Background: Patients with kidney disease are at increased risk for gastrointestinal bleeding (GIB). This study aimed to investigate the incidence, causes, interventions, and inpatient outcomes of GIB in patients with advanced chronic kidney disease (ACKD), end-stage kidney disease (ESKD), and kidney transplant recipients (KT), compared to those without CKD (NCKD). Methods: This retrospective study utilized the Nationwide Inpatient Sample (NIS) database to identify adult patients admitted non-electively with GIB from 2016 to 2019. Patients were stratified into five groups: ACKD (CKD stages 4 or 5), ESKD, KT, NCKD, and others (including CKD stages 1-3 and unspecified CKD). We compared outcomes across these groups and conducted subgroup analyses within the ACKD and ESKD groups to explore the association between mortality and the timing of endoscopic evaluation. Multivariate logistic regression (for binary outcomes) and linear regression (for continuous outcomes) models were used to analyze the dependent variables. Results: A total of 2,163,929 patients were included. The incidence of GIB hospitalizations was higher in the ACKD (3.2%) and ESKD (3.4%) groups, and lower in the KT group (2.1%) compared to the NCKD group (2.2%). All-cause in-hospital mortality was increased in ACKD, ESKD, and KT (3.0%, 3.1%, 2.0% respectively) compared to NCKD (1.7%). ESKD patients had higher rates of mechanical ventilation, vasopressor support, and blood transfusion, along with prolonged and costly hospitalizations (p < 0.001). ACKD and ESKD groups had lower rates of early endoscopy (<24 hours) and higher rates of delayed endoscopy (>48 hours) with delayed endoscopy linked to increased mortality. ACKD and ESKD were independent risk factors for angiodysplasia bleeding, while KT was a risk factor for diverticular and esophageal bleeding. Conclusions: ACKD and ESKD are independent risk factors for GIB hospitalizations and in-hospital mortality, with delayed endoscopy further worsening outcomes. Tailored treatment plans are essential to improve outcomes in this complex population.

Introduction: The role of healthcare disparities in contributing to a later stage of diagnosis and decreased overall survival (OS) in hepatocellular carcinoma (HCC) has not been explored. Our study aimed to determine which social determinants of health (SDOH) are associated with late-stage HCC and whether these factors are associated with survival. We utilized the National Cancer Database (NCDB), a hospital-based cancer registry that captures approximately 75% of diagnosed cancers in the U.S. and Puerto Rico to explore this issue. Methods: We identified all adult cases of HCC in the NCDB from 2004-2020. The primary outcome of interest was a diagnosis of Stage IV HCC with a secondary outcome of OS. Demographic cofactors included race, income, education via percent high school completion (HSC), insurance status and Charlson-Deyo comorbidity score (CDCS). Multivariable logistic regression models evaluated odds of a Stage IV diagnosis. Multivariable Cox proportional hazards model examined HR’s for OS. Analysis was performed using STATA. Results: 273,940 patients were included with mean age of 64.5 (SD 11.1). In univariate analysis, higher education, income, and insurance status decreased the odds of Stage IV cancer at diagnosis, while Black race increased it. In multivariable analysis (Table 1), higher education [>93.7% HSC vs < 81.4%, OR 0.88 (0.87-0.88)], private insurance [vs uninsured, OR 0.69 (0.68-0.70)] and higher income decreased the odds of Stage IV HCC diagnosis, whereas Black race [vs White OR 1.14 (1.14-1.15)] and CDCS ≥3 [vs 0, OR 1.60 (1.58-1.61)] increased the odds of Stage IV HCC. In the adjusted Cox