The Impact of the COVID Pandemic on Diverticulitis Surgery

Introduction: The COVID-19 pandemic disrupted maintenance healthcare and elective surgical volume, particularly for benign diseases, including diverticulitis. The study evaluates if the surgical management of diverticulitis was impacted by the pandemic. Method(s): All colectomies for diverticulitis in ACS-NSQIP between 2017-2020 were identified by CPT and ICD codes. Cases were divided into groups by the operation year and quarter variables. The first quarter of 2020 was excluded. The pre- COVID group included cases before 2020 and the post-COVID group included cases after the first quarter of 2020. Associations between groups and baseline demographics and postoperative outcomes were compared. Result(s): 46,839 colectomies were evaluated with 38,860 pre- COVID and 7,979 post-COVID. The groups were similar except for CHF(p=0.027) and ASA classification (p<0.001), which were higher post-COVID. However, pandemic cases were associated with significant markers of disease severity. Pandemic cases were more likely to have preoperative sepsis (p<0.001), wound class 4 (p<0.001), and emergency status (p<0.001). There was no difference in the rates of minimally invasive surgery (MIS) or conversion to open among MIS cases. There were also a higher percentage of Hartmann's procedures (p<0.001) post-COVID. However, there was no difference in mortality rates, length of stay, reoperation, open abdomen, readmission, reintubation, or prolonged intubation. There was an association between the pandemic and rates of postoperative pneumonia(p<0.001), ileus (p=0.003), and septic shock (p<0.001). Conclusion(s): During the first year of the pandemic diverticulitis surgeries were performed on sicker patients, more commonly emergencies, and Hartmann's procedures. However, these patients maintained comparable postoperative outcomes.

Diagnosing the acute abdomen during a global contrast shortage: a single centre experience.

BACKGROUND: The COVID-19 pandemic led to a global shortage of iodinated contrast media (ICM) in early 2022. ICM is used in more than half of the computed tomography of the abdomen and pelvis (CTAP) performed to diagnose an acute abdomen (AA). In response to the shortage, the RANZCR published contrast-conserving recommendations. This study aimed to compare AA diagnostic outcomes of non-contrast CTs performed before and during the shortage. METHODS: A single-centre retrospective observational cohort study of all adult patients presenting with an AA who underwent a CTAP was conducted during the contrast shortage period from May to July 2022. The pre-shortage control comparison group was from January to March 2022; key demographics, imaging modality indication and diagnostic outcomes were collected and analysed using SPSS v27. RESULTS: Nine hundred and sixty-two cases met the inclusion criteria, of which n = 502, 52.2% were in the shortage period group. There was a significant increase of 464% in the number of non-contrast CTAPs performed during the shortage period (P < 0.001). For the six AA pathologies, only n = 3, 1.8% of non-contrast CTAPs had equivocal findings requiring further imaging with a contrast CTAP. Of the total CTs performed, n = 464, 48.2% were negative. CONCLUSION: This study showed that when non-contrast CTs are selected appropriately, they appear to be non-inferior to contrast-enhanced CTAPs in diagnosing acute appendicitis, colitis, diverticulitis, hernia, collection, and obstruction. This study highlights the need for further research into utilizing non-contrast scans for assessing the AA to minimize contrast-associated complications.

Segmental Colitis Associated with Diverticulosis (SCAD).

PURPOSE OF REVIEW: A distinctive, possibly "novel" form of a segmental inflammatory colonic disease process associated with diverticular disease (so-called SCAD or segmental-colitis-associated-diverticulosis) is reviewed. RECENT FINDINGS: Although this phenotype of inflammatory colonic disease was initially recognized decades ago, mainly in the elderly, recent evidence from long term natural history studies along with meta-analyses confirms that its clinical course is usually benign and drug-responsive. Interestingly, its appearance in some treated with monoclonal agents (eg., ipilimumab associated colitis) or infected with coronavirus-19 may have critical implications for its pathogenesis. This review further explores the implications of recognition of this pattern of colonic inflammatory disease, with relevance for physicians involved in both clinical practice and clinical trials of newer therapeutic agents.

