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

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

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.

A contrasting diagnosis: iododerma

An 86-year-old woman presented to the emergency department with acute shortness of breath. She was treated with intravenous furosemide for acute-on-chronic heart failure. Her past medical history included atrial fibrillation, hypertension, diverticulosis and hypothyroidism. Rivaroxaban and levothyroxine were her only long-term medications. On day 5 of hospital admission, she developed painful haemorrhagic and purulent bullae on her dorsal hands, head and neck. These evolved to large suppurative, vegetative plaques over a 72 h period and she developed additional lesions on her trunk, upper back and thighs. The patient had routine blood tests, which showed a raised C-reactive protein at 260 mg L-1, and an acute kidney injury with a glomerular filtration rate of 54 mL-1 min-1. She had a negative COVID-19 swab, and swabs from the lesions for bacterial culture and viral polymerase chain reaction were negative. She had a normal serum protein electrophoresis, immunoglobulin, antinuclear antibody and antineutrophil cytoplasmic antibody. She had computed tomography of her chest 24 h prior to the onset of her lesions, which showed mild bilateral pleural effusions in keeping with fluid overload secondary to heart failure. A biopsy taken from her hand showed orthokeratosis and parakeratosis, and there was bulla formation subepidermally. There was a dense neutrophilic infiltrate with microabscess formation with scattered eosinophils and lymphocytes. There was no evidence of vasculitis. Direct immunofluorescence was negative and a tissue culture for atypical mycobacteria was negative. The patient was commenced on high-dose intravenous methylprednisolone at 500 mg for 3 days followed by 40 mg prednisolone orally for 1 week, but there was a limited response. Our initial differential was Sweet syndrome or pyoderma vegetans;however, the patient had no fevers and no risk factors (malignancy, inflammatory disease, infection, etc.). She also had no response to high-dose oral prednisolone. Given the timing of her CT examination in relation to her acute dermatosis and the use of radioiodine for contrast, we assessed the patient's serum iodine and urine iodine. These were both high at 1.02 mmol L-1 (reference interval 0.32- 0.63) and 3.46 mmol L-1 (reference interval 0.0-2.43), respectively. A diagnosis of iododerma was made. The patient's eruption slowly resolved and at 12 weeks there was evidence of postinflammatory skin changes only. Her urine and serum iodine were rechecked, and both had normalized. In the last 20 years there have been approximately 20 case reports of iododerma. Most have been following iodine contrast use in patients with abnormal kidney function, like our patient. Most describe an acneiform eruption that subsequently evolves to vegetative plaques (Chalela JG, Aguilar L. Iododerma from contrast material. N Engl J Med 2016;374: 2477). Iododerma is largely a diagnosis of exclusion, but histopathology and urine and serum iodine levels can help support diagnosis.

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.

Lower Gastrointestinal Bleeding Management as Per British Society Gastroenterology Guidelines: A Departmental Audit, Pilgrim Hospital

Aim: In 2019, the British Society of Gastroenterology (BSG) published the first United Kingdom national guidelines for acute lower gastrointestinal bleeding (LGIB),(1) following inadequacies in LGIB emergency service provision.(1,2) Method: We performed a retrospective cohort study (January 2019 to September 2020), using paper and electronic notes through coded data, for all LGIB emergency surgical admissions for LGIB. Paper and electronic notes were used, in retrieving data. Primary outcome end-points: evaluate our standards as per BSG guidelines. Result(s): 48 patients were identified as matching the inclusion criteria, with a median age of 64.75 and diverticular diseases accounting for the majority of cases. None of the patients were categorised in the group of being stable/unstable or had their Oakland scores calculated. 62.5% of patients were offered outpatient investigations versus 6.25% for inpatient investigations. 0% of unstable patients were offered a CT angiogram (as no patients were stratified as unstable). 75% of patients achieved haemoglobin target levels post-transfusion. 100% of patients taking warfarin and dual antiplatelets followed guidelines versus 50% on clopidogrel, 80% on dual antiplatelet therapy and 63.6% on aspirin alone. Conclusion(s): This study found that our department did not adhere to the BSG guidelines. This can be improved through the routine calculation of the Oakland score and shock index, which will stratify clinical risk. Additionally creating an agreed trust management pathway and assigning a gastrointestinal bleed lead will allow for earlier detection and encourage better clinical practice. Whilst there were limitations due to restricted data collection, as a result of the coronavirus, further research will identify how these implementations can be amended and if the changes are effective in local practice.

