Characterization of Demographics and Concomittant Symptoms in Patients with Post COVID-19 Conditions or Long COVID

Objectives: Post COVID-19 conditions or long COVID continues to burden the healthcare system. With the introduction of new code in October 2021 to appropriately capture this condition (U09.9), we have enough data to understand the detailed demographic and clinical characterization of the patients with long COVID. As this new clinical entity continues to evolve, our study will provide insights for care management and planning. Method(s): We conducted a retrospective cohort study from a large deidentified database of US health insurance claims. The study population included all individuals with at least one ICD-10 code for COVID (U07.1) between June 1, 2021, and November 30, 2022. Individuals with at least one ICD-10 code for long COVID (U09.9), at least 7 days after COVID diagnosis were termed "Long COVID" patients. Index date was defined as the first long COVID diagnosis date. We also assessed the most prevalent diagnosis codes within the 30 days pre- and post-index to understand top symptoms. Result(s): A cohort of 253,145 patients (62% female patients;38% male patients) were identified. Among this cohort, 3.2% were pediatric patients aged 0 - 17 years;73.3 % aged 18 - 64 years and 23.5 % aged 65+ years. Most prevalent symptoms that increased in the 30 day pre- and post-index: Nervous system symptoms (6 fold), fatigue (7 fold), Dyspnea (4.3 fold), esophagitis (1.6 fold) chronic kidney disease (1.3 fold) among others. Conclusion(s): Our findings indicate that long COVID is more prevalent in females, with fatigue and dyspnea emerging as top symptoms. These findings are consistent with the published literature. However, we uncovered additional symptoms such as nervous system symptoms, chronic kidney disease among others. Additional analysis is planned to evaluate the association of these symptoms with sociodemographic features to understand the health inequity aspects of long COVID.Copyright © 2023

Evaluating Efficacy Of Functional Luminal Imaging Probe In Preoperative Evaluation For Antireflux Procedures

Introduction: The COVID-19 pandemic caused significant decreases in outpatient procedures, many of which are required before to antireflux operation (ARS). The purpose of this study was to add functional luminal imaging probe (FLIP) to esophagogastroduodenoscopy (EGD) and esophageal pH monitoring to assess its utility in decreasing the need for follow up studies in patients being evaluated for ARS. Method(s): Retrospective observational study was performed on 81 patients being evaluated for GERD who underwent EGD, pH monitoring, and FLIP. Data collected included average distensibility index (DI) at 60 mL, presence of repetitive anterograde or retrograde contractions, hiatal hernia dimensions, pathology results, pH data, and need for follow-up testing. Result(s): Based on FLIP results, HRM was recommended in 35 patients (43.2%). This included 14 patients with DI suggestive of significant esophagogastric junction outflow obstruction, eight of whom completed HRM with four confirmed as achalasia. FLIP results were suspicious for eosinophilic esophagitis (EoE) in four patients of which one was confirmed as EoE on biopsy. Gastric emptying study was felt to be necessary for 11 patients before to ARS. Conclusion(s): FLIP identified patients with possible alternative pathologies including achalasia and EoE that would otherwise be a contraindication to ARS. FLIP at the time of EGD and pH monitoring is useful as it guides the clinical decision on need for additional outpatient procedures, which may be difficult to obtain in pandemic conditions. FLIP was effective at reducing the requirements for further follow-up testing in the majority of patients being evaluated for potential ARS.

Herpes Gastritis: A Rare Cause of Gastric Outlet Obstruction

Introduction: Gastrointestinal tract involvement from herpes simplex virus is commonly associated with esophagitis. However, herpes simplex infection of the stomach is very rare with only a handful of cases being reported in immunocompromised patients. We present a case of herpes gastritis causing gastric outlet obstruction in an otherwise healthy, immunocompetent individual. Case Description/Methods: A 37-year-old male with a recent past medical history of COVID-19 infection, presented to the hospital with intractable nausea, vomiting, bloating, and early satiety for two days. Upon evaluation, CBC and CMP were remarkable for a WBC of 12.5 k/mm3 and ALT and AST of 124 U/L and 129 U/L, respectively. Lipase was 373 U/L. A CT abdomen/pelvis w/contrast showed circumferential wall thickening with edematous changes in the antrum consistent with localized inflammatory response. There was suspicion for gastric lymphoma and patient was admitted for further workup. An EGD was performed which showed exudative esophagitis and antral wall edema with luminal narrowing of gastric antrum. Endoscopic ultrasound (EUS) showed a 2.5 x 3 cm antral wall lesion worrisome for linitis plastica. Esophageal biopsies showed focal cytologic changes consistent with herpes esophagitis. The FNA of the gastric antral wall showed multinucleation of the basal cell layer with classic ground glass nuclei, consistent with herpes infection. No dysplasia or malignancy was seen. Both HSV1 and HSV2 IgG were elevated. HSV IgM was normal. A HSV PCR was ordered but never resulted. Patient was started on Valacyclovir 1 g PO BID for 10 days. He underwent a follow-up EGD 3 months later which showed complete resolution of the gastric antral changes (Figure). Discussion(s): Herpes gastritis is extremely rare. Literature review has revealed only 3 case reports of herpes gastritis;and all involved immunocompromised patients. To the best of our knowledge, this is the first case of herpes gastritis in an immunocompetent patient. Our patient presented with symptoms of gastric outlet obstruction which was caused by local inflammation from herpes simplex. It is unclear if having a COVID 19 infection altered patient's immunity and lead to herpes gastritis. This may need further investigation. No established guideline exists for treatment duration. Our patient received 10-day course of Valacyclovir, and his symptoms improved. Furthermore, patient had complete resolution of the herpes infection on follow-up EGD, indicating adequate treatment response.