One-Year Comparison of Clinical and Endoscopic Outcomes of Tofacitinib Versus Vedolizumab for Ulcerative Colitis After Anti-Tumor Necrosis Factor Failure: A Real-World Cohort Study in the United States

Background: Tofacitinib (tofa) is an oral Janus kinase inhibitor for the treatment of ulcerative colitis (UC). We compared 52 week real-world outcomes of tofa vs vedolizumab (vedo) for UC after anti-TNF failure. Method(s): In this retrospective cohort study, adults initiated tofa or vedo after failure of >=1 anti-TNF between 5/1/18 and 4/1/21 at a large U.S. medical center. Vedo patients were frequency matched to tofa patients 2:1 by age and sex. The primary outcome was steroid-free clinical remission at 12 and 52 (+/- 4) weeks (SFCR 12 and 52, simple clinical colitis activity index [SCCAI] <=2 or provider assessment and no use of oral/IV steroids for >=30 days). The secondary outcome was endoscopic response (ER) within 52 weeks (decrease in Mayo endoscopic subscore [MES] by >=1 point). Other outcomes within 52 weeks: Endoscopic remission (MES=0), biochemical response/remission (improvement by 25%/normalization of C-reactive protein), drug discontinuation for non-response (NR), improvement in arthralgia, UC hospitalization, and adverse events (AEs). Multivariable logistic regression was performed for primary/secondary outcomes adjusting for UC duration, number of prior anti-TNFs, steroid/immunomodulator use, albumin, Montreal disease extent >E1, MES = 3, and UC hospitalization within 12 months. Result(s): 136 vedo patients were matched to 68 tofa patients. Tofa patients had more anti-TNF exposures, higher CRP and SCCAI, and most had prior vedolizumab exposure (Table 1). 54% of tofa vs 46% of vedo patients achieved SFCR 12 and 59% vs 45% achieved SFCR 52. Within 52 weeks, 74% tofa vs 55% vedo had ER, 30% vs 27% had endoscopic remission, 55% vs 50% had improvement in arthralgia, 71% vs 59% had biochemical response, 46% vs 32% had biochemical remission, 5% vs 13% had UC hospitalization, 30% vs 29% discontinued treatment for NR, and 0% vs 2% discontinued treatment due to AEs (vedo group only: Perforated diverticulitis, nausea, and oral pain) (Figure 1). During available follow-up (not limited to 52 weeks), the most common AEs (reported among >1% of total cohort) included rash (0% tofa vs 4% vedo), C. difficileinfection (1% vs 2%), shingles (2% vs 1%), COVID-19 (1% vs 2%), other infection (2% vs 4%), and elevated liver enzymes (1% vs 2%) (Figure 2). After multivariable logistic regression, tofa was associated with a non-significantly higher odds of SFCR 12 (OR 1.66, 95% CI 0.77-3.62) and significantly higher odds of SFCR 52 (OR 2.15, 95% CI 1.01-4.61) and ER within 52 weeks (aOR 3.42, 95% CI 1.08- 10.80) vs vedo. Conclusion(s): Tofa was associated with higher odds of SFCR 52 and ER vs vedo for UC. AEs were consistent with known safety profiles. Due to limited sample sizes, larger cohort studies are needed.

Effect of the COVID-19 pandemic on emergency department utilization of computed tomography scans of appendicitis and diverticulitis.

PURPOSE: Investigating the effect of the COVID-19 lockdown on adult patient visits, computed tomography (CT) abdominal scans, and presentations of appendicitis and diverticulitis, to emergency departments (ED) in St. John's NL. METHODS: A retrospective quantitative analysis was applied, using ED visits and Canadian Triage and Acuity Scale (CTAS) scores. mPower (Nuance Communications, UK) identified CT abdominal scan reports, which were categorized into (1) normal/other, (2) appendicitis, or (3) diverticulitis. Time intervals included pre-lockdown (January-February), lockdown (March-June), and post-lockdown (July-August). Data from 2018 to 2019 (January-August) were used to generate expected patient volumes for 2020, and pre- and post-lockdown were included to control for other variables outside the lockdown. RESULTS: Chi-squared goodness of fit tested for deviations from predicted means for 2018-2019. Compared to expectations, daily ED visits from January to August 2020 showed a significant (p < 0.001) decrease in patient volumes independent of gender, age, and CTAS scores. During and post-lockdown, CT abdominal scans did not drop in proportion to patient volume. Appendicitis presentations remained indifferent to lockdown, while diverticulitis presentations appeared to wane, with no difference in combined complicated cases in comparison to what was expected. CONCLUSION: During lockdown, significantly fewer patients presented to the ED. The proportion of ordered CT abdominal scans increased significantly per person seen, without change in CTAS scores. Considering combined pathology cases increased during the lockdown, ED physicians were warranted in increasing abdominal imaging as patients did not avoid the ED. This may have resulted from a change in clinical practice where the uncertainty of COVID-19 increased CT scan usage.

Utility of monocyte distribution width in the differential diagnosis between simple and complicated diverticulitis: a retrospective cohort study.

