Introduction: Gastrointestinal follicular lymphoma (FL) is a rare, but distinct extra-nodal variant of non-Hodgkin’s lymphoma. Its incidence has grown outside of known genetic inheritance, due to epigenetic mutations from increased toxic exposure to benzene and pesticides, expanded life spans, and widespread standardized screening efforts. Diagnosis is by colonoscopy-obtained tissue staining and can be missed if alternative CRC screening methods are used in lieu. Case Description/Methods: A 54-year-old Ukranian male with a past medical history of HTN and GERD came in for an asymptomatic screening colonoscopy. One 8 mm polyp in the transverse colon was positive for FL. IHC staining demonstrated atypical small B-lymphocytes, positive for CD45+, CD20+, PAX5+, CD10+, and BCL-2+. Bloodwork, including LDH, beta-2-microglobulin, were normal. A staging PET scan was negative indicating an isolated disease within the colonic polyp. As the patient was asymptomatic, no further treatment was indicated and the patient was scheduled for regular follow-up. Discussion: GI FL is a B-cell lymphoma with an incidence slightly higher in women and a median age of 65. Occurrence outside of the bone marrow, spleen, or liver is uncommon. Descending incidence within the GI tract is the duodenum, ileum, stomach, and rarely colon. Within the colon, it presents asymptomatically. Definitive diagnosis is by a colonoscopy-obtained tissue staining. Colonoscopy adherence is generally high after the age of 65, given the median age of colorectal cancer incidence is 67 and the availability of Medicare coverage. However, if alternatively approved screening modalities are utilized such as the gFOBT, FIT, FIT-DNA, or flexible sigmoidoscopy, then the diagnosis of a FL might be missed until either mass or metastatic effects become apparent. Diagnostic work-up includes IHC staining for CD-20, CD-36, a follicular cell pattern, increase in B cells, bcl-2, bcl-6, and a 14:18 translocation by FISH or PCR (85% of cases). Investigation into a primary NHL, leukemia, or MDS includes flow cytometry, bone marrow biopsy, and cytogenetics. Increased LDH indicates rapid progression with staging done by PET or pan CTs. Colonic FL have a 10-year survival rate of 80% and an indolent course, so treatment is only indicated if the patient is symptomatic. Treatment for stage 1 is radiation, stages 2-4 is CHO P-R chemotherapy. Adjuvant or refractory treatments include anti-CD20 monoclonal antibodies, such as rituximab or obinutuzumab.Figure 1.: A. 8mm semi pedunculated polyp in the transverse colon. B. Polyp site post hot snare removal C. Colonic mucosa with nodular infiltrate of atypical small b lymphocytes; predominantly with centrocyte-like morphology.

ID: 3527921 ENDOSCOPIC INTRAPERITONEAL SUBSEROSAL DISSECTION (EISD): BETTER VIEW, SAFER OPERATION Xinyang Liu*, Jianwei Hu, Pinghong Zhou Gastric submucosal tumor (SMT) originated from deep layers of the gastric wall can be resected by EFTR or STER. However, the lesions are usually in a tangent position, and the endoscopic view from gastric lumen is inherent poor. In addition, the highly movable tumor with limited endoscopic exposure increases the difficulty in the en bloc resection as well as safe hemostasis. Herein, we developed a modified method, called endoscopic intraperitoneal subserosal dissection (EISD), for the removal of gastric SMT with predominately extraluminal growth pattern. The specific steps of our technique were as follows. First, 1.5-cm gastric mucosal incision was created about 4-cm proximal to the lesion after submucosal injection. Subsequently, a short submucosal tunnel was created, and the gastric muscularis propria was then intentionally perforated about 3-cm away from the lesion. After locating the lesion on the serosa from the abdominal cavity, the tumor was carefully dissected from the serosa and the underlying muscularis propria without interruption of the tumor capsule. Subserosal injection was performed when necessary to create working space or to identify the layer. Caution should be taken to avoid the damage of the integrity of the mucosa during the dissection. The lesion was then removed after full dissection. Finally, after careful hemostasis, the tunnel entrance was closed. The video showed the two EISD cases of stromal tumor in the gastric body originated from the deep muscularis propria with predominantly extraluminal growth. The operating time was 70 and 65 minutes, respectively. The follow-up endoscopy and CT showed satisfactory healing with no residual tumor. There are several advantages of EISD. First, the maintaining of mucosa intact could reduce complications due to perforation. Second, the tunnel makes closure of the wound much easier than the otherwise unsmooth full-thickness defect created by EFTR. More importantly, the distance between the perforation and the lesion enables the operator to have a direct and full exposure of the lesion from the abdominal cavity instead of the tangent view from the gastric cavity, which provides the critical view of safety both for dissection and hemostasis. In addition, for most SMTs with a predominately extraluminal growth pattern, the highly movable tumors challenge the angle of the scope in traditional EFTR or STER, thus increasing the risk of tumor residual and capsule damage. On the contrary, dissection from the serosal side in the abdominal cavity helps to stabilize the lesion. In conclusion, EISD is a feasible and safe attempt for the removal of gastric SMT with predominately extraluminal growth pattern, and large-scale prospective studies are needed to evaluate its safety and efficacy.

