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Enteropathy-associated T-cell lymphoma (EATL) is a tumor of intraepithelial T-lymphocytes arising in the small intestine. Based on the genetic profile, immunohistochemistry, and histology, EATL is divided into two subtypes. EATL type I occurs in individuals with celiac disease (CD) while EATL type II is a sporadic form that occurs in individuals without CD. Intensive chemotherapy and surgery are the mainstay treatment. However, despite the currently available treatment options, the five-year survival rate is only 9%. EATL presents as abdominal pain, nausea, or slow gastrointestinal bleeding. Severe bleeding leading to hemodynamic instability is rarely known in EATL. Therefore, we present a unique case of EATL who presented with acute and severe gastrointestinal bleeding with no prior history of CD.

Gastrointestinal symptoms are common and frequently reported in Coronavirus Disease-2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It is unclear if SARS-CoV-2 is associated with increased risk of gastrointestinal bleeding (GIB). Nevertheless, GIB in COVID-19 patients poses unique challenges to patients due to high-risk of concomitant respiratory failure and to endoscopy personnel due to risk of airborne transmission during endoscopic procedures. Many management issues related to COVID-19 are still being studied. In this case series, we attempt to discuss the important clinical implications related to the management of GIB in COVID-19 patients.

70 Background: Loeb et al. recently highlighted that academic physicians were statistically more likely to recommend genetic testing to prostate cancer patients per NCCN guidelines compared to physicians at community practices. Several articles have outlined the rate of pathogenic mutations and metastasis free survival (MFS) for prostate cancer patients treated at academic institutions. However, there is a relative paucity of equivalent data regarding patients treated at community urology clinics. We felt it was important to retrospectively review data from our large community based uro-oncology practice and present our findings in an effort to clarify this topic. Methods: We collected data on 562 prostate cancer patients treated at our multidisciplinary uro-oncology clinic between 2016 and 2018. We found 363 patients that satisfied the inclusion criteria of having germline genetic mutation testing and at least 1 year of follow-up. Patients were stratified into three categories based on the results of their germline genetic test: negative for germline mutations, positive for germline pathogenic mutations, or positive for VUS (variant of uncertain significance) mutations. Analysis of variances (ANOVA) was conducted to assess for any differences in age, Gleason score, metastasis rate, and MFS across the groups. A significance level of.05 was used. Results: All patients were treated according to guideline recommendations as was standard for the practice. There was no statistically significant difference in average age or Gleason score between the groups. There was also no statistically significant difference between the MFS across the three groups. Although the metastasis rate and MFS in the group without any mutations (9.8%, 18.3 months) was clinically significant compared to the groups with pathogenic mutations (7.5%, 16.5 months) and VUS mutations (7%, 16.6 months), the differences were not statistically significant (p=.754 and.127 respectively). Conclusions: In our community based uro-oncology practice, we found no statistically significant difference in MFS between patients with pathogenic germline mutations, patients without germline mutations, and patients with VUS mutations at 1 year of follow-up. This does not exclude the possibility of an impact of germline mutations on MFS as the data matures to reach 5 or more years of follow-up.[Table: see text]

INTRODUCTION: We report an unusual case of a patient with COVID-19 who presented with acute mesenteric ischemia without pulmonary symptoms We believe that this observation has important implications for early identification and management of patients with COVID-19 CASE DESCRIPTION/METHODS: An 87 year-old female with atrial fibrillation, not on anticoagulation due to falls, presented to the ED with acute abdominal pain and bloody diarrhea She denied recent travel but had exposure to a relative who had COVID-19 Initial vitals, including O2 saturation were normal On exam she exhibited diffuse abdominal tenderness out of proportion to palpation and bloody stool in the rectum Laboratory studies:WBC 8 4,RBC 12 7,platelets 277,INR 1 0, PTT 36,CRP 25,D-dimer 2262,LDH 126, and lactate 4 0 CT abdomen and pelvis showed focal occlusion of the SMA with ischemic enteritis and colitis involving the terminal ileum and ascending colon Moreover, a pneumonia was noted with typical findings of COVID-19 The patient was started on a heparin drip and underwent thrombectomy with catheter-directed thrombolysis A repeat angiogram demonstrated satisfactory SMA perfusion The patient's abdominal pain and bloody diarrhea resolved A nasopharyngeal swab was taken (SARS-CoV-2 RT-PCR) which resulted positive on day 2 of admission Though she remained asymptomatic, she was treated with Plaquenil and discharged on day 7 with Xarelto, Plavix, and Atorvastatin The patient returned 13 days later with dyspnea requiring O2 via NC and no GI symptoms CXR showed worsening pneumonia She was treated with antibiotics and steroids and was discharged on day 2 with 2L of O2 DISCUSSION: The mechanism of COVID-19 induced GI injury or thrombosis is unknown The virus may have certain tropism to the GI tract as evidenced by the presence of virus in the stool This may be due to the expression of ACE2 receptors in enterocytes to which the virus binds to and enters the cells, thus increasing GI permeability The small bowel, a lymphoid organ, may serve as an entry for the virus and potentiate the immune response Endothelial cells also express the ACE2 receptor Thus, the virus may predispose patients to thrombosis via endothelial dysfunction and activation of the coagulation cascade related to the interaction of the virus with the receptor No cases of mesenteric ischemia related to COVID-19 were found Unusual GI presentations of COVID-19 without pulmonary symptoms should alert gastroenterologists to identify those with the illness promptly