BACKGROUND: Colonic diverticulitis is a leading cause of abdominal pain. The monocyte distribution width (MDW) is a novel inflammatory biomarker with prognostic significance for coronavirus disease and pancreatitis; however, no study has assessed its correlation with the severity of colonic diverticulitis. METHODS: This single-center retrospective cohort study included patients older than 18 years who presented to the emergency department between November 1, 2020, and May 31, 2021, and received a diagnosis of acute colonic diverticulitis after abdominal computed tomography. The characteristics and laboratory parameters of patients with simple versus complicated diverticulitis were compared. The significance of categorical data was assessed using the chi-square or Fisher's exact test. The Mann-Whitney U test was used for continuous variables. Multivariable regression analysis was performed to identify predictors of complicated colonic diverticulitis. Receiver operator characteristic (ROC) curves were used to test the efficacy of inflammatory biomarkers in distinguishing simple from complicated cases. RESULTS: Of the 160 patients enrolled, 21 (13.125%) had complicated diverticulitis. Although right-sided was more prevalent than left-sided colonic diverticulitis (70% versus 30%), complicated diverticulitis was more common in those with left-sided colonic diverticulitis (61.905%, p = 0.001). Age, white blood cell (WBC) count, neutrophil count, C-reactive protein (CRP) level, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and MDW were significantly higher in the complicated diverticulitis group (p < 0.05). Logistic regression analysis indicated that the left-sided location and the MDW were significant and independent predictors of complicated diverticulitis. The area under the ROC curve (AUC) was as follows: MDW, 0.870 (95% confidence interval [CI], 0.784-0.956); CRP, 0.800 (95% CI, 0.707-0.892); NLR, 0.724 (95% CI, 0.616-0.832); PLR, 0.662 (95% CI, 0.525-0.798); and WBC, 0.679 (95% CI, 0.563-0.795). When the MDW cutoff was 20.38, the sensitivity and specificity were maximized to 90.5% and 80.6%, respectively. CONCLUSIONS: A large MDW was a significant and independent predictor of complicated diverticulitis. The optimal cutoff value for MDW is 20.38 as it exhibits maximum sensitivity and specificity for distinguishing between simple and complicated diverticulitis The MDW may aid in planning antibiotic therapy for patients with colonic diverticulitis in the emergency department.

Does the microbiome play a role in the pathogenesis of colonic diverticular disease? A systematic review.

BACKGROUND AND AIMS: The role of the microbiota in diverticulosis and diverticular disease is underexplored. This systematic review aimed to assess all literature pertaining to the microbiota and metabolome associations in asymptomatic diverticulosis, symptomatic uncomplicated diverticular disease (SUDD), and diverticulitis pathophysiology. METHODS: Seven databases were searched for relevant studies published up to September 28, 2022. Data were screened in Covidence and extracted to Excel. Critical appraisal was undertaken using the Newcastle Ottawa Scale for case/control studies. RESULTS: Of the 413 papers screened by title and abstract, 48 full-text papers were reviewed in detail with 12 studies meeting the inclusion criteria. Overall, alpha and beta diversity were unchanged in diverticulosis; however, significant changes in alpha diversity were evident in diverticulitis. A similar Bacteroidetes to Firmicutes ratio compared with controls was reported across studies. The genus-level comparisons showed no relationship with diverticular disease. Butyrate-producing microbial species were decreased in abundance, suggesting a possible contribution to the pathogenesis of diverticular disease. Comamonas species was significantly increased in asymptomatic diverticulosis patients who later developed diverticulitis. Metabolome analysis reported significant differences in diverticulosis and SUDD, with upregulated uracil being the most consistent outcome in both. No significant differences were reported in the mycobiome. CONCLUSION: Overall, there is no convincing evidence of microbial dysbiosis in colonic diverticula to suggest that the microbiota contributes to the pathogenesis of asymptomatic diverticulosis, SUDD, or diverticular disease. Future research investigating microbiota involvement in colonic diverticula should consider an investigation of mucosa-associated microbial changes within the colonic diverticulum itself.

Emergency surgical treatment of colonic acute diverticulitis: a multicenter observational study on behalf of the Italian society of colorectal surgery (SICCR) Lombardy committee.