Introduction: A transcatheter aortic valve replacement (TAVR) carries a 2% risk of postoperative upper gastrointestinal bleeding. It presents as extensive bleeding resulting in hemorrhagic shock or respiratory failure. In this case, an early clot with sentinel bleeding prevented the widening of a full thickness aortoesophageal fistula formed from the TAVR placement, was symptomatic enough to prompt an earlier esophagogastroduodenoscopy (EGD) and prevented a probable fatality. Case Description/Methods: An 85-year-old male with a past medical history of AAA repair, GERD, HLD, TIA, aortic dissection s/p coronary bypass graft, AS with TAVR 5 months prior presented with hematemesis after initiating colonoscopy bowel prep. He also had unintentional 30-lb weight loss over 3 months, fecal incontinence, and melena. Medications include a daily aspirin. Abdominal CT demonstrated an 8cm aortic arch aneurysm, a 5cm descending thoracic aortic aneurysm, and a 5.8 x 4 cm collection posterolateral to the aorta with proximal dilation of the esophagus. EGD demonstrated a partially obstructing protruding mass in the esophagus 20 cm from the incisors with sentinel bleeding from an adherent clot. The mass was determined to be extrinsic compression from the aortic arch aneurysm with the TAVR seen through the aortoesophageal fistula (Image 1A-1B). The stomach and duodenum were unremarkable. Patient was transferred to vascular surgery where a 1cm compressed Amplatzer Vascular Plug II embolization and reinforcement of the endoleak was done. Patient remained hemodynamically stable and discharged home with a vascular follow up. Discussion: Aorto-esophageal fistula following TAVR is a rare complication with a wide etiology ranging from infections, antithrombotic use, pressure necrosis, angiodysplasia, underlying PUD, or uncontrolled comorbidities such as HTN. Our patient’s risk factors were his elderly age, comorbidities, use of daily aspirin, and contribution from the pressure or ischemic necrosis of the aortic aneurysm compressing on the esophagus. Presentation involves hemoptysis, chest pain, hemorrhagic shock, respiratory failure and frank bleeding. CTA is considered the initial test of diagnosis as endoscopy, though sensitive, could rupture the clot and unleash massive bleeding. In this case, sentinel bleeding and visualization of the TAVR through the fistula was enough to diagnose and retreat to be treated appropriately with embolization and reinforcement.Figure 1.: Esophageal mass with pathology.

A 34-year-old male presented with multiple gunshot wounds with a bullet lodged in the pelvis next to the rectum. A barium enema demonstrated a leak. Gastroenterology was consulted for bullet retrieval for ballistics and closure of the defect. We describe the techniques utilized to remove the extraluminal bullet and close the defect.