Esophageal Mucosal Calcinosis: A Rare Site of Calcium Deposition in End-Stage Renal Disease

Introduction: Calciphylaxis, otherwise known as calcium uremic arteriolopathy, is defined as calcium deposition around blood vessels in skin and fat tissue which occurs in 1-4% of patients with end-stage renal disease (ESRD). Calcium deposition in the esophagus is extremely rare;to date, there have been only 4 cases reported worldwide. We report the fifth case of esophageal mucosal calcinosis occurring in a young male with ESRD. Case Description/Methods: A 37-year-old Thai man with ESRD on peritoneal dialysis since 2005 presented with generalized weakness and odynophagia due to oral ulcers, resulting in poor PO intake. He denied drinking alcohol, illicit drug use, or smoking. On exam his abdomen was soft, non-distended, non-tender, without any guarding. Past medical history included hypertension and COVID-19 in January 2022. Laboratory tests revealed neutropenia and pancytopenia, hyperphosphatemia, and hypocalcemia. EGD revealed distal esophageal esophagitis and hemorrhagic erosive gastropathy. Biopsy showed ulcerative esophagitis with dystrophic calcification, consistent with esophageal mucosal calcinosis .No intestinal metaplasia was noted. Immunohistochemistry was negative for CMV, HSV1, and HSV2. The patient was treated with pantoprazole 40mg IV every 12 hours, Magic Mouthwash 5ml qid, and Carafate 10mg qid. He was transferred to a cancer center where he had a bone marrow biopsy formed which was negative. His symptoms resolved and the patient was discharged to home (Figure). Discussion(s): Esophageal mucosal calcinosis is extremely rare. It is due to a combination of factors involving acidosis and the phenotypic differentiation (and apoptosis) of vascular smooth muscle cells (VSMC) into chondrocytes or osteoblast-like cells. These changes, along with the passive accumulation of calcium and phosphate, induce calcification. Acidosis is well-known to promote inflammation of the arterial walls, releasing cytokines that induce vascular calcification. The benefits of treatment with sodium thiosulfate remain unclear. An ample collection of cases should help devise standardized treatment options and establish management guidelines for this condition.

A Case of Primary Biliary Cirrhosis With New Onset Hyperthyroidism and Supratherapeutic INR

Introduction: Hyperthyroidism is known to increase catabolism of vitamin-K-dependent clotting factors (II, VII, IX, X) and increase the response of vitamin K antagonists, usually warfarin. Primary biliary cirrhosis (PBC) has been associated with thyroid dysfunction (TD), especially with autoimmune thyroid disease. In the below case, a patient with known PBC on warfarin is found to have severely elevated INR related to new-onset hyperthyroidism with clinical consequences of hemorrhage including upper GI bleed. Case Description/Methods: A 64-year-old female with PBC and antiphospholipid antibody syndrome on warfarin was admitted for hemorrhagic epiglottitis requiring emergency intubation and supratherapeutic INR. Her PBC was diagnosed as stage II on biopsy 23 years ago and has remained clinically stable on ursodiol therapy. On presentation, the patient was tachycardic, tachypneic, and had O2 saturations <90% on HFNC prior to intubation. Physical exam significant for larger goiter with diffuse upper airway swelling. She was admitted and found to have COVID-19 infection, INR .16.0 and PT>200.0 (limit of lab), WBC of 22.8, and lactate of 2.5. LFTs WNL aside from albumin of 2.0. TSH was <0.0017 (limit of lab) and free T4 of 3.4, free T3 of 5.3. TSH receptor antibody (TRAB) and thyroid stimulating immunoglobulin (TSI) levels were normal. Her last TSH was normal a year ago. CTA chest found a 5.7cm heterogeneous, partially calcified superior mediastinal mass consistent with multinodular thyroid goiter. Patient was initially given prothrombin complex concentrate and vitamin K with correction of INR over the following few days. She was extubated and started on methimazole. During the hospital course, she was found to have coffee ground emesis for which an EGD was done with findings of non-bleeding gastric ulcer (Forrest Class IIc) and LA Grade D esophagitis with adherent clot and bleeding for which hemostatic spray was applied. Patient was discharged a few days later following resumption of warfarin and on pantoprazole and methimazole. Discussion(s): The above case demonstrates a rare case of PBC and new-onset hyperthyroidism due to multinodular thyroid goiter causing significantly elevated INR in the setting of warfarin use with hospital course complicated by GI bleed. PBC is associated with TD - hyperthyroidism, hypothyroidism, and thyroid cancer. Hyperthyroidism is less commonly associated with PBC compared to other TDs but should be considered especially with a finding of elevated INR.

