Autologous Gastrointestinal Graft-vs-Host Disease in a Patient With Multiple Myeloma and Hematopoietic Stem Cell Transplantation.

Graft-vs-host disease (GVHD) of the gastrointestinal (GI) tract is notably a serious complication of allogeneic hematopoietic stem cell transplant (HSCT). However, GI GVHD has rarely been reported in autologous HSCT, and the pathophysiology remains unclear. Diagnosing GVHD after autologous HSCT requires a high level of clinical suspicion, given its nonspecific clinical presentation and endoscopic findings necessitating a histological diagnosis for confirmation. We present a case of autologous GVHD involving the GI tract in a patient with multiple myeloma who responded well to corticosteroids, highlighting the importance of early identification of this rare entity to initiate therapy and improve outcomes.

Cutaneous Crohn's disease after proctocolectomy for medically refractory colonic Crohn's disease: a case series and review of the literature.

Background: Cutaneous Crohn's disease (CCD), also known as metastatic Crohn's disease (CD), is one of the rarest and most challenging cutaneous manifestations of CD. It is characterized by non-caseating granulomatous inflammation of the skin at sites that are non-contiguous with the gastrointestinal (GI) tract. Diagnosis of CCD needs a high clinical suspicion since morphological presentation varies widely and lacks an apparent correlation to the activity of the luminal CD. The onset of CCD in patients without active GI CD is a particularly understudied phenomenon. Methods: We present a case series of a unique patient group who developed CCD while in remission from a luminal CD perspective, mainly after a proctocolectomy for Crohn's colitis. We also provide a literature review and summary of case reports of CCD after proctocolectomy. Results: Our 4 adult patients diagnosed with CCD after proctocolectomy presented herein, were successfully treated with high-dose corticosteroids, followed by biologic therapy. Furthermore, a comprehensive review of CCD is provided regarding its pathogenesis, clinical presentation, differential diagnosis, and the evidence behind the available treatments. Conclusions: CCD should be considered in any CD patient presenting with skin lesions regardless of their disease activity status and history of proctocolectomy. The treatment remains challenging; biologics remain the cornerstone and a multidisciplinary approach is recommended. Larger randomized clinical trials are essential to determine the optimal treatment protocol and to improve outcomes.

Availability of PEth testing is associated with reduced eligibility for liver transplant among patients with alcohol-related liver disease.

BACKGROUND: Serum phosphatidylethanol (PEth) is a highly sensitive test to detect alcohol use. We evaluated whether the availability of PEth testing impacted rates of liver transplant evaluation terminations and delistings. METHODS: Medical record data were collected for patients who initiated transplant evaluation due to alcohol-related liver disease in the pre-PEth (2017) or PEth (2019) eras. Inverse probability weighting (IPW) was used to balance baseline patient characteristics. Outcomes included termination of evaluation or delisting due to alcohol use; patients were censored at receipt of transplant; death was considered a competing risk. The Fine-Gray method was performed to determine whether PEth testing affected risk of evaluation termination/ delisting due to alcohol use. RESULTS: Three hundred and seventy-five patients with alcohol-related indications for transplant (157 in 2017; 210 in 2019) were included. The final IPW-adjusted model for the composite outcome of terminations/delisting due to alcohol use retained two significant variables (P < .05): PEth era and BMI category. Patients evaluated during the PEth era were almost three times more likely to experience an alcohol-related termination/delisting than those in the pre-PEth era (sHR = 2.86; 95%CI 1.67-4.97) CONCLUSION: We found that availability of PEth testing at our institution was associated with a higher rate of exclusion of patients from eligibility for liver transplant. Use of PEth testing has significant potential to inform decisions regarding transplant candidacy for patients with alcohol-related liver disease.

Liver Injury as a Surrogate for Inflammation and Predictor of Outcomes in COVID-19.

Respiratory failure is the most common cause of death in patients with corona virus disease 2019 (COVID-19). There have been many investigations to determine predictors of bad outcomes in patients with this illness. Liver enzyme elevation has been described in hospitalized patients with severe COVID-19; however, little is known about the significance of liver injury regarding outcomes. We conducted a retrospective chart review of 348 patients admitted with COVID-19 in our quaternary care center. Liver injury on admission was defined based on the laboratory cutoff of aspartate aminotransferase >35 IU/L and/or alanine aminotransferase >52 IU/L. Patients were divided into two cohorts based on the presence or absence of liver injury. These cohorts were compared to assess differences in presentation, complications, and outcomes. The primary outcome was respiratory failure requiring intubation, and the secondary outcome was in-hospital mortality. The presence of new onset liver enzyme elevation on presentation was associated with increased severity of illness, need for mechanical ventilation, and mortality. Presence of liver injury increased the chance of acute hypoxic respiratory failure requiring mechanical ventilation by 1.79 times. The degree and timeline of liver enzyme elevation during hospitalization corresponded with elevations of other inflammatory markers. Conclusion: Liver injury appears to correlate with the inflammatory syndrome caused by COVID-19, with the degree of liver injury corresponding with severity of inflammation. We suggest early and continued monitoring of liver enzymes as they can be useful to identify patients who may need early escalation of care.

P059 Impact of PHQ-9 Screen on Early Identification of Depression in IBD Clinic.