INTRODUCTION: The gastrointestinal (GI) tract is a well-known site for extranodal lymphoma involvement, representing 30-40% of lymphomas. The stomach is known to be the most common site followed by small intestine and colorectum. The development of chronic liver disease and cirrhosis in patients with pre-existing lymphoproliferative disorder has been well described. However, the development of lymphoma in subjects with cirrhosis is rare. CASE DESCRIPTION/METHODS: We report a 55-year-old male history of alcoholic decompensated cirrhosis with ascites, and esophageal varices, presented with two weeks of epigastric abdominal pain and worsening ascites.Labs remarkable for Hb 9.1 gm/dl, INR 2.0, ALT 44 IU/ml, AST 67 IU/ml, ALP 253 mg/dl, bilirubin 5.2 mg/dl and normal AFP. ABD CT scan demonstrates mild gastric wall thickening, cirrhosis, moderate ascites, and multiple new hypodense liver lesions.The lesions were classified as an intermediate probability for HCC based on the LI-RADS classification system (LI RADS 3) (figure A/B).Due to the CT findings in the setting of cirrhosis, a provisional diagnosis of HCC was made.Upper endoscopy EGD demonstrates medium non-bleeding esophageal varices and multiple new umbilicated, ulcerated, firm, submucosal nodules throughout the gastric body(figure C).Biopsy of the submucosal nodule revealed high-grade B-cell lymphoma (HGBL) involving the lamina propria, without Helicobacter Pylori. Neoplastic cells were positive for CD20, Pax-5, BCL-6, CD10, BCL-2, 95% positive for lymphoma cells (figure D). Targeted biopsy of the liver lesions demonstrates similar cell morphology and immunostaining profile confirming the diagnosis of metastatic diffuse B-cell lymphoma (DBCL) (Figure E). DISCUSSION: PGL constitutes < 5% of all primary gastric neoplasms. The incidence of DBCL in cirrhosis is extremely rare. HBV and H. pylori have been postulated to cause chronic antigenic stimulation resulting in dysregulation in immune function leading to monoclonal gammopathy and malignant lymphoproliferative disease. Presentation of PGL is nonspecific ranging from abdominal pain, weight loss, GI bleeding, and rarely GI perforation. DBCL can be localized to the stomach or have distant metastasis involving the liver.These hepatic lesions lack the radiologic characteristic of HCC such as arterial enhancement, pseudo capsule, and washout further supporting diagnosis of lymphoma. Metastatic PGL can mimick HCC in cirrhosis and will require targeted liver biopsy to make diagnosis.Figure A/B.: Cross sectional imaging A-arterial phase. B-portal venous phase.Figure C.: EGD image of umbilicated mucosal gastric lesions.Figure D.: Gastric lesion biopsy. Figure E: Targeted liver lesion biopsy showing lymphoma cells similar in morphology to stomach biopsy D.

INTRODUCTION: Lemmel syndrome is a rare syndrome defined as obstructive jaundice resulting from external compression of the common bile duct due to a duodenal peri-ampullary diverticulum (DPAD). We present a rare case of a young man with Lemmel syndrome instigated by a foreign body (FB) ingestion. CASE DESCRIPTION/METHODS: 55-year-old man with no PMH presented to ED with complaints of three days of severe right upper quadrant abdominal pain associated with nausea and fatigue. On further history the patient recalls swallowing a duck bone close to the onset of his symptoms. Clinical examination revealed epigastric tenderness with a positive murphy sign. Laboratory data were significant for an ALT of 322 IU/ml, an AST of 228 IU/ml, an ALP of 194 mg/d, a total bilirubin of 7.3, a direct bilirubin of 5 mg/d and lipase of 347U/l. Abdominal ultrasound imaging showed slight gallbladder wall thickening with a mildly dilated common bile duct up to 9 mm with no gallstones or common bile duct (CBD) stones. MRCP showed a large duodenal periampullary diverticulum with a sharp longitudinal FB inside the diverticulum pressing on the CBD causing 10mm dilatation of the CBD. The patient was initiated on broad-spectrum antibiotics and was IV crystalloid solution. An esophagogastroduodenoscopy was performed and demonstrated a long duck bone lying transversely inside the diverticulum causing mucosal injury and compressing the duodenal ampulla. Successful endoscopic removal of the duck bone using rat-toothed forceps was performed with resultant resolution of the patient’s symptoms and normalization of his liver function tests. DISCUSSION: Duodenal diverticula (DD) occur in 2-5% of the population. Most duodenal diverticula occur in the duodenal bulb with 80-90% of DD being asymptomatic. A small proportion of DD may cause complications such as small bacterial overgrowth, diverticulitis, bleeding, or obstruction. Foreign body ingestion of sharp edge objects in patients with DD can be especially dangerous as it can lead to intestinal perforation. An even rarer complication of DD is Lemmel syndrome defined as external compression of the common bile duct causing obstructive jaundice. We report a unique case of Lemmel syndrome with a FB lodgment in a duodenal diverticulum causing obstructive jaundice. The common treatment for Lemmel syndrome is sphincterotomy and plastic stent placement. In our case conservative management with FB removal was able to remedy the patients' obstructive jaundice symptoms.Figure A.: Foreign body (FB) in the duodenal diveritculum obstructing CBD.