Single-center experience in robotic-assisted Colorectal Surgery during COVID pandemic: First 72 cases

Aim: To present an analysis of The first 2-years' experience of robotic-assisted Colorectal procedures (RACp) using The DaVinci Xi platform. Method(s): This data were prospectively collected and include 72 RACp between February 2020 and December 2021.Indications were: malignancy in 74.3%, diverticular disease 10%, inflammatory bowel disease 8.6%, rectal prolapse 4.3%, intussusception 1.4% and recurrent volvulus 1.4%. Result(s): Over The 13-month study period, 72 RACp were performed including elective 57 cases and 15 semi-elective cases. These comprised: 25 right hemicolectomies, 25 high anterior resections, 6 extended right hemicolectomies,4 low anterior resections, 4 subtotal colectomies 2 restorative proctectomies, 3 abdominoperineal excisions of The rectum, 3 rectopexies that were performed. 51.2% were female and 48.6% were male with a median age of 45 years (22-85 years) and The median body mass index was 31 (18-46) kg/m2. Preoperative American Society of Anaesthesiology scores were reported as 1-2 in 72.9% (n=51) of patients and 27.1%(n=19) as 3. The median length of stay was 5 days (1-35), with readmission rate within 30 days of 8.6% (n=6) that were resolved conservatively. The mean operating time was 268 minutes and The mean console operative time was 158 minutes, with only 3 (4.3%) reported cases of conversion to open. The incidence of postoperative complications was 24.3% (Clavien-Dindo (CD) I/II-12.9%, CD III-10%, and CD V-1 case with superimposed COVID 19 within 30 days. Conclusion(s): RACp is a safe and viable modality in The treatment of Colorectal conditions and can be introduced safely with appropriate guidance and proctorship.

DIEULAFOY LESION CAUSING LOWER GI BLEEDING: A CASE OF COVID-19 CRITICAL ILLNESS PROMPTING UNUSUAL PRESENTATION OF A MORE RARE CONDITION

SESSION TITLE: COVID-19 Case Report Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Dieulafoy lesions are abnormally dilated submucosal vessels remain uncommon cause of upper gastrointestinal bleeding, accounting for approximately 1.5% of all GI bleeds [1]. Although the exact etiology remains unknown, multiple co-morbid conditions have been attributed to this condition, including heart diseases, hypertension, chronic kidney disease, diabetes, or excessive alcohol use [2].In our case, it was identified as a cause of lower GI bleed in a critically ill Covid patient. CASE PRESENTATION: A 49-year-old male with a history of diabetes, internal hemorrhoids, and diverticulosis was admitted to the hospital due to hypoxic respiratory failure from COVID pneumonia with characteristic CT findings of bilateral ground-glass opacification. On admission, the patient was afebrile, normotensive, tachypneic with a respiratory rate of 34.The physical examination was unremarkable except for coarse crackles in upper and middle lung zones. We treated patient with Dexamethasone and Remdesivir. His hypoxia deteriorated, and he was eventually intubated. On admission patient hemoglobin was within normal range. During the patient's hospital course, he had a significant drop in hemoglobin, requiring multiple blood transfusions. Blood clots were found on perianal examination. Flexible sigmoidoscopy revealed blood in the rectosigmoid colon. A visible vessel without apparent ulcer was seen in the rectum, which was actively oozing blood. It was determined to be a Dieulafoy lesion. The affected area was injected with epinephrine for hemostasis, and subsequently, hemostatic clips were placed. After the procedure patient did not have any repeat episodes of hematochezia or drop in hemoglobin. DISCUSSION: Dieulafoy lesions are an uncommon cause of GI bleeding and are usually present in the upper gastrointestinal tract. Furthermore, they caused hemodynamically significant bleeding from the lower gastrointestinal tract in our case. Dieulafoy lesions can be asymptomatic or may bleed intermittently to cause severe hemodynamic compromise. They may be missed on endoscopy due to the small size and intermittent bleeding [2]. In up to 9-40% of the cases, these lesions tend to rebleed. Therefore the patients need close monitoring [3]. In our case, after the intervention with the clips, the patient's bleeding stopped, and he had no further blood loss from the lesion. CONCLUSIONS: Dieulafoy's lesion is an infrequent cause of gastrointestinal bleeding, and it is challenging to diagnose [3]. It is a rare cause of GI bleeding, and even in those instances, it is found chiefly in upper GI bleed cases but can also be the cause of lower GI bleeding. Knowing that GI bleeding in Covid patients leads to worse outcomes, it is prudent to account for rare causes of GI bleed during the work-up. Reference #1: Van Zanten SV, Bartelsman J, Schipper M, Tytgat G. Recurrent massive haematemesis from Dieulafoy vascular malformations–a review of 101 cases. Gut. 1986;27(2):213. Reference #2: Shin HJ, Ju JS, Kim KD, et al. Risk factors for Dieulafoy lesions in the upper gastrointestinal tract. Clinical Endoscopy. 2015;48(3):228. Reference #3: Baettig B, Haecki W, Lammer F, Jost R. Dieulafoy's disease: endoscopic treatment and follow up. Gut. 1993;34(10):1418-1421. DISCLOSURES: No relevant relationships by Swe Swe Hlaing No relevant relationships by Joyann Kroser No relevant relationships by Hui Chong Lau No relevant relationships by Sze Jia Ng No relevant relationships by Subha Saeed No relevant relationships by Muhammad Moiz Tahir