proportional hazard model, higher education [ >93.7% HSC vs < 81.4%, HR 0.85 (0.85-0.86)], income >$63,333 [vs < $40,227, HR 0.72 (0.72-0.73)], private insurance [vs uninsured, HR 0.67 (0.67-0.69)] improved OS, whereas Black race [vs White HR 1.18 (1.18-1.19)] and CDCS ≥3 [vs 0, HR 1.71 (1.7-1.72)] decreased it. Conclusion: SDOH impacted the delivery of care in patients with HCC especially contributing to the diagnosis of advanced disease and decreased overall survival. This study demonstrated that lower socioeconomic status, educational attainment, poor overall health, Black race, and being uninsured are predictors of later stage diagnosis and in turn, may impart worsened risk of survival. Reducing disparities in cancer care require collective investment of healthcare providers, policymakers, and public health officials. Table 1. - Odds of Being Diagnosed with Stage IV HCC (vs. Stages 0–III) and Cox-Proportional Hazard Model for Overall Survival of Patients with Stage IV HCC Factors Logistic Regression Model: Cox Proportional Hazard Model: Stage IV vs 0-III Overall Survival (OS) OR 95% CI P-Value HR 95% CI P-Value Age 1.04 1.02-1.04 < 0.01 1.14 1.14-1.15 <0.001 Sex Female Ref - - Ref - - Male 1.22 1.20-1.22 < 0.001 1.28 1.28-1.29 < 0.001 Race White Ref - - Ref - - Black 1.14 1.14-1.15 < 0.001 1.18 1.18-1.19 < 0.001 Hispanic 1.06 1.04-1.07 < 0.001 1.10 1.09-1.11 < 0.001 Insurance Status Uninsured Ref - - Ref - - Medicaid 0.84 0.83-0.85 < 0.001 0.83 0.83-0.85 < 0.001 Medicare 0.93 0.93-0.95 < 0.001 0.92 0.92-0.95 < 0.001 Private 0.69 0.68-0.70 < 0.001 0.67 0.67-0.69 < 0.001 Education >93.7% Ref - - Ref - - 89.2%-93.7% 0.94 0.94-0.96 < 0.001 0.93 0.93-0.94 < 0.001 82.5%-89.1% 0.92 0.91-0.94 < 0.001 0.91 0.91-0.92 < 0.001 < 81.4% 0.88 0.87-0.88 < 0.001 0.85 0.85-0.86 < 0.001 Income < $40,227 Ref - - Ref - - $40,228-$50,353 0.91 0.89-0.92 < 0.001 0.89 0.89-0.91 < 0.001 $50,352-$63,332 0.90 0.89-0.90 < 0.001 0.88 0.82-0.89 < 0.001 >$63.333 0.73 0.72-0.74 < 0.001 0.72 0.72-0.73 < 0.001 Charlson-Deyo Score 0 Ref - - Ref - - 1 1.02 1.02-1.03 < 0.001 1.1 1.1-1.12 < 0.001 2 1.45 1.44-1.46 < 0.001 1.47 1.47-1.48 < 0.001 ≥3 1.6 1.58-1.61 < 0.001 1.71 1.70-1.72 < 0.001

Background: The Canada-United Kingdom-Adelaide (CANUKA) score was developed to stratify patients who experience upper gastrointestinal bleeding (UGIB) to predict who could be discharged from the emergency department. Our aim was to determine if the CANUKA score could be utilized for UGIB in-patients undergoing endoscopy in predicting adverse outcomes. We additionally sought to establish a CANUKA score cut point to predict adverse outcomes and in-hospital mortality and compare this to established scoring systems. Methods: Between January 1, 2018 to June 30, 2019 all patients who underwent upper endoscopy after admission for UGIB were identified. We assigned a CANUKA score and compared the area under the receiver operating curve to established scoring systems. Results: Our data set included 641 patients, with a mean age of 59.5±14.5 years. A CANUKA score ≥10 was associated with an adverse outcome [unadjusted odds ratio, 3.08 (1.79, 5.27)]. No patients experienced an adverse outcome with a CANUKA score <4. No patients died with a CANUKA score <6. Those with a CANUKA score of <10 had an in-hospital mortality of 2.1% compared with 6.8% for those with a score ≥10 (P=0.008). AIMS65 had the best area under the receiver operating characteristic curve (0.809) for predicting mortality. Conclusions: The CANUKA score may serve utility as a predictor of adverse outcomes and mortality in patients admitted with UGIB undergoing endoscopy. Future studies, ideally prospective and multicenter, will be needed to validate its clinical utility.