INTRODUCTION: A dental floss pick is made of disposable two prongs extending from a thin plastic body of high-impact polystyrene material with a single thread of floss which runs between the two prongs. While the incidence of accidental toothpick ingestion among adults is not common and is considered a medical emergency. The incidence of floss toothpick ingestion is extremely rare and carries a similar risk. CASE DESCRIPTION/METHODS: A 27-year-old man with no PMH presented to the gastroenterology clinic complaining of epigastric abdominal pain awaking him from his sleep for the past three weeks. He reports the accidental swallowing of a dental floss pick 3 weeks prior to his visit. Labs were unremarkable. Cross-sectional imaging with an abdominal CT scan with contrast showed a filling defect in the shape of a pick in the region of the antrum of the stomach extending towards with pylorus with associated thickening of the stomach wall. Upper endoscopic evaluation was performed and demonstrated an impacted dental floss pick with the floss thread eroding into the pylorus (Image A). The dental floss pick was grasped and secured using a snare and gently detached from the pylorus resulting in a superficial pyloric ulceration. The dental floss stick was removed from the stomach using a snare and with the assistance of a flexible rubber hood in order to protect the esophageal and pharyngeal mucosa from sharp edge injury as well as to prevent dental pick floss entrapment in the pharyngeal airway upon withdrawal. The bell portion of the plastic hood was everted during withdrawal at the gastroesophageal junction with the toothpick side pointing away from the endoscope (Image B). Successful extraction of the dental floss stick was performed (Image C). DISCUSSION: To our knowledge this is the first reported case of a dental floss pick stick ingested and impacted in the gastrointestinal tract. While the incidence of unintentional toothpick pick ingestion is extremely rare with limited literature there is a body of literature discussing toothpick ingestions. With toothpick ingestions spontaneous passage of the toothpick is unlikely and there is an 18% mortality rate. The most common symptom is pain localized to the area of the impacted toothpick and if perforation of a major blood vessel occurs massive blood loss and shock can occur.Given that dental floss pick sticks have a wider base than toothpicks but still contain a sharp edge they too are unlikely to pass spontaneously and should prompt urgent endoscopic evaluation.Image A.: The dental floss stick eroding into Pylorus.Image B.: The dental floss stick removal using a snare and with the assistance of a flexible rubber hood.Image C.: Successful extraction of dental floss stick.

INTRODUCTION: Gastric Cancer is the fifth most common malignancy globally and the second in overall cancer-related mortality. A mixed adenoneuroendocrine carcinoma (MANEC) of the stomach is a rare condition defined by WHO as a tumor with both neuroendocrine as well as non-neuroendocrine or exocrine components. We present a unique case of a gastric MANEC. CASE DESCRIPTION/METHODS: An 84-year-old woman with a past medical history of hyperlipidemia, hypothyroidism, osteoporosis, gout was found to have a drop in Hb from 10.7 to 7.8 with melena. She underwent Esophagoduodenoscopy (EGD) which revealed multiple small and large gastric polyps throughout the stomach. Biopsies revealed well-differentiated MANEC. An endoscopic ultrasound (EUS) revealed the largest polyps measured 2.5 - 3.5 cm in size with some extending into the submucosa. Endoscopic mucosal resection was performed of the three largest polyps. Pathology revealed invasive moderately differentiated adenocarcinoma, limited to the muscularis mucosae with foci of well differentiated neuroendocrine tumor infiltrating the submucosa. The neuroendocrine tumor was strongly positive for synaptophysin and chromogranin with Ki 67 stain less than 2%. Subsequently, PET-CT scan was performed demonstrating minimal uptake localized to the borderline in size portocaval node with no enlarge or avid perigastric adenopathy. Case was reviewed at tumor board and is scheduled for a total gastrectomy. DISCUSSION: The diagnosis and treatment of gastric cancer has been an ongoing challenge facing modern gastroenterologists. MANEC is a rare condition which comprises both exocrine and endocrine tumors of at least 30% of each tumor component. These tumors often present with nonspecific clinical symptoms similar to those of conventional gastric cancer, many with metastatic disease. These cancers can be aggressive and are associated with poor prognosis. For tumors with neuroendocrine components, long acting somatostatin analogs can be used to halt proliferation of endocrine cells. They can also lead to regression of gastric neuroendocrine tumor and have proven to be a viable therapeutic option. Endoscopic submucosal dissection (or ESD) may be a feasible diagnostic and therapeutic option for gastric neuroendocrine or adenocarcinoma neoplasms. Additional treatment choice for MANEC is partial, subtotal, or complete gastrectomy depending on the location.Figure 1.: Endoscopic Image of Gastric MANEC.