A CASE OF SARS-COV-2 ASSOCIATED WITH QUADRUPLE BACTERIAL COINFECTION

SESSION TITLE: COVID-19 Co-Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: SARS-CoV-2 has been associated with co-infecting pathogens, such as bacteria, viruses, and fungi. Little has been reported about community acquired atypical bacterial co-infections with SARS-CoV-2. We present a case of a patient with recent COVID-19 pneumonia and diagnosis of Legionella and Mycoplasma pneumonia, in addition of E. coli and C. perfringens bacteremia, that emphasizes SARS-CoV-2 impact in human immunity and the need to consider community acquired infections. CASE PRESENTATION: A 64-year-old male with history of hypertension, alcohol use disorder, iron deficiency anemia, and recent COVID-19 pneumonia presented to the ED with shortness of breath, dark urine, and increased confusion. The patient was admitted to the hospital a week prior with COVID-19 pneumonia and acute kidney injury. He received dexamethasone, remdesivir, and IV fluids. After 8 days, he was discharged home. Upon evaluation, he was afebrile and normotensive, but tachycardic, 129/min, on 4 L of nasal cannula sating 100%. On exam, the patient was oriented only to person and had decreased breath sounds bilaterally. Labs revealed an elevated WBC, 15.3 K/mcL, with left shift, low Hgb, 7.8 g/dL, with low MCV, 61 fL, increased BUN/Cr, 56 mg/dL and 2.8 mg/dL, and an abnormal hepatic panel, AST 121 U/L, ALT 45 U/L, alkaline phosphatase 153 U/L. Ammonia, GGT, CPK and lactic acid were within normal range;but the D-dimer and procalcitonin were elevated, 4618 ng/mL and 25.12 ng/mL, respectively. A urinalysis showed gross pyuria, positive leukocyte esterase and mild proteinuria. CT head showed no acute abnormalities, but the chest X-Ray revealed a hazy opacity in the left mid and lower lung, followed by a CT chest that demonstrated peripheral and lower lobe ground glass opacities and a CT abdomen that showed right sided perinephric and periureteral stranding. Given increased risk for thromboembolism, a VQ scan was done being negative for pulmonary embolism. The patient was admitted with acute metabolic encephalopathy, acute kidney injury, transaminitis, pyelonephritis and concern for hospital acquired pneumonia. Vancomycin, cefepime and metronidazole were ordered. HIV screen was negative. COVID-19 PCR, Legionella urine antigen and Mycoplasma IgG and IgM serologies were positive. Blood cultures grew E. coli and C. perfringens. Infectious Disease and Gastroenterology were consulted. The patient was started on azithromycin and a colonoscopy was done showing only diverticulosis. After an extended hospital course, the patient was cleared for discharge, without oxygen needs, to a nursing home with appropriate follow up. DISCUSSION: Co-infection with bacteria causing atypical pneumonia and bacteremia should be considered in patients with recent or current SARS-CoV-2. CONCLUSIONS: Prompt identification of co-existing pathogens can promote a safe and evidence-based approach to the treatment of patients with SARS-CoV-2. Reference #1: Alhuofie S. (2021). An Elderly COVID-19 Patient with Community-Acquired Legionella and Mycoplasma Coinfections: A Rare Case Report. Healthcare (Basel, Switzerland), 9(11), 1598. https://doi.org/10.3390/healthcare9111598 Reference #2: Hoque, M. N., Akter, S., Mishu, I. D., Islam, M. R., Rahman, M. S., Akhter, M., Islam, I., Hasan, M. M., Rahaman, M. M., Sultana, M., Islam, T., & Hossain, M. A. (2021). Microbial co-infections in COVID-19: Associated microbiota and underlying mechanisms of pathogenesis. Microbial pathogenesis, 156, 104941. https://doi.org/10.1016/j.micpath.2021.104941 Reference #3: Zhu, X., Ge, Y., Wu, T., Zhao, K., Chen, Y., Wu, B., Zhu, F., Zhu, B., & Cui, L. (2020). Co-infection with respiratory pathogens among COVID-2019 cases. Virus research, 285, 198005. https://doi.org/10.1016/j.virusres.2020.198005 DISCLOSURES: No relevant relationships by Albert Chang No relevant relationships by Eric Chang No relevant relationships by KOMAL KAUR No relevant relationships by Katiria Pintor Jime ez