Introduction: Management of symptomatic mature pancreatic fluid collections (PFCs) such as pancreatic pseudocysts or walled-off necrosis now involve the use of lumen-apposing metal stents (LAMS) under endoscopic ultrasound (EUS) guidance. LAMS appear to be superior compared to traditional plastic stents however require close follow up. Numerous studies have shown a benefit of LAMS for short-term (e.g., 4-week) outcomes. However, there is a lack of data evaluating longer term outcomes. Our aim was to investigate 90-day readmission rates after LAMS placement over an 8-year period. Methods: We identified all patients ≥ 18 years who underwent deployment of a LAMS from 01/01/2014 to 06/01/2021 at our urban, safety net hospital. We subsequently collected demographic data, cyst characteristics, and stent information. Follow-up upper endoscopies and imaging were examined to determine stent removal date and assess for complications. Hospital admission rates 90 days before and after stent placement were collected. Admissions were stratified into gastrointestinal (GI)-related or other. Results: We identified 27 patients who underwent LAMS for drainage of mature PFCs. Of these, 18 were simple pancreatic pseudocysts (PP), 6 walled-off necrosis (WON), and 3 mixed collections. Mean age was 52.1 ± 11.0 years, 66.7% male, 66.7 % non-white, and 59.3% reported alcohol use. The average collection was 6.6 ± 2.0 cm. Stents were removed in 81.5% of patients at a median of 37.5 days. 7.4% were lost to follow up, and 22.2% of patients had stent complications during follow-up: 2 bleeding, 2 stent migration, and 2 stent occlusions. Patients on average had 1.00 ± 0.20 hospital admissions in the 90 days prior to stent placement vs 0.48 ± 0.17 admissions 90 days after placement (mean difference 0.52 ± 0.17, p< 0.05). Of these patients, 64.7% of pre-stent hospitalizations were due to GI complaints vs 22.2% of post-stent hospitalizations (p< 0.05). Neither cyst size nor time to stent removal were significantly related to complications. Conclusion: LAMS for the management of mature pancreatic fluid collections were effective at reducing 90-day readmission rates especially in the setting of GI-related complaints. Although there was a delay in LAMS removal with a median of 38 days, it did not appear to translate into higher complication rates. Perhaps an extended use of LAMS beyond 4 weeks may prove to be safe and efficacious, however larger studies are required.

Introduction: Anti-programmed death-1 (PD-1) and programmed death-ligand (PD-L1) immunotherapy have been studied as adjuvant and neoadjuvant treatment for patients with advanced esophageal or gastro-esophageal junction (GEJ) cancer. Our aim was to use the highest quality data available to perform a meta-analysis evaluating their efficacy and safety. Methods: We reviewed PubMed, MEDLINE, Embase, and Web of Science Core Collection databases from inception to Aug 1st, 2021, to identify studies evaluating the efficacy and safety profile of PD-1 and PD-L1 inhibitor immunotherapy in the management of advanced refractory esophageal or GEJ cancer. Our primary outcome was overall survival. Secondary outcomes were progression-free survival, and objective response including complete response, partial response, stable disease, and progressive disease. Adverse effects were characterized according to Common Terminology Criteria for Adverse Events v 4.0. Pooled rates with 95% confidence intervals (CI) for all outcomes were calculated using a random-effect model. Results: Literature review identified 12 randomized clinical trial articles and one retrospective chart review study suitable for meta-analysis. Most studies were performed in East Asia. The median age of participants from all studies ranged from 60 to 65 years The majority of patients included in the studies had stage III or stage IV disease. Pooled 6- and 12- month overall survival rates were 71% (95% CI 62%-83%) and 41% (95% CI 34%-49%), respectively (Figure). Pooled 6- and 12- month progression-free survival rates were 30% (18%-52%) and 15% (7%-35%), respectively (Figure). Response rates were as follows: complete response 4% (1%-14%); partial response 30% (17%-52%); stable disease 23% (19%-27%,) and progressive disease 