INTRODUCTION: Cases of rectal foreign bodies may be challenging to approach. In part, this is due to the wide variety of potential culprit objects which may be inserted into a patient's rectum. Here we present a case of an apple impacted in the distal sigmoid colon and the techniques utilized to remove it. CASE DESCRIPTION/METHODS: A 37 year old male with no significant past medical history initially presented to the ED with abdominal pain. The patient describes he was intoxicated with his friends during the previous evening and did not clearly recall the exact events. However, he awoke with abdominal and rectal pain with constipation. The patient was hemodynamically stable and laboratory studies were unremarkable. Physical exam demonstrated a rounded suprapubic mass. Imaging obtained demonstrated a round foreign body consistent with an apple in the distal sigmoid colon. An EGD scope was placed and an apple was seen in the distal sigmoid colon. A guidewire was passed around the apple and an 18 mm extraction balloon was inserted proximal to the apple and inflated. A pull technique was utilized, however the balloon continued to slip past the apple. Next, we switched to a double-channel scope and tried to use 2 balloons simultaneously to pull the apple, however we were unsuccessful. Subsequently, ESD with dry cut current was used to drill through the center of the apple. Once the top layers were cut, APC (2L flow, 50 watts) was used to cut through the core of the apple and create a tunnel. An 18 mm stone extraction balloon was passed through and inflated. With traction, the apple was able to move however the balloon tore through the tunnel created in the apple. Since the apple remained fixed we used OR sponge forceps and ENT forceps to break down the apple. Finally, the patient was placed in a lithotomy position and using downward pressure on the pelvis, the remaining pieces of apple were grasped with sponge forceps and removed. The scope was re-inserted after extraction and areas erythema and few burn marks from the APC were found. The patient was stably discharged the following day. DISCUSSION: Here we describe a successful extraction of an apple impacted in the sigmoid colon. We attempted multiple modalities, yet had the greatest success after having cut through the apple with ESD and APC prior to mobilization and extraction with forceps. When considering future cases, we would suggest using an overtube to vent excess argon gas and minimize potential mucosal damage from APC.

INTRODUCTION: COVID-19 pandemic has ravaged the world with more than 1 million cases, and 110,000 deaths as of June 2020 This pandemic impacted our healthcare system by all angles including outpatient care Telehealth was extensively utilized We conducted a study to assess the impact of Telehealth during the COVID-19 Pandemic on patient care METHODS: A retrospective analysis of outpatient gastroenterology (GI) visits were conducted General demographic information, labs, imaging, interpreter use, duration visit, medications, endoscopic procedures were collected Statistical analysis was performed using STATA software V 16 RESULTS: In a total sample size of 151 patients, the mean age was 51 ± 13 5 years with 74 males and 77 females The majority of the patients were Hispanics (n = 101), followed by Asians (n = 33), White (n = 10) and African American (n = 7) 26% patients were unable to reach (n = 26), 1% died of COVID19 (n = 3) The mean duration of telehealth conversation was 20 minutes The most common diagnosis of GI visit were dyspepsia (n = 42), followed by cirrhosis (n = 15), IBD (n = 11), PUD (n = 9), dysphagia (n = 8) and GI bleeding (n = 7) The patients received various drug treatments based on their clinical condition including PPI (n = 31);H2-blockers (n = 8);5-ASA (n = 7);diuretics (n = 6);Biologic therapy (n = 5);beta-blockers (n = 5);lactulose (n = 3);and rifaximin (n = 3) ± patients were unable to get the refill of their medications and 8 patients were afraid to get the refill (Figure 1) 34% patients missed blood work for their follow-up (n = 51) and 15% patients had delay in getting imaging as diagnostic and screening (n = 23) 59 patients needed to have procedures, 3% urgent (n = 4), 9% time essential (n = 14), and 26% required routine screening (n = 40) (Figure 2) Lastly, there was 3 patients who had confirmed COVID19 and required hospitalization with good recovery CONCLUSION: Despite a dramatic shift in the outpatient care to telehealth medicine, many clinicians expect future roles in telehealth There are many barriers to outpatient care especially in this pandemic, summarized by a delay in getting blood work, medications and fear of approaching hospitals for medication refill (Table Presented)