Colonic diverticulitis can be treated conservatively, but some cases require surgery. Patients can undergo Hartmann's procedure (H) or resection with primary anastomosis (RA), with or without diverting stoma. This multicenter observational retrospective study aims to evaluate the adherence to current guidelines by assessing the rate of RA and H in Lombardy, Italy, and to analyze differences in patients' features. This study included data collected from nine surgical units performing emergency surgery in Lombardy, in 2019 and 2021. Data for each year were retrospectively collected through a survey among Italian Society of Colorectal Surgery (SICCR) Lombardy members. Additional data were about: Hinchey's classification, laparoscopic (VLS) or converted procedures, procedures with more than two operators, procedures in which the first operator was older than 40 years, night or weekend procedures, older-than-80 patients, COVID-19 positivity (just 2021). The total number of operations performed was 254, 115 RA and 130 H (45.3% and 51.2%, diff. 12%, p = 0.73), and 9 (3.5%) other procedures. RAs were more frequent for Hinchey 1 and 2 patients, whereas Hs were more frequent for Hinchey 3 and 4. RAs without ileostomy were significantly less than Hs (66 vs. 130, p = 0.04). Laparoscopy was more used for RA compared to H (57 vs. 21, p = 0.03), whereas no difference was found between RA and H with respect to conversion rate, the presence of more than two operators in the team, the presence of a first operator older than 40 years, night or weekend operations, and for older-than-80 patients. This study confirms the adherence to current guidelines for the treatment of acute colonic diverticulitis in Lombardy, Italy. It can be considered as a preliminary survey with interesting results that may open the way to a further prospective observational study to clarify some aspects in the management of this disease.

Fusobacterium nucleatum Pyogenic Liver Abscess and the Role of Bacterial Virulence and Gut Microbiota Dysbiosis.

In the United States, pyogenic liver abscesses are often due to monomicrobial infection and are rarely documented to be a consequence of Fusobacterium infection, a common cause of Lemierre's syndrome. Recent advances in gut microbial studies have identified Fusobacterium as a commensal gut flora that becomes pathogenic in the setting of dysbiosis resulting from colorectal diseases, such as diverticulitis. While the bacteria's tropism for the liver remains to be elucidated, the virulence pattern of Fusobacterium and the portal venous drainage system have allowed us to understand the bacterium's propensity for causing right hepatic abscesses. In this case report, we detail an immunocompetent man with a history of sigmoid diverticulitis who developed a right hepatic abscess due to Fusobacterium nucleatum, while delineating a review of the literature on the virulent properties of the bacterium and the impact of gut microbiota dysbiosis in its pathogenicity. A descriptive analysis was also performed to identify the characteristics of patients who are at risk in hopes of further improving the clinical diagnostic schema for this condition.

A Case Report on Superior Mesenteric Artery Thrombosis in a Covid-19 Patient

INTRODUCTION: This case report discussed and reviewed an atypical presentation of COVID 19 involving superior mesenteric artery thrombosis with associated ischemic colitis. Thrombosis had been reported in up to 50 percent of patients with severe COVID -19. The pathophysiology of thrombosis in COVID 19 infection may include increasing blood viscosity and endothelial damage. DESCRIPTION: Case: A 59-year-old male with GERD, hiatal hernia, and diverticulitis was presented with ten days history of abdominal pain and vomiting, which later became coffee ground in nature. He was diagnosed with COVID 19 seven days before his presentation. Lab work showed hypokalemia with lactic acidosis, polycythemia, leukocytosis, thrombocytosis, and elevated D dimer. Esophagogastroduodenoscopy demonstrated actively bleeding Mallory Weiss tear successfully treated with bipolar circumactive probe cautery (BICAP). The patient's abdominal pain worsened, and a repeat CTA abdomen revealed a superior mesenteric artery thrombosis with thickening of the distal small bowel and ascending colon. Vascular surgery was consulted, and performed catheter-assisted tPA thrombolysis to the SMA. Atrial fibrillation, diverticulitis, and other possible causes were eliminated as etiologies. DISCUSSION: Acute mesenteric ischemia is a rare abdominal emergency. Due to rapid deterioration, early diagnosis and treatment are momentous for management. Severe abdominal pain and hematemesis are the keys to starting the evaluation. Initial investigation should include basic labs with a coagulation profile;the most common abnormalities are polycythemia, metabolic acidosis, lactic acidosis, and leukocytosis. CTA provides exquisite detail of the vascular anatomy and beneficial information regarding other bowel pathologies. After diagnosis, definitive management with fluid resuscitation, antibiotics, and IV high dose unfractionated heparin, if not contraindicated, should be initiated immediately. Recently, catheter-directed procedures for intravascular thrombectomy have been used with tPA. CONCLUSION(S): In our case, we attempted to emphasize the importance of a high index of suspicion with proper history, physical examination, and appropriate imaging for proper diagnosis and management of this life-threatening incident.

Acute uncomplicated diverticulitis: To scope or not to scope?