48% (39%-59%). The most common side effect was constipation. It occurred in 17% (7%-41%) and was graded 1-2 (mild) in all cases. Other common adverse effects were diarrhea, anorexia, nausea, and vomiting. The most common non-GI adverse effect was fatigue, with an overall rate of 16% (9%-28%). Fatigue was graded as 1-2 in 94% of cases. The other common non-GI side effects included hypothyroidism and rash. Conclusion: In summary, use of PD-1/PD-L1 inhibitors provides clinically meaningful rates of survival and response. They demonstrate a well-tolerated safety profile thus supporting their current role as adjuvant or neoadjuvant therapy for advanced esophageal and GEJ cancer.Figure 1.: Overall survival rate at 6- and 12- month in patients taking PD-1/PD-L1 inhibitors

Introduction: Rectal bleeding (RB) is a symptom of colorectal cancer (CRC) that often prompts endoscopic investigation. The outcomes of RB in the setting of CRC have not been well described. We investigated the outcomes of patients diagnosed with stage IV CRC after presenting with RB. Methods: We retrospectively analyzed patients ages 18 years and older diagnosed with Stage IV CRC from 2011 to 2017 in our academic, safety-net hospital. Patients were excluded if they were not diagnosed via diagnostic colonoscopy. Patients were stratified based on RB at presentation. Location of tumors were categorized as right-sided colorectal cancer (RCRC) and left-sided colorectal cancer (LCRC). RCRC included those located from the cecum to the proximal two-thirds of the transverse colon. LCRC included those located from the distal one-third of the transverse colon to the rectum. Results: Sixty-nine patients met the inclusion criteria. General characteristics are shown in Table. Those without RB had significantly higher Charlson Comorbidity Index (CCI) scores (p < 0.05). The average time from presentation to endoscopy in those with RB compared to those without RB were 0.9 + 1.5 months and 1.2 + 3.3 months, respectively (p = 0.53). All thirty-five patients with RB had LCRC. For those without RB, eighteen had RCRC and sixteen had LCRC. There were no differences in times to surgery (p = 0.09), systemic therapy (p = 0.27), or any treatment (p = 0.14). Median survival in those with RB was 1377 days and those without RB was 358 days. Using the Cox proportional hazards model with CCI, gender, and race as covariates for multivariate analysis, the average length of survival remained significantly higher in patients with RB (p < 0.01, HR 0.43, 95% CI 0.23-0.80) (Figure). Conclusion: RCRC and LCRC have been documented to have different morphological and molecular characteristics, with RCRC often being described as more aggressive than LCRC. In our study, all patients who presented with RB had LCRC and more than half of the patients without RB had RCRC. The absence of RB was associated with increased mortality after controlling for age, comorbidities, gender, and race. Furthermore, there were no differences in time to either endoscopy or treatment. In conclusion, RB in CRC may be more indicative of left-sided disease which may be associated with a less aggressive disease course. However, more research is required to fully understand the association between RB and clinical outcomes.Figure 1.: Survival curve using the Cox proportional hazards model with CCI, race, and gender as covariates for multivariate analysis. Red line: Rectal Bleeding. Black line: No Rectal Bleeding. p < 0.01, HR: 0.43, 95% CI: 0.23 - 0.80 Table 1. - General characteristics, time from presentation to endoscopy, median survival, and times to treatment in patients with stage IV colorectal cancer Rectal Bleeding No Rectal Bleeding Significance Number of Patients 35 34 Age at Diagnosis 57.9 + 13.0 62.2 ± 13.8 n.s. Sex Male 20 (57.1%) 17 (50.0%) n.s. Female 15 (42.9%) 17 (50.0%) Race White 15 (42.9%) 12 (35.3%) n.s. Black 19 (54.3%) 20 (58.8%) Other 1 (2.9%) 2 (5.9%) Charlson Comorbidity Index 5.6 ± 2.3 6.9 ± 2.0 < 0.05 Time from presentation to endoscopy (months) 0.9 ± 1.5 1.2 ± 3.3 n.s. Median Survival (days) 1377 358 < 0.01 Time to first treatment (months) 2.7 ± 4.8 1.3 ± 1.8 n.s. Time to surgery (months) 4.2 ± 3.2 2.2 ± 3.0 n.s. Time to systemic treatment (months) 3.0 ± 4.7 1.8 ± 1.8 n.s.