INTRODUCTION: Garcinia Cambogia (GC), is a fruit found in South East Asia and used widely in food preparation and preservatives. GC is also used in traditional medicinal preparations in order to treat gastrointestinal disturbances, intestinal parasites, and as diabetic supplement. In addition, GC can be found as an active ingredient in many over the counter weight loss & appetite suppressant supplements. GC can rarely case hepatotoxicity and fulminant hepatitis. We report the first case of GC induced AIH. CASE DESCRIPTION/METHODS: We report a 39-year-old female with no PMH who presented with fatigue and dark color urine. Clinical exam demonstrated a palpable liver and scleral icterus. The patient reported using a “slimming herbal tea supplement” containing pure GC for weight loss 5 weeks prior to presentation. Significant labs included ALT 1803 IU/L; AST 1026 IU/L; ALP 139 mg/dl and T.Billirubin 5.2 mg/dL. Further liver work up revealed an elevated ANA 1:160 titer; ASMA 1:320; & IgG 1814. The patient was initiated on intravenous N-Acetyl cysteine NAC without improvement. Liver biopsy was performed and demonstrated moderate mixed inflammatory cells including lymphocytes, plasma cells, neutrophils and rare eosinophils in the portal tracts. Interface hepatitis and cholestasis was also noted. Findings were consistent with drug-induced liver injury (DILI) with a background of AIH (figure A). The patient was initiated on Prednisone 40 mg orally daily with a resultant improvement in liver function tests and autoimmune markers. Upon tapering of her steroids her liver function began to rise and she was started on immunosuppressive therapy for long term maintenance with good response (Table B). DISCUSSION: GC has anecdotal weight loss benefits through it being converted to Hydroxycitric acid (HCA). HCA can cause a steatohepatitis by increasing hepatic collagen accumulation, lipid peroxidation, and pro-inflammatory cytokines resulting in oxidative stress. The incidence of GC hepatotoxicity is 1:10,000 people in the U.S. Liver enzyme elevation is usually characterized by elevated aminotransferases 4–5 times the upper normal limit (UNL). Classically AIH serology markers are negative in GC liver injury. GC liver injury can last for 2–3 months with normalizing of liver function tests by 5 months. We report the first case of GC triggered AIH successfully treated with immunosuppressive therapy.Figure A.: Moderate mixed inflammatory cells including lymphocytes, plasma cells, neutrophils and rare eosinophils in the portal tracts. Interface hepatitis and cholestasis also noted. No fibrosis on trichrome stain.Table B.: Laboratory data during hospitalization.

INTRODUCTION: COVID-19 pandemic has created chaos in the healthcare system and widely impacted our personal and academic life. We conducted a survey questionnaire for gastroenterology trainees to understand the educational, psychological, physical and social impact of this crisis. METHODS: National based survey questionnaires were securely sent to program coordinators and distributed to all gastroenterology fellows from various parts of the United States, via email over 3 weeks period. RESULTS: A total of 246 GI fellows participated (153 males & 93 females), with a mean age of 35 ± 5 years. 67% were married (n = 165) and 31% had children (n = 76) (Figure 1). Majority of the trainees are American graduates (69%). Our sample consisted of 212 fellows from university program and 34 from community program. The year of fellowship was evenly distributed between 1st (n = 88), 2nd (n = 77) and 3rd year (n = 75) of training. During the pandemic, 91% fellows participated in telehealth visits (n = 224) and only 5 fellows reported lack of supervisors in this situation. Majority of the fellows continued practicing GI related issues (N = 227) and on top of that, 22.4% were deployed covering medicine wards (n = 56), 9% covering ICU (n = 22), and only one fellow covered ED. 121 fellows reporting COVID19 severely impacted their GI practice, followed by 87 fellows reporting moderate to severe effects and 38 experiencing mild to moderate impacts. 41% of fellows were not following social distancing mainly due to lack of space to sit 6 feet apart and also since they were wearing a mask. 22.4% (n = 54) of fellows felt that they would not have sufficient procedural volume and/or training to be a practicing gastroenterologist but only 3.7% (n = 9) wanted to extend the fellowship. The fellows wanted more procedural training in colonoscopy (45%) with polypectomy (52.4%) and hemostasis (38.6%). In order to minimize COVID19 exposure, many hospitals allowed only attending to perform procedures. The majority of the fellows disagreed with this new practice (46%; n = 115) (Figure-2). Finally, 4.9% fellows acquired COVID-19 (n = 12) and only one was admitted (4 of those fellows did not have proper PPE). CONCLUSION: COVID-19 pandemic has a major impact affecting the learning process in GI fellowship programs. The fear among many trainees is mainly due to the lack of performing GI procedures and the impact on their skill in the future.Table 1.: Showing the baseline demo-graphical data of all gastroenterology fellowship traineesFigure 1.: Map based on the location and zip codes of the gastroenterology fellow trainees.Figure 2.: Showing the impacts of COVID-19 on gastroenterology fellowship trainees.