BACKGROUND: Over the past two decades there has been significant research linking inflammatory bowel disease (IBD) to depression. The chronicity of symptoms coupled with the financial burden of treatment costs, missed days of work/school and interpersonal relationship stress are contributing factors in the diagnosis of depression. The prevalence of depression within the IBD community is 15% and depressive symptoms are noted in 20% of patients. Furthermore, IBD patients with severe uncontrolled disease have higher rates of depression (40.7%) than those in remission (16.5%). The association between IBD and depression is linked to lower quality of life, poor medication compliance, worse disease outcomes, increased hospitalization, and higher suicidal risk. Early diagnosis and treatment of depression in IBD patients is paramount in achieving and maintaining IBD disease remission. While the association between IBD and depression is well-known, identifying depression can be a challenge. Review of recent literature shows that depression is under screened in IBD clinics. We present a prospective quality improvement study at a robust IBD center evaluating the impact of a validated depression screen (PHQ-9) on identifying depression compared to standard of care. METHODS: We compared the prevalence of depression in the IBD clinic in the control group using the history and diagnosis of depression and compared it against the intervention group after HQ-9 screening. Control group patient data was collected from June 2020 to July 2020 via virtual and in person visits. Intervention group PHQ-9 data was collected in person visits from January - March 2020 and post-intervention data collection was placed on hold until November 2020 due to the COVID pandemic. One randomly selected patient from each clinic session was asked to participate in the study at the time of visit. The primary end point was to compare the rates of depression and identify any barriers in providing early treatment for depression. The secondary endpoint was to identify high risk patients that are prone to depression. Categorical variables were analyzed by chi square analysis or fischer exact tests. Numerical data were analyzed using T-test. RESULTS: A total of 111 patients were screened. 60 patients were randomized to the control group (i.e. EMR based review for depression) and 51 patients were screened via survey during in person clinic visit. The identified depression rate from control vs intervention group is 20% vs. 35% (p = 0.071). Rates of depression were 15% in non-fistulizing Crohn's disease vs. 41.4% in fistulizing Crohn's disease (p = 0.003). Multivariate model for predicting depression noted to be significant for extra-intestinal manifestations OR of 3.06 (1.03, 9.12) p = 0.045 and age OR of 0.97 (0.94, 1.00) p = 0.042. Control vs. intervention identification of depression in patients with extra-intestinal manifestations is notable for OR of 3.31 (1.15, 9.52) p = 0.026 in the univariate model and OR of 3.30 (1.07, 10.16) p = 0.038 in the multivariate model. CONCLUSION: Key findings including identification of depression is higher in the intervention group compared to the control group. Though the data is not statistically significant, this is likely secondary to the small sample size in the setting of the pandemic. In addition, univariate analysis revealed a statistically significant finding that the older the age of the patient, the less likely they are to have depression. Our data showed that the mean age of depressed patients was 38.3 compared to nondepressed patients whose mean age is 47.1. Further analysis can help elucidate this finding, for example identifying if older patients are being treated for depression or more likely to seek out therapists compared to younger patients. Univariate analysis also revealed that intestinal Crohn's disease was a risk factor for depression. This is possibly secondary to the severity of disease in these individuals, especially if their IBD is causing an impact on their quality of life. Looking into the number of hospitalizations, days off from work or school, and coexisting medical diagnoses can allow us to further understand if depression stems from their disease. Given preliminary findings, we plan to continue this study for a larger sample size and further determine if there is a significant delay in identifying depression with the current standard of care.

Life-threatening Gastrointestinal Bleeding Secondary to Kaposi's Sarcoma of the Duodenum.

The use of antiretroviral therapy has decreased the incidence of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) complications. However, Kaposi's sarcoma (KS) is not uncommon. KS can involve any organ, including the gastrointestinal tract. The disease usually remains asymptomatic, but hemorrhages have been reported due to the hypervascular nature of the lesions. We report a case of a newly diagnosed HIV-infected patient, who presented with upper gastrointestinal bleeding. His bleeding had become life-threatening after an adequate endoscopic sampling of the lesions to the extent where he was transferred to the intensive care unit and required multiple units of blood product transfusion and a selective embolization by interventional radiology to achieve hemostasis.

Findings on Colonoscopy after Diverticulitis: A Multicenter Review.

Diverticular disease is a common problem where patients with diverticulosis have a 1-4 per cent risk of acute diverticulitis. Current guidelines recommend a colonoscopy after.the resolution of acute diverticulitis. The aim of this study was to evaluate the yield of significant findings on colonoscopy after an episode of diverticulitis. This is a retrospective analysis of patients who underwent colonoscopy after an episode of diverticulitis between November 2005 and August 2017 at three major teaching hospitals. Advanced adenomas were defined as adenomas ≥1 cm, serrated adenomas, and tubulovillous or villous adenomas. A total of 584 patients (298 males; 51%) underwent colonoscopy for a history of diverticulitis after resolution of acute symptoms. Colonoscopy was complete in 488 patients (84%). Among these 488 patients, 446 had diverticular disease, 31 had advanced adenomas, and four had adenocarcinomas. Colonoscopies were incomplete in 96 patients (16%). Forty-six of those patients underwent surgery. The overall incidence of advanced adenomas and adenocarcinomas was 32 (5.4%) and nine (1.5%), respectively. In our study, the prevalence of advanced adenomas and adenocarcinomas was relatively high compared with the average risk individuals. Our findings support that patients after an episode of diverticulitis should continue to get a colonoscopy.