Introduction: Although non-modi fi able factors such as age, sex, and race have been associated with increased risk of developing colon cancer, there are limited studies investigating modi fi able factors. Some studieshaveshown fi berandcalciumtobeprotective,whileprocessedmeatsandalcoholtoberiskfactors.Thedata,however,remainscontroversial.Theaimsofthisstudyareto1)re-evaluatetheepidemiology of colon cancer and 2) explore the nutritional status of those with early colon cancer diagnosis. Methods: The National Health and Nutrition Examination Survey (NHANES) is a survey designed to assess the health and nutritional status of adults and children across the United States (US). Nutritional information wascollected viaa 24-hour diet recall, and thosewith reliable recallwere demographic andnutritional who self-reported The sample size was appropriately weighted strati ed years age analysis. Results: There were 5,767,593 self-reported cases of colon cancer in the US from 2007-2016 with reliable nutritional recall. Demographic data strati fi ed by cohort is outlined in Table along with caloric and dietary intake. The average age of colon cancer diagnosis was 56.5 6 15.3 years of which 19.4% were diagnosed early (age , 45). Univariate analysis showed those with early diagnosis had higher calorie (p , 0.001), fi ber (p , 0.001), calcium (p , 0.001), ca ff eine (p , 0.001), and alcohol consumption (p , 0.001) than those diagnosed over 45. After controlling for BMI, race, sex, education, and income using logistic regression, we found that patients with higher caloric intake ( $ 2000 kcal) were more likely to be diagnosed with early onset colon cancer (OR: 3.81, 95% CI: 3.79-3.82). Conclusion: There were on average 576,759 reported cases of colon cancer per year in the US of which approximately 1/5 th were diagnosed before 45. Females, non-Hispanic whites, and higher education/ income were associated with early colon cancer diagnosis possibly due to earlier screening. Contrary to other studies, higher fi ber and calcium intake did not appear to be protective. However, those with early diagnosis did have higher alcohol intake. Our data suggests those with high caloric intake, a modi fi able risk factor, increases the odds of developing early cancer by over threefold, perhaps due to chronic underlying in fl ammation. angiotensin-converting enzyme 2 (ACE2) and cellular serine proteases (TMPRSS2) in enterocytes, which cause altered intestinal permeability. The purpose of this study was to determine the incidence of diarrhea as it relates to COVID-19 infection and to determine if having concomitant diarrhea had a signi fi cant impact on disease course. Methods: A retrospective chart review of 164,730 patients in a hospital system who were older than 18 years of age and had a positive SARS-CoV-2 test from March 2020 to February 2022 was completed. Diarrhea was determined using ICD code or patient ’ s symptoms. Patients with confounding variables such as IBD, IBS, Celiac, Clostridium di ffi cile, and pancreatic insu ffi ciency were excluded. Demographic

Rishabh Khatri: NO financial relationship with a commercial interest | Jay Patel: NO financial relationship with a commercial interest | Jun Song: NO financial relationship with a commercial interest | Zachary Jurkowski: NO financial relationship with a commercial interest | Neil Nadpara: NO financial relationship with a commercial interest | Tiffany Lambrou: NO financial relationship with a commercial interest | Marlana Radcliffe: NO financial relationship with a commercial interest | Kamal Baig: NO financial relationship with a commercial interest | Woo Jung Lee: YES financial relationship with a commercial interest;Olympus:Consulting | Saraswathi Cappelle: NO financial relationship with a commercial interest | Stephen Heller: YES financial relationship with a commercial interest;Olympus:Consulting | Frank Friedenberg: NO financial relationship with a commercial interest