INTRODUCTION: Cocaine toxicity is a well-recognized phenomenon which presents with a multitude of potentially lethal medical complications. Ingestion of high doses of cocaine can result in systemic toxicity, evident by rhabdomyolysis, acute renal failure, DIC, and hyperthermia. When liver injury occurs it is termed cocaine-induced hepatotoxicity (CIH). CASE DESCRIPTION/METHODS: We report a 31-year-old male with a history of cocaine abuse brought into the emergency department (ED) after sustaining trauma from a subway platform. On arrival the patient was combative, agitated, hypotensive, and tachycardic. The patient required urgent intubation for airway protection. Abdominal examination was unremarkable. Labs revealed elevated AST 2248 U/L; ALT 893 U/L; ALP 78, bilirubin 2.5 mg/dl and an INR 2. The patient was found to have rhabdomyolysis with an elevated CPK 100,830 with associated renal injury and a serum creatinine 3.4 and a BUN 39 mg/dl. The patient also had a Lactate of 22. A toxicology drug screen was positive for cocaine with a level 9593 ng/ml. The patient was initiated on an N-Acetyl cysteine (NAC) drip. Liver workup was negative including EBV/CMV/HSV and autoimmune hepatitis. US showed no evidence of hepatic or portal vein thrombosis. The patient developed a fever of 103 F. Infectious workup was unremarkable. A head CT revealed no evidence of cerebral edema. Eventually, the patient was extubated and had a good recovery. DISCUSSION: CIH can occur through two concurrent mechanisms. One avenue of injury is the conversion of cocaine into a toxic metabolite called norcocaine (NC) via P450 metabolism. The second pathway to injury is through vasoconstriction of the central veins in the liver leading to massive hepatic inflammation and necrosis. Hepatic damage due to cocaine is usually of rapid onset and usually appears within several hours following cocaine use. The injury can last for a couple of days. This hepatocellular injury leads to AST > ALT 10–12 times the upper normal limit (UNL). CIH is also associated with an elevated LDH and an ALT/LDH ratio of 0.5. This is in contrast to other causes of shock liver which classically has an ALT/LDH ratio of 1–1.5. An important pathognomic marker of CIH is a high-grade fever associated and rhabdomyolysis. Classic liver biopsy findings include centrilobular hepatic necrosis (zone 3), fatty infiltration, and eosinophilic cell infiltration. The course of CIH is usually self-limited and may benefit from NAC administration.Table 1.: Laboratory data during hospitalization

Colorectal cancer (CRC) incidence has been increasing in the United States among adults younger than 50 years. Colorectal adenomas are well-known precursors to colorectal cancers. Occurrence of colorectal adenomas in older adults has been studied extensively; however, data on the prevalence of CRC precursor lesions in younger adults is limited. Assess the prevalence, demographics, endoscopic and histological features of patients under 50 with CRC precursor polyps Pathology reports from the Kips Bay Endoscopy Center (KBEC), a large private adult gastrointestinal endoscopy unit in New York City, were examined from calendar year 2016 in order to find pre-cancerous polyps in patients younger than the recommended average-risk colonoscopy screening age of 50. A total of 6,963 colonoscopies were performed. Of those, 1,445 were performed in patients from 18-49 years. In this group, 168 patients (11.6%) were found to have CRC precursor lesions and 1 patient had colon cancer. Excluded were 73 patients with high risk screening and 7 patients with IBD surveillance as an indication. A cohort of 89 patients was analyzed: 49 were female and 40 were male. The indications for these patients were abdominal pain, change in bowel habit, diarrhea and rectal bleeding. Overall, 76% were white, 9.4% Asian, 7.3% African-American, 2.1% Hispanic and 5.2% mixed race. A total of 111 polyps were resected; 53 polyps in patients 18-40 years of age and 58 in patient 40-49 years. Of the polyps removed, 77 (69.4 %) were tubular adenomas (TA), 4 (3.6%) were tubule-villous adenomas (TVA), 1 (0.9%) was a TVA with high-grade dysplasia (HGD) and 29 polyps (26.1%) were serrated adenomas. The size of the polyps ranged from 0.3 cm to 1.8 cm. The polyps were distributed throughout the colon: 17 (15.3%) in the rectum, 25 (22.5%) in the sigmoid colon, 14 (12.6%) in the descending colon, 7 (6.3%) at the splenic flexure), 10 (9.0%) in the transverse colon, 7 (6.3%) at the hepatic flexure, 14 (12.6%) in the ascending colon and 17 polyps (15.3%) in the cecum. One 49 year old patient underwent colonoscopy for abdominal pain and was diagnosed with invasive adenocarcinoma in a setting of an 8 mm TA with HGD in the ascending colon. The overall prevalence of CRC precursor lesion in these low risk patients 18-49 years of age was 6.1%. We found a surprisingly high prevalence of colorectal cancer precursor lesions in low risk young adults who would not otherwise have been screened for colon cancer according to current guidelines. In light of alarming statistics demonstrating increasing CRC incidence among young adults in the US, further larger scale studies are required to establish true prevalence and need for earlier endoscopic screening for CRC precursors lesions in this young population.