Aims: To investigate whether endoscopic follow up after a CT proven diagnosis of acute uncomplicated diverticulitis detected additional pathology, specifically Colorectal cancer, and if our findings support The European Society of Coloproctology's consensus statement that "a single episode of CT verified uncomplicated diverticulitis endoscopic follow-up remains controversial and may not be necessary". Method(s): A retrospective study evaluated every General Surgical emergency admission with acute uncomplicated diverticulitis to our unit in a 5 year period (2015-2020) to assess for radiological diagnosis and endoscopic follow up. Result(s): Over The 5 years there were 685 admissions with acute uncomplicated diverticulitis affecting 547 individuals. 74.3% of admissions and 80.3% of individuals underwent a Computerised Tomography (CT) during admission. 244 admissions (48%) went On to have an endoscopic examination, with 12.3% of these being inpatient investigations. 50% (122) of patients undergoing endoscopy had confirmed uncomplicated diverticulitis. Of The remaining patients undergoing endoscopy, 79.5% had no pathology detected. Only 1 malignant polyp was discovered On endoscopy with no tumours detected. Conclusion(s): CT has a high sensitivity and specificity in The diagnosis of acute uncomplicated diverticulitis. We suggest that it is reasonable not to utilise endoscopy as a screening tool after uncomplicated diverticulitis and The risks versus benefits must be carefully considered, especially in The era of Covid-19 where resources are tight and waiting lists ever growing. An endoscopic procedure is a costly, uncomfortable procedure that puts The patient at risk of morbidity and mortality. Our findings support The European Society of Coloproctology's statement regarding endoscopic follow-up.

Management and ambulation of uncomplicated acute diverticulitis during the CoVID-19 Pandemic-a clinical audit in a district general hospital

Aims: To audit The management (ambulation versus admission) of acute diverticulitis presenting to a London DGH. Method(s): A retrospective clinical audit. Data On cases of acute diverticulitis presenting to The general surgical Department at Ealing Hospital were collected over a period of 92 days. The medical notes were screened and The indication for admission in hospital was recorded. Each admission was then assessed for compliance with standard criteria for appropriate admission, derived from national guidelines by NICE. Patients admitted despite not meting these criteria were deemed as inappropriate admissions. Result(s): mAll patient referrals to General Surgery at Ealing Hospital were screened from 1/7/21 to 30/9/21. 618 patients were identified. A total of 18 patients presented with radiologically-confirmed diverticulitis in this period (2.9%). Of these, 14 patients were admitted (77.8%). None of The patients ambulated met The criteria for admission. If The admitting teams were to adhere to National Guidelines, 15 of The 18 patients presented and 11 of The 14 patients admitted could have been safely ambulated. In inappropriately-admitted cases, none received surgical intervention. The mean number of days spent in hospital for inappropriate admissions was 3.27 (Range 1-8 days). This translates to 49 patient-days that could have been safely avoided according to national guidelines. The cost incurred by The NHS by The inappropriate admission of these patients is estimated at 78,400 p.a. Conclusion(s): Safe ambulation of patients presenting with acute uncomplicated diverticulitis can improve departmental efficacy, patient flow and ultimately reduce bed pressures and expenditure associated with hospital admissions.

The influence of the national lockdown during the COVID-19 pandemiconSurgical presentations and admissions in a University hospital

Background: The COVID-19 pandemic has significantly revolutionised medical practice around The world. Healthcare resources had to be prioritise for The management of patients infected with The virus whilst routine and elective surgeries were postponed in order to Free up hospital beds in anticipation for The influx of patients with COVID-19 requiring hospital admission. With The government announcing a national lockdown in March 2020, a striking reduction in The number of patients presenting to hospital was noted. Aim(s): Our aim was to establish how The COVID-19 pandemic has impacted on The number and presentations of General Surgical patients in a University hospital. Method(s): We conducted a retrospective study on General Surgical patients who were reviewed by The Surgical team at The University teaching hospital. Data was collected over two 7-weeks periods;between The 23rd March and 10th May 2020 (The first lockdown duration in The UK) and The corresponding 7-weeks in 2019 (that is between 25th March and 12th May 2019). Result(s): The analysis of our data showed that there was a significant reduction in The number of Surgical patients being admitted. 399 patients were admitted between 25th March and 12th May 2019 compared to only 245 patients during The lockdown period. The average admissions per day over The 7-weeks period dropped from 9 admissions per day in 2019 to 5 admission per day during national lockdown. Small bowel obstruction and pancreatitis remained common diagnoses in both 7-weeks periods, however diverticulitis was less common during lockdown.

COVID-19-Related Intestinal Ischemia in A 7-Year Old Boy.