Opportunities for Virtual Care in Eosinophilic Esophagitis: Real-World Dietary Therapy Practice

Introduction: Dietary therapy for eosinophilic esophagitis (EoE) is an effective first-line treatment aimed at identifying triggers by systematically removing then reintroducing food groups. Success on diet therapy can be augmented by working with a dietitian, but this is not a universal clinical resource. Virtual or telehealth approaches to nutrition care may offer opportunities to implement diet therapy for EoE. We conducted a retrospective study at a tertiary center with six GI dietitians to compare real-world standard in-person versus virtual EoE nutrition practices in terms of access, follow-up< and disease control. Method(s): We identified adults with EoE referred to GI nutrition through query of the electronic medical record by ICD-10 diagnoses and confirmed by chart review. As all nutrition visits prior to the COVID pandemic were performed in-person, standard care was defined as care established in January-December 2019 and virtual care in January-December 2021. Associations were analyzed using Chi-squared and Student's t test (Table). Result(s): A total of 204 patients were included;99 referred for standard in-person and 105 virtual nutrition care. The cohorts did not differ significantly by gender, age at the time of referral, race, and distance lived to our center. Of these, 55.6% (55) standard and 48.6% (51) virtual visits were completed with a dietitian (p=0.341) and 4-food elimination diet was the most commonly planned diet. The majority initiated the diet (80.0% standard, 78.4% virtual, p=0.842) and among them, half successfully attained histologic remission with the elimination phase (63.6% standard, 47.5% virtual, p=0.324). Ultimate treatments plans included remaining on dietary therapy (25.5% standard, 23.5% virtual, p=0.728), no treatment or lost to follow-up (34.6% standard, 25.5% virtual), and medication (25.5% standard, 41.2% virtual). Conclusion(s): There is a growing demand for nutrition care in EoE and in our tertiary practice, we found no differences in the success and response rate on elimination diet or follow-up between patients receiving standard or virtual nutrition care. Virtual approaches to implementing EoE dietary therapy may serve to complement in-person care and offer opportunities for those lacking local dietitian access. However, up to one-third of patients are lost to follow-up or remain untreated, also highlighting a need to identify, understand, and overcome barriers to treatment uptake and disease control .

Dupilumab efficacy and safety up to 52 weeks in adult and adolescent patients with eosinophilic esophagitis: Results from parts B and C of the randomized, placebo-controlled, three-part, phase 3 LIBERTY EoE TREET Study

Introduction (contexte de la recherche): In Parts A and B of the 3-part phase 3 LIBERTY EoE TREET study (NCT03633617), dupilumab 300 mg weekly (DPL qw) vs. placebo (PBO) demonstrated significant efficacy and acceptable safety up to 24 weeks (wks) in adults and adolescents with eosinophilic esophagitis (EoE). For patients (pts) who completed Parts A or B, Part C was an extended active treatment period for 28 wks. Objectif: To assess the safety and efficacy of DPL in pts who completed Part B and continued to Part C, up to 52 wks. Methodes: Of 80 DPL qw pts in Part B, 74 continued DPL qw in Part C (DPL/DPL). Of 79 PBO pts in Part B, 37 pts received DPL qw in Part C (PBO/DPL). Part B co-primary endpoints were proportion of pts achieving peak esophageal intraepithelial eosinophil (eos) count <= 6 eos/high power field (hpf) and absolute change from Part B baseline (BL) in Dysphagia Symptom Score (DSQ) score at Wk 24. Secondary endpoints included peak eos count, EREFS, and HSS grade and stage scores. In Part C, all co-primary and secondary endpoints were assessed at Wk 52 as secondary endpoints. Safety was also assessed. Resultats: Part B BL characteristics were similar across groups. At Wk 52 of Part C, 84.6% of DPL/DPL and 67.6% of PBO/DPL groups achieved peak eos count of <= 6 eos/hpf and mean (SD) absolute change from Part B BL in DSQ score was -30.26 (15.39) for DPL/DPL and -27.25 (11.46) for PBO/DPL pts. At Wk 52, peak eos count, EREFS, HSS grade and stage scores were reduced, compared with Part B BL, and EDP and T2 NESs were suppressed in DPL/DPL and PBO/DPL groups. Dupilumab demonstrated an acceptable safety profile in Part C;the most common (occurring >= 10%) treatment-emergent adverse events in DPL/DPL and PBO/DPL groups were injection-site reactions (13.5% and 10.8%), COVID-19 (9.5% and 10.8%) and nasopharyngitis (4.1% and 10.8%). Conclusion(s): As observed in Part A/C, dupilumab qw demonstrated persistent improvements in clinical, symptomatic, histologic, endoscopic and molecular features of EoE up to 52 wks and had an acceptable safety profile. PBO pts from Part B who received dupilumab in Part C showed similar efficacy to dupilumab qw pts of Part B.Copyright © 2023