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.

ACUTE COMPLICATED COLONIC DIVERTICULITIS IN PATIENTS WITH COVID-19: A SINGLE-CENTER CASE SERIES

Purpose/Background: The management of acute diverticulitis has evolved, adapting a more individualized approach. With a high postoperative mortality rate in patients with COVID-19, adapting a more conservative management could be beneficial for the management of acute complicated diverticulitis. Hypothesis/Aim: This study aims to review the clinical profile, treatment strategies and outcomes of COVID-19 patients with acute complicated colonic diverticulitis at a single tertiary hospital in the Philippines. Methods/Interventions: The study is a descriptive case series on COVID-19 patients who were also diagnosed with acute colonic diverticulitis between May 2020 to August 2021 at a single tertiary institution in the Philippines. The demographics, clinical history, severity of COVID-19, type of intervention, and post-procedural outcomes of the five patients are reported. Whole abdomen CT scan was performed in confirming the presence of colonic diverticulitis. Results/Outcome(s): Five cases of COVID-19 diagnosed concomitantly with acute colonic diverticulitis were included in the study. All five cases underwent an intervention for their diverticular disease. One patient underwent surgical intervention after failure of conservative management. Four patients underwent percutaneous drainage. Two of them were successfully treated with percutaneous drainage while the other two had treatment failure. The first case of treatment failure subsequently underwent surgery with a good postoperative outcome. The second case, however, succumbed to COVID-19 complications. Limitations: There are two limitations of this study. First, this is a mainly a descriptive case series study design;hence, no statistical analyses were performed. Second, the patients included were limited only to COVID-19 with complicated diverticulitis who needs an intervention, either percutaneous or surgical approaches. Conclusions/Discussion: This case series was able to demonstrate that a nonoperative approach can be safely employed in managing acute complicated diverticulitis without jeopardizing the treatment of COVID-19. In the same way, utilizing this conservative method provides an opportunity to optimize the patient if surgery is eventually needed.

Perforation of Jejunal Diverticula in COVID-19 Positive Patients: A Case Series

Jejunal diverticulosis is the herniation of mucosa through weakened wall of jejunum on the mesenteric border. Individuals are usually asymptomatic for most of their lives and are diagnosed incidentally by radiological investigations or during surgery. Increased number of hospital admissions and investigations done to better understand the phenomenon of Coronavirus Disease 2019 (COVID-19) had increased the rate of incidental diagnosis. Four patients admitted to the COVID-19 ward of the hospital were diagnosed with COVID-19. They were treated according to the protocol followed in the state, which included high dose of steroids. During the course of treatment, they experienced abdominal pain with distension and were diagnosed with Jejunal Diverticulitis with perforation. Exploratory laparotomy with jejunal resection and jejuno-jejunal anastomosis with feeding jejunostomy was performed and adequate postoperative care was provided. Two out of the four patients survived and were discharged after they achieved full recovery and became COVID-19 negative. The cause of perforation can be attributed to the high dose of steroids used during the treatment as steroids have been proved to cause spontaneous bowel perforations.