Severe abdominal pain and vomiting are common symptoms in children with pediatric multisystem inflammatory syndrome (PIMS). Mesenteric lymphadenitis and aseptic peritonitis are predominantly reported in cases where acute surgical abdomen was suspected and laparotomy was performed at the early stage of the pandemic. These reports generally discouraged surgeons to perform exploration in COVID-19-related cases and medical management was prioritized. Only a few COVID-19-specific surgical cases with intestinal ischemia were published. Here, we report another case of COVID-19-related intestinal ischemia complicated with Meckel's diverticulitis in a non-immunocompromised child who clearly required surgical intervention. In our case, the combination of COVID-19-related vasculitis and low blood pressure episodes may have contributed to this severe outcome.

A CASE OF EGGERTHELLA BACTEREMIA IN A PATIENT WITH COVID-19

SESSION TITLE: COVID-19 Co-Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: We present a case of Eggerthella bacteremia in a patient with COVID-19. CASE PRESENTATION: A 69-year-old woman presented to the emergency room with chief complaint of cough, dyspnea, and malaise. After testing positive with a home COVID-19 test three days earlier, she continued to have worsening respiratory status and was brought in via ambulance. She was found to be tachycardic and hypoxic, requiring high-flow oxygen to maintain saturation in the emergency department. Chest X-ray showed bilateral patchy opacities consistent with multifocal COVID-19 pneumonia, and she was admitted to the intensive care unit for acute hypoxic respiratory failure. COVID-19 drug therapy was initiated, including baricitinib, remdesivir and decadron. Shortly after hospitalization, she began to endorse worsening abdominal pain. Physical exam elicited tenderness to palpation of her right lower quadrant. Abdominal CT scan showed distal ileum fluid collection concerning for possible bowel perforation. She underwent exploratory laparotomy which confirmed perforation, and a small bowel resection with anastomosis was performed. Blood cultures were positive for gram-positive bacilli, which were further identified as Eggerthella species. She required mechanical ventilation for worsening respiratory function post-surgery but remained unresponsive on the ventilator. The patient was administered vancomycin but continued to decline and eventually expired. DISCUSSION: Eggerthella is an anaerobic, gram-positive bacilli present in the gut microflora. Eggerthella infection has most often been reported in intra-abdominal infections. However, cases of bacteremia infection remain sparse. Most infections have been associated with other gastrointestinal processes including Crohn's disease, ulcerative colitis, appendicitis, and diverticulitis abscesses. Our case involved a patient with no significant gastrointestinal history admitted for COVID-19 pneumonia infection on baricitinib complicated by bowel perforation and bacteremia. Bowel perforation is a known risk factor of baricitinib use, and these risks should be discussed with the patient before beginning therapy. Overall mortality for Eggerthella species infection remains high, with some estimates as high as 31%. Much remains unknown about the impact on gut microbiome by SARS-CoV-2, however, early research suggests a higher rate of fungal co-infection in patients with COVID-19. As the literature on COVID-19 expands, more and more unusual pathogens such as Eggerthella may be found to contribute to the morbidity and mortality of patients being treated for COVID-19. CONCLUSIONS: Unusual pathogens such as Eggerthella may complicate a patient's hospital course while undergoing treatment for COVID-19. Reference #1: Alejandra Ugarte-Torres, Mark R Gillrie, Thomas P Griener, Deirdre L Church, Eggerthella lenta Bloodstream Infections Are Associated With Increased Mortality Following Empiric Piperacillin-Tazobactam (TZP) Monotherapy: A Population-based Cohort Study, Clinical Infectious Diseases, Volume 67, Issue 2, 15 July 2018. Reference #2: Gardiner BJ, Tai AY, Kotsanas D, et al. Clinical and microbiological characteristics of Eggerthella lenta bacteremia. J Clin Microbiol. 2015. Reference #3: Lau SK, Woo PC, Fung AM, Chan K-M, Woo GK, Yuen K-Y. Anaerobic, non-sporulating, gram-positive bacilli bacteraemia characterized by 16s rrna gene sequencing. Journal of medical microbiology. 2004. DISCLOSURES: No relevant relationships by Kristin Davis No relevant relationships by Charles Peng

Acute Cholecystitis and Diverticular Abscess Patient with COVID-19 Infection.

This is a case of a 53-year-old African American woman with newly diagnosed concomitant acute cholecystitis, diverticulitis, and SARS-COV-2 infection. She underwent treatment for COVID-19 with antibiotics and supportive treatment, and on day 32 after initial symptoms presented, she had an elective laparoscopic cholecystectomy. Our patient was one of the first cases to present with acute cholecystitis and diverticulitis complicated by COVID-19, and serves as a template for surgical management of non-emergent abdominal pathologies in the midst of the COVID-19 pandemic.