A Case of Left Ventricular Thrombus and Herpetic Esophagitis in an Immunocompetent Patient With COVID-19.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been associated with thrombosis, both venous and arterial, but the mechanism behind this coagulation is not fully understood. Several cases involving coronavirus disease 2019 (COVID-19)-positive patients with left ventricular thrombus (LVT), particularly in those with low ejection fraction, have been reported. This report describes a case of a 57-year-old male patient who presented to the hospital with altered mental status and a positive SARS-CoV-2 polymerase chain reaction (PCR) test. CT of the chest revealed the presence of an LVT, and transthoracic echocardiography showed a reduced ejection fraction and confirmed the presence of the thrombus. The patient also reported epigastric chest pain and several bloody bowel movements. A colonoscopy revealed internal hemorrhoids. An esophagogastroduodenoscopy revealed the presence of multiple esophageal ulcers, and biopsy results confirmed herpes simplex virus (HSV) infection. The patient had no history of organ or bone marrow transplant, long-term immunosuppressive therapy, or HIV infection. He was eventually discharged on apixaban for his LVT and acyclovir for his HSV esophagitis.

Eosinophilic Oesophagitis in Children: A Single Uk Tertiary Centre Experience

The incidence of Eosinophilic Oesophagitis (EoE) is increasing worldwide in the paediatric population. Management of these children is complex, and includes elimination diet (2/4/6 food), steroids etc. It is recommended to perform endoscopies between each reintroduction to assess disease activity. In our centre dietary exclusion is the standard practice. Since 2019 we follow a step-up approach with regards to elimination diet starting with 2 food exclusion diet (FED) and building up as required. Food is reintroduced gradually with significant dietetic support and proactive monitoring including endoscopy. Objectives We looked at the outcomes of children with EoE referred to Maidstone and Tunbridge Wells NHS Trust from Kent and East Sussex. Methods Retrospective review of case notes of paediatric patients diagnosed with EoE between January 2015 and December 2020. Data collected included symptoms, endoscopy findings and histology at diagnosis and compared the same after dietary intervention. Results 21 patients were diagnosed with EoE between January 2015 and December 2020 between 5-16 yrs Median age at diagnosis 11years. Frequently seen in boys (65%). Dysphagia was the predominant symptom (76%) followed by vomiting (60%), abdominal pain (50%), and choking (20%). Features of EoE were seen during endoscopy in 71% and oesophagus looked endoscopically normal in 29% of patients. Diagnosis was made on eosinophil count as per ESPGHAN guidance. The frequency and timing of repeat endoscopies following dietary intervention varied due to a multitude of factors including COVID-19 restrictions (between 4-9 months median 4 months). Histological remission (Eosinophils <15 pHPF) was achieved in 15/21 (70%) of patients. 7/10 children on 2FED, 3/3 patients on 4FED and 5/5 children on 6FED achieved histological resolution. The 6FED group took significantly longer to identify the causative food, establish long term dietary management and required more endoscopies. Food was reintroduced gradually on an individual basis with the aim of introducing back all food groups. 13/15 continue to be on milk free diet, 5/15 remain on milk and wheat free diet, 1/15 on soya and egg free diet and the other patient remains on 4FED (parental choice). 2 patients have started steroids due to on-going symptoms findings on surveillance endoscopy and histological following re-introduction. Summary and Conclusion Dysphagia was the predominant symptom in our cohort of patients. Furrowing and oedema was the major finding during endoscopy. With dietary exclusion endoscopic resolution was seen in 62% and histological resolution seen in 70% of patients at first surveillance endoscopy. Re-introduction continues to remains a major challenge and we have not been able to introduce all the food groups in any of our patients due to either symptoms or recurrence on endoscopy/histology.

Duodenal Stricture as a Rare, Possible Complication of Eosinophilic Gastrointestinal Disease (Egid)

