Infective endocarditis (IE) is one of the leading causes of life-threatening infections and is most often observed among patients who use intravenous (IV) drugs. We discuss the unique presentation of a 31-yearold gentleman with a two-week history of sore throat and shortness of breath, who returned to his community emergency room with persistent symptoms of streptococcal pharyngitis. A thorough history, physical examination, and diagnostic workup were conducted, where a large, protruding, highly mobile vegetation was observed on echocardiogram. His blood cultures grew methicillin-resistant Staphylococcus aureus. A vegetation measuring over 5 cm was surgically removed from his tricuspid valve. Following the operation, he underwent six weeks of extensive in-patient medical management with IV antibiotics to treat IE. This patient made a complete recovery and has since returned home.

Introduction: Management of brisk variceal bleeding is challenging and nerve-racking for both gastroenterologists and intensivists. When visibility is hampered, a Sengstaken-Blakemore (SB) tube is used to tamponade as a temporary bridge to Transjugular intrahepatic portosystemic shunt (TIPS). Traditionally, the SB tube is placed blindly, or with the help of radiography to confirm gastric balloon location. Catastrophic complications are reported with blind approach including distension of the esophagus or trachea leading to rupture. Endoscopic SB placement has been described in literature as a successful technique. We report 3 cases with successful placement of SB tubes in massive variceal hemorrhage as a bridge to TIPS. Case Description/Methods: Case 1: A 36-year-old gentleman with alcoholic cirrhosis presented with hematemesis 2 days after undergoing variceal banding. Bleeding post-banding ulcers were confirmed with endoscopy and treated with hemoclips and epinephrine. Despite the intervention, the patient had recurrence of bleeding the following day with hematemesis. Repeat endoscopic intervention was limited due to poor visibility from brisk bleeding. An SB tube was placed endoscopically, and he underwent emergent TIPS that same day. The SB tube was removed 24 hours later with no recurrence of bleeding, and he was discharged to home. Case 2: A 68-year-old gentleman with alcoholic cirrhosis and history of variceal bleeding presented with hematemesis. Emergency endoscopy found massive bleeding, however the source of bleeding could not be located. An SB tube was endoscopically placed and an emergent TIPS was performed on the same day. The SB tube was removed 24 hours later with no recurrence of bleeding. After a 10day hospital stay, he was ultimately discharged to hospice. Case 3: A middle-aged woman presented to the hospital with active variceal bleeding. She underwent successful endoscopic SB tube placement as a bridge to TIPS. Although she also had successful placement and no rebleeding, she ultimately succumbed to her disease. Discussion: Endoscopic SB tube placement is an effective bridge to emergent TIPS due to the improved hemostasis and decreased likelihood of rebleeding. This technique also limits the complications of blind placement, such as inadvertently distending the gastric balloon in the wrong location. Therefore, gastroenterologists should consider endoscopic placement of a SB tube when other endoscopic interventions fail to achieve hemostasis in variceal hemorrhage (Figure 1).

Table 1. Baseline characteristics of individuals with Therapy-associated Polyposis based on age at diagnosis of primary cancer Total N544 Age at Cancer Diagnosis: < 18 Years Old N524 Age at Cancer Diagnosis: 18 Years and Over N520 p-value Age at Cancer Diagnosis (median, years) 16.

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