Voici le cas d'une Afro-Américaine de 53 ans chez qui on a diagnostiqué récemment une cholécystite aiguë concomitante, une diverticulite et une infection par le SRAS-COV-2. Elle a été traitée pour l'infection COVID-19 avec des antibiotiques et un traitement de soutien, et le 32e jour après l'apparition des premiers symptômes, elle a subi une cholécystectomie laparoscopique élective. Notre patiente a été l'un des premiers cas à présenter une cholécystite et une diverticulite aiguës compliquées par le COVID-19, et sert de modèle pour la gestion chirurgicale des pathologies abdominales non urgentes au milieu de la pandémie de COVID-19. Mots-clés: COVID-19, Diverticulite, Cholécystite, SARCOV-2.

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.

THE PROPER STUDY: A 48-WEEK ANALYSIS of A PAN-EU REAL-WORLD STUDY of SB5 BIOSIMILAR FOLLOWING TRANSITION from REFERENCE ADALIMUMAB in PATIENTS with RHEUMATOID ARTHRITIS, AXIAL SPONDYLOARTHRITIS or PSORIATIC ARTHRITIS

Background: SB5, a biosimilar to reference adalimumab (ADL), received EU marketing authorisation in 2017, based on pre-clinical and clinical phase I and III studies that demonstrated bioequivalence and comparable efficacy, safety and immunogenicity to ADL. Objectives: The real-world study 'PROPER' is designed to provide insights into outcomes of the transition from ADL to SB5 outside the randomised, controlled, clinical trial setting. Methods: Under an umbrella design, 1000 patients with immune-mediated infammatory disease were enrolled at centres in Belgium, Germany, Ireland, Italy, Spain and the UK, and followed for 48 weeks post-transition. Eligible patients with a diagnosis of rheumatoid arthritis (RA), axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), ulcerative colitis or Crohn's disease had been transitioned to SB5 as part of routine treatment following a minimum of 16 weeks' treatment with ADL. Data were captured from patient charts retrospectively for 24 weeks prior to and prospectively and/or retrospectively up to 48 weeks after SB5 initiation. This analysis of the rheumatology cohort reports clinical characteristics, disease scores, persistence on SB5, clinical management and safety up to the closing date of November 30th, 2021. Results: Of the 496 patients included in this analysis, the majority were enrolled in UK (n=174), Germany (n=145) and Spain (n=73);Italy, Ireland and Belgium enrolled 45, 44 and 15 patients respectively. At study close, 487 patients had completed 48 weeks of follow-up;397 of those remained on SB5 throughout. Methotrexate was received as concomitant therapy by 37% of patients and 20% had received a biologic therapy prior to reference ADL. Most patients (89.3% of RA, 92.1% of axSpA, 97.3% of PsA) transitioned to SB5 at the same dose regimen received for ADL. Clinical characteristics, SB5 dose and fare are detailed in Table 1, disease scores in Figure 1. Fifteen patients each experienced one unrelated Serious Adverse Event (SAE): 2 in the axSpA cohort [tachycardia, intracranial haemorrhage];6 in the PsA cohort [myocardial infarct (2), breast carcinoma, COVID-19, gallbladder calculus, dyspnoea];7 in the RA cohort [facial numbness, depression, COVID-19, pneumonia, diverticulitis, parvovirus, coronary occlusion]. Tw o patients reported SAEs considered causally related to SB5: Herpes zoster and pneumonia (RA cohort), and ALS with worsening (PsA cohort). Conclusion: This analysis of a large, contemporary cohort of EU patients with established RA, axSpA or PsA shows treatment effectiveness maintained at 48 weeks after switching from ADL to SB5, with most patients continuing on SB5 Q2W throughout. Episodes of fare were uncommon, and the importance of patient-reported symptoms in recognition of fare is evident. No new safety signals were observed.

COLONOSCOPY COMPLETION RATES AND PATIENT TOLERANCE AFTER COMPLICATED DIVERTICULITIS;IS CT COLONOSCOPY A BETTER OPTION?