EGID is a recently described condition with an unknown etiology and pathogenesis. There are three case reports of duodenal stricture associated with EGID: one in an adult requiring pancreaticoduodenectomy due to the suspicion of malignancy and 2 cases in a child and a young adult, who responded to oral steroids. We report the case of a 10-year-old who presented to A&E with a 9-month history of epigastric abdominal pain and 1 episode of haematemesis, on a background of asthma. He was treated for Helicobacter pylori, based on a positive stool antigen. Abdominal pain and vomiting persisted, therefore an oesophago-gastro-duodenoscopy (OGD) was performed. This identified widespread white plaques throughout the oesophagus, erythema and nodularity of the gastric antrum and white nodules in the first part of the duodenum. Histology revealed changes of EGID and eosinophilic oesophagitis (EOE) and patient was commenced on Montelukast, oral viscous Budesonide (OVB), Cetirizine and continued proton pump inhibitor (PPI). After the allergy workup identified house dust mites, cat sensitisation and fish allergy, a 6-food elimination diet was initiated. During the next 2 years, symptoms subsided, and endoscopy changes improved, with only mild signs of active EOE while on OVB, PPI and diary/egg/fish free diet. However, the patient relapsed due to poor compliance to treatment. He became more unwell during the Covid pandemic with recurrent vomiting and static weight. A trial of dupilumab was considered, however his reassessment OGD had to be delayed due to restricted access to theatre. He was treated empirically with a reducing course of oral prednisolone, with temporary response. The endoscopic assessment performed subsequently showed erythema, erosions and white plaques in the distal oesophagus and gastric antrum with narrowing between the first and the second part of the duodenum (D2), that could not be entered. Histology identified mild upper oesophagitis (4 eosinophils (eos)/HPF), active middle and lower oesophagitis (20 eos/HPF and 12 eos/HPF, respectively), chronic gastritis (80 eos/HPF) and nonspecific reactive changes of the proximal duodenum. A barium meal confirmed a duodenal stricture. At this stage, we recommended a sloppy diet and a second weaning course of oral prednisolone, along with Montelukast. He was subsequently commenced on azathioprine for maintenance of remission. A repeat barium study and small bowel MRI performed post course of steroids and on azathioprine revealed stable appearances of the proximal duodenal stricture, excluding the presence of further strictures. While the patient has responded to the course of oral steroids and azathioprine, a repeat upper GI endoscopy is currently planned to dilate the duodenal stricture. The challenges posed by this case were the rarity of the condition, limited treatment options and access to endoscopy during the Covid pandemic and the fact that unlike previous case reports a sustained remission could not be obtained on steroids, and a maintenance immunosuppressive medication was required. We can conclude that this subgroup of patients should be monitored closely for signs of bowel obstruction and will require more intense treatment, including immunomodulators, endoscopic dilatation and or surgery.

Worsened Fibrostenotic Outcomes in Eosinophilic Esophagitis Patients Due to COVID-19-Related Endoscopy Cancellations.

BACKGROUND: Indirect consequences of COVID-19 in eosinophilic esophagitis (EoE) are not known. AIM: To determine the impact of COVID-19-related endoscopy cancellations on outcomes in EoE patients. METHODS: In this retrospective cohort study, we assessed whether adult EoE patients who had routine endoscopy scheduled from mid-March 2020 to May 2020 (pandemic start) were canceled or proceeded, and if canceled, ultimately returned. We extracted clinical, endoscopic, and histologic data for their pre-COVID procedure as well as the next procedure performed, if a patient returned. Outcomes included histologic response (< 15 eos/hpf) and endoscopic severity. Those with delayed care were compared to those who returned as scheduled. RESULTS: Of 102 patients identified, 75 had procedures canceled, and 20 (27%) never returned. For the 55 who were canceled but returned, mean time between procedures was 1.1 ± 0.7 years with a delay of 0.5 ± 0.3 years. While treatment rates were similar between the pre- and delayed post-COVID EGD, more patients required a dilation after their return (71% vs 58%; p = 0.05) and their esophageal diameter had significantly decreased (16.8 mm to 15.0 mm; p < 0.001). Of 17 individuals who did not have stricture, narrowing, or dilation pre-pandemic, during their next endoscopy 5 (29%) had a stricture, 1 (6%) had a narrowing, and 7 (41%) required dilation. CONCLUSION: Of EoE patients with canceled endoscopies during the beginning of the COVID-19 pandemic, > 25% never returned for care, which is a previously unmeasured impact of the pandemic. Those who returned had > 1 year between procedures with progression of fibrotic features and need for esophageal dilation.

Iron-deficiency anemia following herpetic esophagitis in a previously healthy female.

Introduction: Herpetic Esophagitis is caused by the Herpes Simplex virus, which generally affects immunocompromised individuals and is rarely seen in healthy individuals. Symptoms are usually self-limiting. Case presentation: We report the case of a 68-year-old female who presented with odynophagia, dysphagia, and epigastric pain with no other underlying disease. Endoscopic findings of soft, nodular, and friable growths just above the squamocolumnar junction with diffuse ulcerations in the distal esophagus, led to the diagnosis. It was confirmed with a histopathological report which revealed multinucleated giant cells with eosinophilic intranuclear inclusions. During follow-up, laboratory investigations revealed iron deficiency anemia, which was the consequence of GI bleeding. Clinical discussion: Herpes Simplex virus esophagitis can occur in immunocompetent individuals and even it can cause food impaction and GI bleeding, which can lead to Iron deficiency anemia. Conclusion: Hence, follow-up of patients is important for early diagnosis and intervention of any complications that may arise.

