Results: The lumbar-sacral light array treatment showed a significant decrease in parasympathetic activity (RSA & RMSSD) whereas pure sacral laser light treatment showed a significant increase in parasympathetic activity (RSA & RMSSD) as well as a reduction in sympathetic activity (Baevsky's stress index: SI) (table). A single session of LLLT was also executed during HRCM in 8 patients with some but not all showing evoked colonic motility. Before COVID-19 shutdown, one patient was successfully treated. With a history of chronic constipation without ability to have spontaneous bowel movements for 5 years, symptoms improved from 13 to 8 (on a 20 scale) and quality of life improved from 1.5 to 2.5 (on a 0-4 scale) after 8 sessions. Sympathetic reactivity from supine to standing markedly reduced, from highly elevated measured as the Baevsky index from 55 to 153 s-2 it improved from 42 to 75 s-2 upon standing after 4 sessions. Parasympathetic reactivity did not change. Conclusions: A single session of sacral LLLT markedly affected autonomic nervous activity reflected in changes in HRV. The LLLT is likely affecting the sacral defecation center through peripheral nerves entering and exiting the spinal cord including the dorsal root ganglia. LLLT treatment of a patient with inability to generate spontaneous bowel movements, resulted in ability to have complete evacuations associated with marked reduction in sympathetic reactivity during the supine-standing test, after 4 LLLT sessions.

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.

MORE THAN A COINCIDENCE: RECURRENT COVID-19 DRIVEN ULCERATIVE COLITIS FLARES

CASE: A 61-year-old male with no prior medical history presented with hematochezia, significant weight loss, and abdominal cramping for the past three months. Abdominal pain was predominantly present in the suprapubic area and alleviated with bowel movements. He reported acute worsening of diarrhea frequency with 15 episodes of bowel movement daily. He had similar symptoms in the past when he was diagnosed with a parasitic infection. Physical exam demonstrated diffuse, mild tenderness in all four abdominal quadrants with hyperactive bowel sounds. Infectious workup was negative at the time for stool parasites or bacteria. Lab results were significant for elevated non-specific inflammatory markers including ESR and CRP. CT abdomen revealed diffuse circumferential wall thickening of the entire colon and rectum and multiple associated pericolonic adenopathies, consistent with an inflammatory process. The patient was admitted for management of ulcerative colitis for intractable pain and worsening diarrhea. Of note, he was also found to test positive for COVID19, without significant respiratory symptoms. Colonoscopy confirmed active ulcerative colitis throughout the colon. He was subsequently treated with a course of steroids and initiated on mesalamine upon discharge. Four months later, he was readmitted for an acute flare-up;he developed increased frequency of bowel movements and severe abdominal pain despite adherence with his medication regimen. He was found to have a new COVID19 infection. Other infectious work up was once again negative, with no evident exacerbating factors for his new flare. He was started on adalimumab with routine infliximab infusions with effective control of symptoms. After resolution of his COVID-19 infection, he since then had no further flares from his ulcerative colitis. IMPACT/DISCUSSION: Studies have now demonstrated links between COVID-19 and the sequelae of certain systemic inflammatory pathologies. Here, the evident trigger for our patient's flares were his underlying, concurrent COVID-19 infections. Even though this may initially appear coincidental during his index hospitalization, his later flare highlights a plausible clinical correlation. Though the pathophysiology of COVID-19 associated inflammatory states remains unclear, it could very likely be implicated in primarily exacerbating ulcerative colitis flare ups. CONCLUSION: Ulcerative colitis flares in the inpatient setting require urgent clinical attention, yet often the exacerbating trigger may be unknown. Here, we describe the importance of taking into consideration COVID-19 infection as an independent risk factor for ulcerative colitis flares.

COVID-19 EXACERBATES EXISTING DIGESTIVE DISORDERS AND TRIGGERS NEW DIGESTIVE SYMPTOMS AND DIAGNOSES: RESULTS FROM AN INTERNATIONAL PATIENT SURVEY

Background/Aims: COVID-19 infection can affect nearly every organ system including the gastrointestinal (GI) tract. GI symptoms such as nausea, pain and diarrhea are common and may be due to infection and/or increased stress and isolation from the pandemic. It is well known that stress affects GI function and sensation, particularly in patients with irritable bowel syndrome (IBS). The aim of the study was to elucidate the impact of the COVID-19 pandemic on GI symptoms. Methods: An international online survey (Alchemer) was available via the International Foundation of GI Disorders (IFFGD) website from August 11, 2021- November 17, 2021. There were 57 questions exploring demographics, GI symptom/disorder classification, care delivery, administration and perceptions of COVID-19 vaccination, and health experiences during the pandemic. No compensation was provided for survey completion and patients were able to selectively answer questions, with some questions not analyzed for this report. Results: Survey data was included from 210 patients with GI symptoms (mean age 47.7 yrs, 83% female, 80% Caucasian). Participants' primary GI conditions included 36% IBS, 26% gastroparesis, 6% constipation, and 9% acid reflux (figure 1). Seventy percent reported the pandemic impacted their GI health and nearly 3 out of 4 (73%) reported increased pandemic-related anxiety or depression. COVID-19 was diagnosed in 40 (19%) participants. Nearly 3 out of 4 (74%) experienced new or worsening GI symptoms after a COVID-19 diagnosis. Almost a third (30%) with COVID-19 were diagnosed with post-infection (PI) IBS and 38% were diagnosed with a new GI disorder other than PI-IBS. New GI diagnoses after COVID-19 included gastroparesis (53%), GERD (13%), and diarrhea (7%) (figure 2). Prior to diagnosis of PI-IBS, 58% did not have a GI diagnosis. Almost half (46%) of patients reported new acid reflux symptoms after COVID-19. Almost 3 out of 4 patients (72%) with COVID-19 noticed changes in digestion and/or bowel movements. More than two thirds (67%) noted COVID-related GI symptoms lasted >3 months. Nearly 3 out of 4 (72%) patients felt their GI symptoms were harder to manage after COVID-19. Conclusions: Our results highlight the significant burden of GI illness imposed by the COVID-19 pandemic. COVID-19 exacerbated existing GI conditions, increased anxiety and depression, and led to a wide range of new GI issues, led by but not limited to PI-IBS. New diagnoses of upper GI disorders including gastroparesis and GERD were surprisingly common. Further prospective studies to validate these observations and understand their pathogenesis are warranted. (Figure Presented) Figure 1: Participants primary gastrointestinal condition or disorder prior to the COVID- 19 pandemic. (Figure Presented) Figure 2: New GI disorders diagnosed after being diagnosed with COVID-19

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).