Introduction ACPGBI and ESCP guidelines suggest colonic examination after acute complicated diverticulitis due to a higher prevalence of colorectal cancer (CRC), but colonoscopy in this cohort can be challenging. We examined completion rates, pain scores and analgesic use in endoscopic follow-up of complicated diverticulitis in a district general hospital. Methods Patients were identified from hospital records with a coded diagnosis of acute diverticulitis from 01/01/2021 - 01/ 07/2021. Electronic records were examined to identify those with complicated diverticulitis on CT who had not had surgery. The endoscopy system was interrogated from 01/01/2021 - 01/01/2022 for these patients. Information was collected on: whether colonoscopy was requested and performed, site reached, quality of mucosal views, pain scores (average of physician and nurse), analgesia and sedation use, and reason for incomplete colonoscopy. We gathered the same data for the preceding and/or succeeding patients on the endoscopy list for comparison. Results From 01/01/2021 - 01/07/2021 there were 49 cases of acute complicated diverticulitis;4 had emergency surgery. of the remaining 45 cases, 28 had a colonoscopy requested. By 01/01/2022, 17 had an colonoscopy (group 1), and the mean time from discharge to endoscopy was 108 days. These were compared to the 26 colonoscopies immediately preceding or succeeding the group 1 colonoscopies (group 2). Colonoscopy completion rates were lower in group 1, and reasons for incomplete examination were: patient discomfort x2, tight angulation x1, muscular hypertrophy x1. Reasons for incomplete examination in group 2 were: poor bowel prep x2. In group 1 the mean pain scores were higher, as was use of fentanyl and midazolam. Entonox use was about equivalent. Conclusions Endoscopic follow-up of complicated diverticulitis was not universal. There was a delay beyond the recommended follow-up at 6 weeks which corresponds with delays in endoscopy for other indications since the COVID-19 pandemic. Completion rates were lower for the complicated diverticulitis group and the procedure was more poorly tolerated. Colonoscopy completion rates have not been looked at specifically for complicated diverticulitis follow-up elsewhere. The completion rates in this sample are lower than those for the endoscopic follow-up of all diverticulitis in other studies. If these rates are found in a larger sample then alternative methods for examining the colon, such as CT colonoscopy, may be a more attractive option.

ATYPICAL PRESENTATION OF LEGIONNAIRES DISEASE WITH DIVERTICULITIS IN IMMUNOSUPPRESSED PATIENT

CASE: A 69-year-old male smoker with stage 3b prostate cancer managed with abiraterone and prednisone, prior severe COVID-19 pneumonia requiring mechanical ventilation, and history of perforated sigmoid diverticulitis presented with 3 days of anorexia, watery diarrhea, and left lower abdominal pain. Two weeks earlier he developed a mild dry cough without fever, dyspnea, or chest pain. There were no sick contacts or recent travel. He was afebrile, and initial routine chemistries and a complete blood count were unremarkable. An abdomino-pelvic CT revealed acute diverticulitis of the distal descending and sigmoid colon. A consolidation at the right lung base was also incidentally noted. Follow up imaging confirmed a multifocal pneumonia on chest Xray. Legionella antigen was detected in the urine. Metronidazole and levofloxacin were initiated with clinical improvement and the patient was discharged home to complete a 10-day course of antibiotics IMPACT/DISCUSSION: Legionella bacteria are gram negative organisms found widespread in soil and bodies of water including lakes, streams, and artificial reservoirs. Transmission is via inhalation of aerosols and a high innoculum is typically needed to cause infection. Host risk factors for infection include older age, impaired cellular immunity, smoking, male sex, and medical co-morbidities such as diabetes mellitus, renal, lung and cardiovascular disease. The two most commonly known syndromes associated with Legionella infection are Legionnaire's disease, a pneumonia occurring typically in the late summer or early autumn months (as in our patient), and Pontiac fever, an acute self- limited febrile illness. The mortality rate for hospitalized Legionnaire's is up to 10%. Extra-pulmonary manifestations are rare and can include skin and soft tissue infections, septic arthritis, endocarditis, myocarditis, peritonitis, pyelonephritis, meningitis, brain abscesses, and surgical site infections. The diagnosis of extra-pulmonary disease requires detection of Legionella at the affected site by culture or polymerase chain reaction. In the absence of a known local Legionella outbreak, our patient's age, sex, smoking status, and underlying immune suppression most likely increased his risk for this sporadic infection. We postulate that the acute diarrhea associated with Legionnaire's disease may have triggered inflammation of his diverticula or the acute diverticulitis was an extra-pulmonary manifestation. To our knowledge, we are the first to report a case of Legionnaire's disease presenting as acute diverticulitis. CONCLUSION: Legionnaire's is a typical disease with many atypical and extra-pulmonary presentations. We present a case of Legionnaire's disease masquerading as acute diverticulitis and urge timely consideration and testing for Legionella in at-risk patients presenting with predominantly GI symptoms and subtle or no respiratory complaints, as it can be life-saving.