The frequency of ulcerative-erosive defects and ulcerative bleeding of the gastroduodenal zone in patients with coronavirus infection COVID-19

Aim: to determine the frequency of erosive and ulcerative defects and ulcerative bleeding of the gastroduodenal zone in patients with COVID-19 infection. Materials and methods. Fibroesophagogastroduodenoscopy was performed in patients in the hospital for the COVID-19 infection treatment when they had heartburn, dyspepsia, or signs of gastrointestinal bleeding among patients. In total, endoscopy was performed in 387 patients (116 men and 271 women, mean age 65.4 years). Erosive esophagitis was assessed according to the Los Angeles classification (1994), candidiasis esophagitis according to the Kodsi classification (1976), esophageal varices according to K. J. Paquet (1983), classification of ulcerative bleeding according to J. A. Forrest (1974). Results. Erosions in the esophagus was found in 25.3% of the examined patients, gastric and duodenal erosions - in 44.4% of persons, gastric and duodenal ulcers - in 10.1% of patients. Gastroduodenal bleeding was determined in 5.7% of the examined patients and was associated with ulcerative defects in 81.8% of cases. Male gender was a strong risk factor for erosions, ulcers, and bleeding from the upper gastrointestinal tract. Conclusion. In patients with COVID-19, complications from the gastrointestinal tract, manifested by ulcerative defects and bleeding from the gastroduodenal zone, are a significant problem. It seems rational to propose to treat patients with COVID-19 infection receiving massive anti-inflammatory, anthrombocytic, anticoagulant therapy in the same way as is customary in the management of cardiological and rheumatological patients for the prevention of NSAID-gastropathy. © 2022 Global Media Technologies. All rights reserved.

Interdisciplinary Approach Is Essential for Sufficient Diagnosis and Therapy in Igg4-Related Disease Involving Multiple Organs

Introduction: IgG4-related disease (IgG4-RD) is a systemic, chronic inflammatory syndrome, with enlargement of involved organs, elevated serum levels of IgG4, dense lymphoplasmocytic infiltrates, rich in IgG4-positive plasma cells, and fibrosis in involved organs. The most frequently involved organs are the pancreato-hepatobiliary tract, salivary and lacrimal glands, the retroperitoneum, kidneys, lungs, and aorta. Often multiple organ systems are involved. As an initial treatment, glucocorticoids are recommended. In patients with relapse along with glucocorticoid dose reduction, various immunosuppressive agents have been reported. Aims & Methods: We reviewed 98 patients (2019-now) who were treated in the special outpatient unit for IgG4-RD at the University Hospital of Essen and identified 10 patients with IgG4-RD involving multiple organ systems. Result(s): The first patient is a 65-year-old male diagnosed with an IgG4- RD involving parotitis, lymphadenitis, sialadenitis with orbitopathy and elevated IgG4 serum level (7400 mg/l). Clinically response to therapy with steroids was documented. The second patient is a 63-year-old man with an IgG4-positive pancreatitis, sialadentis, lymphadenopathy, and elevated IgG4 serum level (3960 mg/l). Immunosuppression with tacrolimus leaded to clinical benefit. As the third patient, we report a 48-year-old man with IgG4-related inflammatory condition in pancreas and kidneys with high IgG4 serum levels. The patient was successfully treated with azathioprine and prednisolone. As the fourth patient, we demonstrate a 34-year-old man with IgG4-related autoimmune hepatitis, lymphadenitis, and pancreatitis. After treatment with tacrolimus in combination with rituximab, a significant decrease of IgG4-level was detected. The fifth patient, a 65-year-old man, was diagnosed with IgG4-related fibro- inflammatory pseudotumors in the liver, esophagitis, and lymphadenopathy combined with high serum levels of IgG4 (12000 mg/l). Clinically response to therapy with steroids and azathioprine was reported. As the sixth patient we demonstrate a 29-year-old male with IgG4-related lymphadenopathy, recurrent myocarditis, and pancreatitis. The patient has symptom-free episodes under low-dose prednisolone. We also found an IgG4-RD with multiple organ involvement in our seventh patient. A 54-year-old man with IgG4-related cholangitis, pancreatitis, prostatitis, and very high serum level of IgG4 (26700 mg/l) were treated with steroids and azathioprine. As our eight case, we present a 23-year-old man with congenital hepatic fibrosis, after living-donor liver transplantation, who developed an IgG4- related disease with high IgG4 serum levels (45300 mg/l) after infection with SARS-CoV-2. Pathologically enlarged lymph nodes were detected. In a biopsy of retroperitoneal lymph nodes, IgG4-positive plasma cells were detectable. Intestinal biopsies have shown numerous positive plasma cells in the IgG4-staining (40 IgG4 positive plasma cells/HPF). Treatment with rituximab is planned. The ninth patient is a 56-year-old woman with lymphadenitis and cholangitis, who clinically responded to a treatment with budesonide. As the last patient we present a 59-year-old man with an IgG4-related aortitis, cardiac fibrosis, cholangitis, hepatitis, exocrine pancreatic insufficiency and Hashimoto's thyroiditis responding very sufficient to rituximab. Conclusion(s): An interdisciplinary approach is essential for a sufficient diagnosis and therapy in IgG4-RD involving multiple organs. This collective is extremely heterogeneous, and treatment is often based on individual concepts.