Objective To evaluate whether multiplex PCR-based molecular testing is noninferior to urine culture for detection of bacterial infections in symptomatic patients. Methods Retrospective record review of 582 consecutive elderly patients presenting with symptoms of lower urinary tract infection (UTI) was conducted. All patients had traditional urine cultures and PCR molecular testing run in parallel. Results A total of 582 patients (mean age 77; range 60-95) with symptoms of lower UTI had both urine cultures and diagnostic PCR between March and July 2018. PCR detected uropathogens in 326 patients (56%, 326/582), while urine culture detected pathogens in 217 patients (37%, 217/582). PCR and culture agreed in 74% of cases (431/582): both were positive in 34% of cases (196/582) and both were negative in 40% of cases (235/582). However, PCR and culture disagreed in 26% of cases (151/582): PCR was positive while culture was negative in 22% of cases (130/582), and culture was positive while PCR was negative in 4% of cases (21/582). Polymicrobial infections were reported in 175 patients (30%, 175/582), with PCR reporting 166 and culture reporting 39. Further, polymicrobial infections were identified in 67 patients (12%, 67/582) in which culture results were negative. Agreement between PCR and urine culture for positive cultures was 90%, exceeding the noninferiority threshold of 85% (95% conflict of interest 85.7%-93.6%). Conclusion Multiplex PCR is noninferior to urine culture for detection and identification of bacteria. Further investigation may show that the accuracy and speed of PCR to diagnose UTI can significantly improve patient outcomes.

Gallstones are the most common cause of acute pancreatitis in the United States and Europe. The majority of patients will follow a benign clinical course, with up to 25% progressing to severe pancreatitis. The role of endoscopic retrograde cholangiopancreatography (ERCP) in acute pancreatitis has changed over the years from a diagnostic test to mostly therapeutic. However, ERCP does not come without risk and should only be used when absolutely necessary. In this chapter, we will review the literature to determine the appropriate timing for ERCP in patients with gallstone pancreatitis. We will also review the growing role magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS) has on our treatment algorithm.

Biliary tract infections are encountered frequently in gastrointestinal (GI) practice. Cholangitis is a clinical syndrome comprising fever, pain, and jaundice. Obstruction and stasis in the biliary tract leads to raised intrabiliary pressure, which subsequently results in bacteremia. There are various etiological factors for cholangitis, such as biliary calculi, strictures, parasites, post-endoscopic retrograde cholangiopancreatography (ERCP), postoperative, etc. In contrast to other causes, biliary parasitoses is more common in Southeast Asia. Common parasites involving the biliary tract include Ascaris lumbricoides, liver flukes, and Echinococcus. The incidence of acquired immune deficiency syndrome–related cholangiopathy has decreased after the availability of potent antiretroviral regimens. More recently, improper reprocessing of the endoscopes has been implicated in outbreaks of multidrug-resistant organisms. With the availability of excellent less invasive or noninvasive modalities like endoscopic ultrasound and magnetic resonance cholangiopancreatography, ERCP is now mainly performed with therapeutic intent. Irrespective of the etiology, the mainstay of management of an infected biliary tract is drainage of infected biliary system. The availability of endoscopic ultrasound (EUS)–guided biliary drainage and enteroscopy-assisted ERCP has allowed safe and easy access to the biliary tree in cases of inaccessible papillae. Therefore, most cases of biliary tract infections can be managed nonoperatively. However, a multidisciplinary approach involving endoscopists, interventional radiologists, and surgeons may be required in some cases, such as recurrent pyogenic cholangitis and hydatid disease of liver.

234 Background: Prior to the guidelines set forth by the 2017 Philadelphia consensus conference, genetic testing for prostate cancer was conducted based on personal and family history of malignancies pursuant to NCCN recommendations. The 2017 guidelines expanded testing criteria to included age at diagnosis, metastatic disease, and tumor sequencing. In spite of these advancements, limited literature is available regarding successful implementation of a streamlined system for genetic testing in prostate cancer. This paper explores the benefits of implementing an on-site guideline-based genetic testing process for prostate cancer patients treated at a multi-disciplinary uro-oncology practice. Methods: Data was retrospectively reviewed for 561 prostate cancer patients seen in a multi-disciplinary uro-oncology clinic since January 2017. Prior to January, 1, 2019 genetic testing was recommended to patients based on NCCN guidelines, and swabs for testing were procured off-site less than 1 mile from the clinic (n=107). After January, 1, 2019 genetic testing was recommended based on the guidelines set forth by the Philadelphia consensus conference, and swabs for testing were procured at the clinic itself (n=454). Results: A statistically significant increase in compliance with genetic testing was observed after the implementation of an on-site, guideline-based testing process. Patient compliance with genetic testing increased from 33.6% to 96.5%. The time to receive the genetic test results (calculated as the time between referral for genetic testing and obtaining the test results) was also significantly improved from 38 days to 21 days. Conclusions: The implementation of an on-site, guideline-based genetic testing model for prostate cancer patients significantly improved compliance with genetic testing to 96.5% and decreased the time to receive genetic test results by 17 days. Overall, adopting a guide-line based model with on-site genetic testing has the potential to significantly improve the detection rate for pathogenic and actionable mutations, increase the utilization of targeted therapies, and increase cascade testing to include at-risk family members.