NEW-ONSET SYSTEMIC LUPUS ERYTHEMATOSUS FOLLOWING COVID-19 VACCINATION: A REPORT OF TWO CASES

Background/Aims There is a growing number of reports of new-onset autoimmune disease or complications of underlying autoimmune disorders following COVID-19 infection and vaccination. Methods We describe two cases of systemic lupus erythematosus (SLE) that developed De novo in two female patients shortly after receiving their COVID-19 vaccinations. Results The first case is a 29-year-old female with no prior medical history. One week following her COVID-19 Pfizer/BioNTech vaccination, she developed widespread pruritus, fatigue, myalgia, arthralgia, fever and night sweats. Blood tests showed pancytopenia and she was referred for an urgent haematology opinion due to lymphoma. Positron Emission Tomography/computed tomography (PET/CT) demonstrated widespread lymphadenopathy. Bone and lymph node biopsy showed reactive changes only. Her symptoms progressed with polyarticular inflammatory arthritis, oral ulceration, Raynaud's, pleuritic chest pain, palmar purpuric rash, and a widespread tender urticarial rash. Further investigations showed low complement C3/C4, anti-double stranded DNA antibody titre (dsDNA) >200 IU/mL, positive Anti-Ro antibody, positive Anti-La antibody, weakly positive anti-RNP antibody and an Anti-C1q antibody >400 units/ml with a urine protein/creatinine ratio (PCR) of 39 mg/mmol. A diagnosis of SLE with urticarial vasculitis was made and she commenced Hydroxychloroquine in addition to weaning prednisolone (60mg). A skin biopsy confirmed lupus vasculitis. Despite high dose prednisolone, urine PCR increased over 2 weeks from 39 to 84 mg/mmol. Renal biopsy demonstrated class 3 lupus nephritis. She was pulsed with 500mg IV methyl prednisolone over 3 days and commenced mycophenolate 1g BD. Within weeks she was in clinical remission. The second case is a 70-year-old female with a past medical history of diverticulosis, uterine fibroids and small hand joint osteoarthritis. She presented with a sudden onset, 6-week history of bilateral symmetrical small and large joint synovitis that developed 8 days following the first dose of the COVID-19 Oxford-AstraZeneca vaccine. Her investigations showed reduced lymphocyte counts (0.9 109/L), raised CRP 26 mg/L and ESR 32 mm/hr. Antinuclear antibodies were weakly positive with a homogenous pattern. DsDNA titre was raised at 175 IU/mL and C4 reduced at 0.14 g/L. There was no proteinuria or any evidence of major internal organ involvement. She was started on a short reducing course of oral prednisolone given the severity of her presenting clinical features. Her symptoms improved, with no recurrence on stopping steroids but she has continued elevation in DsDNA;a conservative management approach is being adopted. Conclusion Both cases met the EULAR/ACR and SLICC classification criteria for SLE. There was a clear temporal association between the onset of SLE symptoms and COVID-19 vaccination. Our cases raise the possible association/causation of SLE following COVID-19 vaccination. Potential mechanisms include immune responses elicited by the COVID-19 vaccination, triggering autoimmunity in genetically predisposed individuals. Further research and data from registries are required.

THE DIFFERENTIAL IMPACT OF COVID-19 ON GASTROINTESTINAL ILLNESSES AND RATES OF HOSPITALIZATION: ANALYSIS FROM A REGIONAL INTEGRATED HEALTHCARE SYSTEM