Comfort in Telemedicine Based on Diagnosis and Reason for Referral in Pediatric Gastroenterology

Background: Telemedicine can provide increased patient access to care, cost savings and high patient satisfaction. Payors have extended reimbursement for telemedicine and although few pediatric gastroenterologists had experience with telemedicine before the COVID-19 pandemic, many practices continue to offer this as a care modality model. Comfort in practicing telemedicine for specific conditions amongst NASPGHAN members is not known. This study evaluates comfort in practicing telemedicine for common indications for outpatient GI consultation referral and follow up visit diagnoses. Method(s): In June-August 2020, we surveyed members of NASPGHAN with an instrument that included two multi-select questions: 1) Which of the following reasons for referral would you feel comfortable completing with telemedicine? 2) Which of the following conditions would you feel comfortable using telemedicine for a routine follow up? Results: 136 participants answered the two survey items. Constipation (n=121, 89%), heartburn (n=109, 80%), and infant reflux (n=109, 80%) were the reasons for referral most frequently selected. Referral of jaundice (n=26, 19%), second opinion (n=45, 33%), and poor weight gain (n=51, 38%) received the least mentions. For follow up appointments, diagnoses of celiac disease (n=126, 93%), functional gastrointestinal disorders (n=126, 93%), eosinophilic esophagitis (n=120, 88%) were the three most frequent, while liver transplantation (n=24, 18%), intestinal failure (n=26, 19%), and short bowel syndrome without intestinal failure (n=34, 25%) were the diagnoses selected the least. 14 respondents selected comfort with all new patient reasons for referral and follow up visits. Conclusion(s): There is variability in provider comfort to utilize telemedicine for providing consultation or follow up care based on reason for referral or patient diagnosis. Provider comfort in providing care should be considered when offering telemedicine as a practice model moving forward. Reasons underlying provider dis/comfort should be explored using qualitative methods. (Figure Presented).

Medical Treatment of Eosinophilic Esophagitis: A Cochrane Review

Background Current therapies for pediatric and adult eosinophilic esophagitis (EoE) include dietary elimination, proton pump inhibitors, swallowed corticosteroids, and biologics. Our aim is to systematically assess the efficacy and safety of published randomized controlled trials (RCTs) of medical therapies for EoE that compare active treatments to placebo or to an active comparator. We consider RCTs that target the induction and maintenance phases of therapy, separately. Methods A search was designed by a Cochrane information specialist and included Cochrane Gut Register, CENTRAL, MEDLINE, Embase, and clinicaltrials.gov databases, from inception to May 2022. Studies that met our search criteria were imported into Covidence for title and review. All authors participated in study screening, and each study was independently evaluated by two authors. Reports of RCTs that met the inclusion criteria were selected for full text review. Multiple reports of the same RCT were collapsed into the parent study. Data from these studies was then extracted to RevMan Web to assess study characteristics, including study design, EoE definition, inclusion / exclusion criteria, age range, interventions, number of patients randomized, number of patients who completed the study, primary and secondary outcomes and conflicts of interest. Studies were also assessed for potential sources of bias including baseline imbalance, selection, performance, detection, attrition, and reporting biases. We used Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) to assess the overall certainty of evidence supporting the primary outcome. Results As of May 2022, we identified 2,638 reports that met our search criteria of which 14 were duplicates, giving a total of 2,624 reports that were imported into Covidence for further review. Following title and screening, 259 reports were selected for full text review, which were collapsed into 46 distinct RCTs that met the inclusion criteria. The primary outcomes for our systematic review were histological improvement, endoscopic improvement, and clinical symptom improvement, all as defined by the study at study endpoint, and withdrawals due to adverse events. The secondary outcomes of our analysis were serious adverse events, endocrine complications, growth concerns, infections, and health-related quality of life. Study outcomes were analyzed on an intention-to-treat basis. Risk ratios (RRs) and corresponding 95% confidence intervals (95% CI) are reported for dichotomous outcomes, and mean difference and standard deviation are reported for continuous outcomes. The data will be presented in full. Conclusions Results of this analysis inform clinicians about the efficacy and potential side effects of different medical therapies for EoE in both pediatric and adult populations. Deficiencies in our current knowledge will be highlighted and will provide direction for design of future RCTs in the field. Future research should continue to explore factors that influence initial and subsequent medical therapy selection for people with EoE.

Esophagitis Dissecans Superficialis after COVID-19; A Case Report.

Esophagitis dissecans superficialis (EDS) is an uncommon disease characterized by esophageal mucosal sloughing. EDS is a benign condition that usually resolves without residual pathology. Medication, chemical irritants, hot drinks, and autoimmune diseases have all been associated with EDS. Here a 60-year-old lady with post-COVID-19 EDS is presented. Her chief complaint was dysphagia and odynophagia for 2 weeks duration. EDS diagnosis was based on endoscopic findings and biopsy. Her problem was improved by a high dose of pantoprazole.