A 27 year old woman was admitted with right hip pain worse with movement for 2 weeks. She also reported RLQ pain and fevers for the last 6 days. She denied diarrhea, hematochezia, nausea or vomiting. She experienced similar abdominal pain a few months prior and was referred for colonoscopy but the symptoms resolved and the colonoscopy was not scheduled. She had no other significant medical history. Vitals on admission were notable for Tmax 38.3°C and HR 105. Exam revealed moderate RLQ and suprapubic tenderness without rebound or guarding. Righ hip was fixed in a flexed position and she was unable to fully extend the hip due to pain. Labs showed WBC 11,700/L, Hgb 12.3g/dL, Plt 524x103/L, ESR 79mm/hr, CRP 20.3mg/dl, albumin 3.3g/dl. CT Abdomen and MR enterography showed inflammation and phlegmon in the RLQ with an abscess in the inflamed iliopsoas muscle. Broad-spectrum antibiotics were initiated. Colorectal surgery performed an exploratory laparoscopy which revealed an inflamed terminal ileum and cecum, fistula and adherent psoas abscess requiring laproscopic ileocecal resection. Pathology showed mucosal ulceration, chronic inflammation, chronic serositis, non-caseating granulomata and the presence of a fistula confirming the diagnosis of psoas abscess secondary to fistulizing Crohn's disease. A psoas abscess (PA) is a rare complication of Crohn's disease (CD) and seldom presents as the first manifestation. When treatment is delayed it can lead to significant morbidity and mortality. The iliopsoas muscle lies posterior to the ileocecal junction and adjacent to the spine, aorta and renal tract, making it a potential site of infection in the setting of intestinal diseases, osteomyelitis, infected aortic aneurysms and UTIs. PA should be suspected in any patient who presents with hip and abdominal pain. CT is the most commonly used imaging modality for diagnosis. Early antibiotic therapy, drainage and surgical consultation are critical. When CD is suspected, open surgical rather than percutaneous drainage should be considered so affected bowel can be resected if necessary. Once this is performed and the patient has recovered from surgery, treatment of fistulizing Crohn's should be initiated. Infliximab, azathioprine and 6-mercaptopurine are most commonly used. While corticosteroids are often indicated in the treatment of CD, they should be avoided in the perioperative period as they increase the risk of postoperative complications.Figure 1Figure 2Figure 3

Introduction: Syncope is a common complaint for general practitioners though an uncommon presentation to a GI office. We present a case of deglutition syncope, a rare syndrome that is often misdiagnosed. Case Description: A 62-year-old female presented with a 3-year history of dysphagia and “passing out while eating”. Her initial symptoms consisted of a sensation of food “sticking” at the lower aspect of her esophagus, followed by brief loss of consciousness. She denied known trigger foods. Episodes occurred within the first few minutes of meals and loss of consciousness lasted for several seconds. In addition, she noted a burning epigastric pain and a 30-pound weight loss due to fear of eating. Previous upper endoscopy showed LA grade A esophagitis, with biopsies negative for celiac disease and H. pylori. She was initiated on a protein pump inhibitor which improved her reflux symptoms. Neurological evaluation had been negative for seizure and demyelinating disorders. High-resolution esophageal manometry was performed, which showed normal peristalsis and normal EGJ relaxation. A 24-hour holter monitor was then performed, which revealed both high degree atrioventricular block and sinus arrest associated with swallowing. The patient was referred for cardiology evaluation and ultimately a dual chamber pacemaker was placed. Her dysphagia and syncope completely resolved after pacemaker placement and symptoms have not recurred in nearly 1 year of follow-up. Discussion: Forty-eight percent of syncopal episodes are non-cardiogenic and 5% of these are related to deglutition syncope. Deglutition syncope is a vagally mediated response to stretch receptors in the LES that send efferent stimuli to the heart, with the end result of sympathetic withdrawal. Susceptible patients include those with a history of achalasia, esophageal diverticulum, esophageal stricture/spasm/cancer, and hiatal hernia. The temperature (specifically colder) and stickiness of foods, as well as eating habits are thought to be triggering factors, however not universal. Cessation of aggravating medications (antihypertensives, etc) is an initial approach to therapy. Surgical correction has been successful in cases such as esophageal carcinoma and stricture. Treatment with anticholinergic medications which block the vagal response can be initiated if not contraindicated. Pacemakers are a more invasive option for patients without structural heart disease. It is also thought that esophageal muscular hypertrophy may play a role, and thus myotomy vs. dilatation may play a role in treatment.