Background and Objective: With the onset of the Coronavirus Disease 2019 (COVID-19) pandemic, various aspects of health care have been affected;however, there has been an unknown effect on hospital admissions for gastrointestinal (GI) diseases and the potential consequences on specific illnesses. Our study aims to characterize the rates of GI disease hospitalizations during the pandemic as compared to prior and any differences between specific gastrointestinal diseases throughout this period. This will be important in highlighting any gaps of care as related to gastroenterology during COVID-19.Methods: We conducted a retrospective, cross-sectional study between the months of January to May from the years 2016-2020 in a regional integrated health care system. January –May 2020 was delineated as the COVID-19 period. ICD-10 codes were used to identify principal diagnoses related to the most common GI hospitalizations in the United States (upper GI hemorrhage, pancreatitis, liver disease, diverticular disease, cholelithiasis). Rates of hospitalization were then calculated per 100,000 members for each calendar month and each respective year. Rates for the 5 most identified GI diseases were then calculated using a similar method from 2019 as compared to 2020. The rate of percent change for each month for these diseases were then analyzed during the pandemic year of 2020 versus the preceding year of 2019.Results: A total of 4589 (rate of 19.57 per 100,000) hospitalizations for GI related diseases occurred between January – May 2020 as opposed to 5328 (rate of 23.10 per 100,000) hospitalizations from January – May 2019 (p=0.03). The median age in 2020 was 59.1 (p= 0.27 compared to 2019) with a 51% female to male ratio. 38% of patients were White, 42% Hispanic, 10% Black, 8% Asian (p=0.58 compared to 2019 for all ethnicities). There was a decrease in the rate of hospitalization in each month from January – April 2020 compared to 2019 with a subsequent rise in May. There was a 2.86 increase in rate of hospitalization (p<0.01) from April to May 2020. There were only significant differences (p<0.05) in hospitalization rates between the months of March – May from 2020 versus 2019. Of the 5 most common GI diseases, upper gastrointestinal hemorrhage showed the highest average rate change of -20% from 2020 to 2019. Cholelithiasis had a change of -15%, pancreatitis with a change of -14%, diverticular disease with a change of -11%, and liver disease with a change of -9%.Conclusion: GI related hospitalizations decreased during the COVID-19 pandemic as com-pared to the previous year. Upper gastrointestinal hemorrhage showed the most average rate change of the GI diseases. Further studies highlighting the implications of these findings, such as mortality and severity of illness during the pandemic, need to be completed to assess the impact COVID-19 on GI disease.(Figure presented)(Table Presented)

NATIONAL TRENDS OF GASTROINTESTINAL BLEED RELATED DISEASES AND PROCEDURES DURING THE COVID PANDEMIC

Background: The COVID 19 pandemic has caused a major disruption in healthcare delivery as lockdown orders and other restrictions have limited the ability to seek care and receive medical care and procedures. This investigation aimed to assess the pandemic impact on the incidence of gastrointestinal bleeds (GIB) related diseases and procedures compared to the pre-pandemic period. Methods: TrinetX, a national federated healthcare database comprised of 61 million patient records, was used to identify the incidence of new GIB related diseases and procedures (variables) performed each month for two periods of the pandemic. The first period was from April 2020-July 2020 (early pandemic), and the second was from August 2020-November 2020 (late pandemic). The mean for each variable was then compared with the pooled monthly incidence from similar periods between 2018-2019 before the pandemic. Descriptive analyses were performed, and comparisons were made using a student's t-test. Diseases and procedures were identified by ICD-10 and CPT codes, respectively. Results: A total of 20 variables were analyzed in both periods (Table 1). In the April 2020-July 2020 period, all 20 GIB related variables showed a statistically significant decrease in the average incidence compared to a similar pre-pandemic period. The top 5 variables were colonoscopy (-44% change, p=0.003), sigmoidoscopy (-40.7% change, p=0.002), polyps (- 38.5%, p=0.007), esophagogastroduodenoscopy (-38% change, p=0.005), and hemorrhoids (-35.8% change, p=0.005). In the Aug 2020-Nov 2020 period, only 8 GIB related variables showed a statistically significant decrease in the average incidence compared to a similar pre-pandemic period. The top 5 variables were colonoscopy (-38.2% change, p=0.01), sigmoidoscopy (-37.8% change, p=0.02), esophagogastroduodenoscopy (-34.8%, p=0.019), diverticulosis (-30.9% change, p=0.03), hemorrhoids (-30.8%, p=0.043). Discussion: The early pandemic period showed statistically significant decreases in all 20 GIB related diseases and procedures variables, while the late pandemic period showed statistically significant decreases in only 8 GIB related variables. This shows that while the healthcare field is improving its handle on the pandemic, patients with GIB have started seeking healthcare. Further research is warranted to examine the future implications of this disruption in the care of patients with GIB during the COVID-19 pandemic.(Table Presented) Pooled mean monthly incidence of Gastrointestinal Bleed related diagnosis and procedure variables related between April 2020-July 2020 (early pandemic), and August 2020-November 2020 (late pandemic) compared to similar periods between 2018-2019 (pre-pandemic).