INTRODUCTION: Liver injury in patients with COVID 19 have been described with an incidence of 14 8%-78% and characterized by elevated AST and ALT levels Here we present a case of a man that presented with acute liver injury found to acute HBV and SARS-CoV-2 co-infection CASE DESCRIPTION/METHODS: A 33 year-old-man presented with jaundice, subjective fever and malaise for 5 days Physical exam showed jaundice, not hypoxic, hemodynamically stable and afebrile Investigations on admission AST 2607 U/L, ALT 1187 U/L, TB 27 2 mg/dL (58 2 mg/dL on day 5), GGT 332 U/L, INR 1 49 IgManti-HBc reactive, HBeAg non-reactive, Anti-HBs Non-reactive, HBV viral load 920000 IU/mL Nasopharyngeal swab for SARS-COV-2 RNA PCR was positive LDH 1026 U/L, CRP 8 0 mg/L, Ferritin 27,775 ng/ml, D-Dimer: 286 ng/dL Absolute lymphocyte count 1 90 103/cumm CT abdomen minimal periportal edema with periportal lymphadenopathy Tenofovir 300 mg/day for 2 days was given, then switched to Entecavir 0 5 mg/day He received Acetylcysteine infusion 100 mg/kg for 5 days On discharge AST 390 U/L, ALT 958 U/L, TB 43 8 mg/dL, INR 1 09 He didn't develop respiratory symptoms DISCUSSION: This case rose the question of the interaction between the two viruses and the appropriate treatment in HBV and SARS-CoV-2 co-infection In a study patients with severe COVID-19 were more likely to have HBV than non-severe cases (2 4% vs 0 6%), it has been proposed that there could be an enhancement of viral replication of HBV due to SARS-CoV-2, and that SARSCoV-2 may directly bind to ACE2 positive cholangiocytes causing hepatic injury A CRP >20mg/ L and lymphopenia , 1 1 103/cumm have been independently associated with liver injury in COVID-19, in most studies liver dysfunction appears to be mild and transient Highly elevated AST and ALT are more commonly seen with HBV, in COVID-19 the median levels of AST and ALT haven been 47 U/L The above suggested liver injury was mediated by HBV, we did not administer any treatment targeting COVID-19 Whether or not SARS-CoV-2 promotes/enhances HBV replication needs to be further studied In the setting of emergent COVID-19 its challenging to treat patients presenting like ours given the increasing number of non-respiratory manifestation of the disease, the decision to give treatment for SARS-CoV-2 can be puzzling Here we have presented a patient with acute HBV and co-infection with SARS-CoV-2 that improved without administering any COVID-19 specific therapy

BACKGROUND Influenza A has been described in association with hepatitis. We present a case of complicated influenza A hepatitis in a pregnant woman, adding to the broad differential of liver disease in pregnancy. CASE A 32-year-old woman, gravida 3 para 2002, at 31 4/7 weeks of gestation had influenza A diagnosed and subsequent development of severe pruritis and elevated liver enzymes (aspartate aminotransferase 659 international units/L, normal 15-46 micromoles/L; alanine aminotransferase 933 international units/L, normal 13-69 micromoles/L; and total bile acids 249.7 micromoles/L, normal 4.5-19.2 micromoles/L). She was treated supportively, and fetal surveillance was normal. Her symptoms resolved over the subsequent 2 weeks, and she delivered a healthy term newborn. CONCLUSION Influenza A infection can be associated with hepatitis in pregnancy, which in our case resolved spontaneously over 10 to 14 days with favorable maternal and perinatal outcomes.

and 2 upper endoscopes on days 0, 7, 14 and 21 following standard protocol for mechanical cleaning and high level disinfection using an automated endoscope reprocessor. Endoscopes were stored hanging per institutional practice. A 1mL aliquot of each sample was inoculated onto trypticase soy agar with 5% sheep blood (blood agar), thiogycollate broth, a CDC anaerobic blood agar plate, and Sabouraud dextrose agar (for yeast and molds). All media were incubated at 2535C for 7 days. Organisms were identified using standard microbiological techniques; results were reported in colony forming units. Results: There were 33 positive cultures from 28 out of the 96 sites tested (29.2% overall contamination rate). 30/33 isolates were typical skin or environmental contaminants, thus clinically insignificant (Table 1). Three potential pathogens were cultured, including