DEVELOPMENT of INFLAMMATORY MYOPATHY after COVID-19

Background: It has been more than a year and a half since the WHO announced a pandemic of a new coronavirus infection caused by SARS-CoV-2. The virus belongs to the respiratory group, but it it can damage various organs and tissues of the body. COVID-19 infection is characterized by pathological activation of immunity, violated synthesis of pro-infammatory, immunoregulatory, anti-infammatory cytokines, such as interleukins-1 and-6, tumor necrosis factor α and others. These features contribute to the development of rheumatic diseases and syndromes in people who have had COVID-19. Cellular and humoral immune responses are also of primary importance in the pathogenesis of infammatory myopathies. Objectives: Description of a case of severe dermatomyositis after COVID-19. Methods: The 34-year-old female patient complained of pain and weakness in the proximal muscles of the upper and lower extremities, difficulty swallowing solid and liquid food, rash on the face, neck, chest and arms. In August 2020 she had a mild case of COVID-19. A month later, faky erythematous papules like Gottron's sign appeared on the extensor surfaces of the metacarpophalangeal joints and proximal interphalangeal joints of the hands. Six months later, sore throats, hoarseness of voice, belching of air, choking on solid food and episodes of subfebrility joined. Refux esophagitis, duodenitis was detected by fbrogastroduodenoscopy. After 9 months, there were muscle pains and muscle weakness, erythema on the face, neck and chest, the patient lost 11 kg. She was hospitalized in the rheumatology department with suspected dermatomyositis. Results: On objective examination: proximal myopathy, erythematous rashes on the face, neck, chest, Gottron's erythema on the hands. In the analyses: clinical analysis of blood and urine without pathology, ANA 1:1280, creatinkinase 5370 IU/l, with an increase in dynamics up to 9260 IU/l, CRP 0.03 mg/dl, LDH 1023 IU/l, rheumatoid factor and anti-ds DNA were negative. Nasal regurgitation was detected during radiography of the pharynx with contrast. Instrumental examination revealed no signs of a tumor process. Fibrogastroduodenoscopy-superfcial refux-esophagitis, duodenitis, Chest CT-interstitial pneumonitis, abdominal ultrasound without pathology, ECG-sinus rhythm, normal EOS position, accelerated A-V conduction, echocardiography-minor separation of pericardial leaves (up to 5 mm), colonoscopy-dolichosigma. The patient was diagnosed with idiopathic dermatomyositis of high activity. Because of progressive myopathy and increasing dysphagia, pulse therapy with methylpredniso-lone500 mg for 3 days and rituximab 1000 mg was performed. She also received metipred 48 mg per day orally, methotrexate 15 mg per week subcutaneously and folic acid 5 mg per week. Against the background of therapy, positive dynamics was noted: swallowing normalized, the severity of myopathy decreased, after 10 days CKdecreased to 2049 IU/l. After 6 months during the control examination: there are no skin rashes, muscle strength is restored, CK 300 IU/l. The dose of methylprednisolone is reduced to 10 mg per day, the patient continues injections of methotrexate 15 mg per week. Conclusion: COVID-19 may be a trigger for the development of infammatory myopathy. In this clinical case there are features of the course and therapy of infammatory myopathies in patients after coronavirus infection.

One Anastomosis Gastric Bypass (OAGB) as a bariatric procedure in a teaching tertiary hospital in Athens during COVID-19 pandemic

Emmanouil Onoufrios Sgouromallis ATHENS1, Konstantinos Livanos Chalandri1, Georgios Xenakis ATHENS1, Melissanthi Bechraki- Triantafyllou ATHENS1, Parmenion Patias Athens1, Ilias Margaris Athens1 2nd Surgical Dept, George Gennimatas General Hospital, Athens, Greece1 Background: OAGB is a bariatric procedure with excellent results while presumed to have a lower learning curve than classic RYGB. COVID-19 pandemic has severe ramifications in the global health system and this effect is amplified in obesity management due to both the fear of perioperative mortality of bariatric patients and the social stigma that often follows. Methods: We retrospectively analyzed the data of 67 consecutive OAGBs performed in our center from March 2020 to end of December 2021. Results: 47 patients were female, mean age was 41.64 while mean preoperative BMI was 50.45. Mean Hgb decrease was 1.43 postoperatively with mean hospital stay of 4.47 days. All procedures were performed by an attending surgeon as supervisor and two 5th year residents with bariatric surgery experience. There were 3 postoperative leaks, 2 of which resolved with conservative management. No patients were infected during their hospital stay while one patient was admitted to the COVID clinic due to a mild infection two months post operatively with an uneventful course. During the short follow-up period hypertension, diabetes and obstructive sleep apnea were significantly improved or disappeared while no patient reported symptoms of reflux esophagitis. Conclusion: OAGB is feasible as a procedure, with an acceptable learning curve in tertiary centers. COVID pandemic did not decrease bariatric procedures;however one patient who was the only death in our study was admitted in ICU with 24 hours delay due to the decreased availability of ICUs during the pandemic, a factor to be considered during this period.