Role of CT scan as initial investigation in colorectal rapid access patients

Background: We looked into CT colonoscopies and CT abdomen and pelvis which were booked as initial investigation in patients referred via the colorectal rapid access pathway. These tests were directly booked following the referral after a nurse led triage. As per our colorectal straight to test protocol (STT) any patients over the age of 75 or unfit individuals will have a CT colonoscopy (virtual colonoscopy) instead of colonoscopy. CT trunk was used during COVID pandemic as the initial investigation when the aerosol generating procedures were stopped. CT trunks are also the initial investigation as per the STT protocol when patients are referred with suspected abdominal mass, weight loss or abdominal pain. Methods: Retrospective analysis of prospective electronic data base of colorectal STT referrals from Feb 2020 to end of October 2020. Results: • Total no colorectal STT referrals -1524 • CT colonoscopies and CT trunks booked as initial investigation 420(27.55%) • Patients who refused to have the scans due to COVID 93/420 (22.14%) • Colorectal cancer diagnosis 25/327 (7.64%) • Non-colorectal cancer diagnosis 20/327(6.11%) Incidental AAA 15/ 327(4.58%) • Normal examination 91/327(27.82%) • Colonic polyps 27/327(8.25%) • Diverticular disease 92/327(28.13%) Conclusion: CT colonoscopies and CT trunks form part of initial diagnostic tool in the colorectal rapid access patients. They are particularly useful in high risk patients who cannot tolerate colonoscopy. These investigations complement the lower GI endoscopy. These scans also identify non-colorectal malignancies and retroperitoneal pathology such as AAA.CT trunks were useful tools during COVID 19 Pandemic.

Incidence of normal colonoscopy in faecal immunochemical test (FIT) positive patients in the colorectal 2-week-wait (2WW) pathway at a district general hospital (DGH)

Introduction: FIT is a quantitative, highly specific test to detect blood in stool for malignant and non-malignant colorectal diagnoses. Incidence of normal colonoscopy following positive FIT is not widely reported. We conducted a retrospective audit to analyse this patient cohort to evaluate diagnostic accuracy and reporting standards of colonoscopy. Method: FIT-positive was defined as>10μgHb/g faeces. Using FIT value, patients were separated into Groups 1, 2 and 3: 10-99, 100-200 and >200μgHb/g faeces respectively. Normal colonoscopy was defined as no neoplastic or benign findings reported. Patients referred in the 2WWpathway after introduction of FIT-testing in October 2019 to the onset of COVID-19 pandemic in March 2020 were included. Data on age, gender, comorbidities and additional investigations were collected. Results: There were 1072 referrals in the study period;405 had FIT done, 265 were FIT-positive and had colonoscopy referral. Four patients were excluded after further investigations showed diverticulosis and gastritis. FIT-stratified normal-colonoscopy rate was 13.3% (28/210) overall, and 14.1% (23/163), 16.7% (2/12) and 8.6% (3/35) for Group 1, 2 and 3 respectively. Conclusions: Our study was limited by the onset of COVID-19 pandemic. In the short study period, 13.3% FIT-positive patients had normal colonoscopy. There are no comparative data in literature for this parameter. Higher FIT-values were associated with lower normal colonoscopy incidence. It is possible that some endoscopists failed to record positive, non-clinically significant findings. We are currently studying larger patient cohorts and in parallel, looking at Bowel Cancer Screening Programme (BCSP) patients.

Colouterine fistula: A case report of a rare complication of diverticular disease managed during the pandemic.

INTRODUCTION AND IMPORTANCE: Colouterine fistulas related to diverticulitis are very rare due to the thickness of the uterine myometrium. Other causes related to colouterine fistula formation particularly malignancy, have to be considered. Diagnosis by imaging or endoscopy may be inconclusive. CASE PRESENTATION: We are presenting a case of a 70-year-old female who presented with malodorous vaginal discharge and painful labial lesions. No previous history of surgery, gynecologic malignancy or other possible causes of the fistula was elicited. CT scan imaging suggested a colouterine fistula. The patient was admitted and underwent Exploratory laparotomy, Hartmann's procedure and total hysterectomy with bilateral salpingo oophorectomy. The patient was discharged without perioperative complications. CLINICAL DISCUSSION: Colouterine fistulas are extremely rare complications of diverticular disease. Diagnosis entails clinical astuteness and judicious use of imaging and endoscopic modalities. Accurate diagnosis is essential to select the appropriate surgical approach, along with intraoperative findings patient status and prevailing conditions. CONCLUSION: This case is being presented not only for the rarity of the case but also for the complexity of the management and decision making during the period of the pandemic.