Angiomyolipoma (AML) is a tumor composed of variable proportions of adipose tissue, spindle and epithelioid smooth muscle-like cells and abnormal thick-walled blood vessels which are usually benign. AML is relatively common in kidney and liver. Gastric angiomyolipoma (GAML) is extremely rare and only 2 cases were reported in the literature. Diagnosis of AML is difficult owing to its rarity and varied immunohistochemical patterns. Here, we report a case of GAML in a 65-year-old male who presented with an episode of hematemesis and intermittent melena for one week. Endoscopy showed a partially obstructing mass arising from gastric antrum with central ulceration. Mass was removed by wedge resection after laparoscopic anterior gastrectomy. Excised specimen showed a benign 6 × 3 × 3 cm homogenous fatty mass with adipose tissue, smooth muscles and prominent vascularity. Immunohistochemistry stains were positive for desmin, smooth muscle actin (SMA), CD34 and negative for human melanoma black (HMB)-45 antigen and CD117. This case reports the largest and HMB-45 negative GAML so far, which can be a very rare cause of upper gastrointestinal bleeding.

Introduction:The pathogenesis of nonalcoholic fatty liver disease (NAFLD) has not been clearly understood, but several studies suggest intestinal bacteria may play a role. Similarly, diverticulitis is associated with changes in the gut microbiome. However, there is a lack of studies on how NAFLD affects the outcomes of diverticulitis. Thus, this study aims to assess the outcomes of diverticulitis among patients with NAFLD. Methods: Adult patients hospitalized with diverticulitis from the National Inpatient Sample (NIS), Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality 2014 were selected. Diagnoses were identified by using ICD-9 CM codes. Patient demographics and outcomes of diverticulitis were compared between the groups with and without NAFLD. The outcomes of interest were inpatient mortality, length of stay, total hospital charge, shock/hypotension, colectomy, abscess, obstruction, fistula, and perforation. Chi-squared tests and independent t-tests were used to compare proportions and means, respectively. Multivariate logistic regression analysis was performed to determine if NAFLD is an independent predictor for the outcomes, adjusting for age, sex, race, and the Charlson Comorbidity Index. Results: Among 48,214 patients with diverticulitis, 1,184 patients had a history of NAFLD. Patients with NAFLD had shorter length of stay (4.2 days vs. 4.7 days, p , 0.05), lower hospital charge ($34,392 vs. $38,652, p , 0.05), and lower mortality (0.0% vs. 0.4%, p , 0.05). After adjusting for age, sex, race, and the Charlson Comorbidity Index, NAFLD was an independent protective factor for colectomy (OR 0.44, 95% CI: 0.34-0.57, p , 0.05) and intestinal abscess (OR 0.67, 95% CI: 0.55-0.81, p , 0.05). Adjusted odds ratios of other outcomes were not statistically significant. Conclusion: Our study indicates that NAFLD is associated with better outcomes of diverticulitis, such as lower rates of colectomy and intestinal abscess among patients hospitalized with diverticulitis, in contrast with worse outcomes associated with NAFLD in many other conditions. The limitation of this study using the NIS database is the difficulty in comparing the severity of diverticulitis between the groups and exact treatment methods, which may have affected the results. Future studies to assess the potential protective effect of NAFLD on outcomes of diverticulitis and understand the pathophysiology of NAFLD and diverticulitis are warranted.

Hypophysitis is the inflammation of the pituitary gland with varying effects on hormone function that may be present secondary to the use of certain medications, infections, systemic inflammatory disorders, and other etiologies. Immunotherapy-related hypophysitis is a rare phenomenon. However, it representsan indicationof treatment interruption.We report a 60-year-old female with renal clear cell carcinoma onNivolumab and Ipilimumab(NIVO/IPI) intravenously (IV). After the second cycle of therapy, the patient reported a fall, with associatedlightheadedness, dizziness, nausea, vomiting, and hotflashes. The patient's symptoms and history were concerning for hypophysitis, so early treatment and cessation of the checkpoint inhibitors led to the patient's clinical improvement.

4375 BACKGROUND: The use of Fresh Frozen Plasma (FFP) has increased considerably in recent years. In the USA there was 70% increase in the use of plasma in 10 years between 1991 and 2001. Around 3.9 million units were transfused in 2001 and 5.7 million units in 2009. FFP is often used inappropriately globally and studies evaluating FFP use in the US are scarce. We conducted a study to assess the trends of FFP use, its implications, appropriateness, and impact of FFP on International Normalized Ratio (INR) in hospitalized adult medical patients with an elevated INR. DESIGN AND METHODS: The study was a retrospective audit of all adult medical in-patients with an INR of 1.2 or higher who received FFP during a 3 month period from December 1, 2011 to February 28, 2012 admitted to Abington Memorial Hospital. A list of all patients who received FFP during the study period was obtained from the blood bank. Patients with major trauma, surgical, post-op, pediatric and obstetric/gynecological patients were excluded. Data was collected on demographics, indications of FFP, pre and post transfusion INR and effect of FFP on pre-transfusion INR. Partial thromboplastin time values (PTT) were not collected. RESULTS: A total of 479 units of FFP were transfused to 97 patients over 114 transfusion episodes. Of the 97 patients, 51 were male (52.6%) and 46 were female (47.3%) with a mean age of 70.4 yrs (median 73 yrs, range 19–95 yrs). Of the total 479 units of FFP, 233 units (48.6%) were given to patients who were not actively bleeding (n=53) with a mean pre-transfusion INR (pre-INR) of 2.82 (range 1.5 to >10, SD 1.6). Warfarin related coagulopathy was noted in 65 patients (67%) and 340 units of FFP (71%) were transfused to these patients. FFP units transfused as pre-procedural prophylaxis were 176 out of 479 (36.7%). Twenty transfusion episodes amounting to 53 units of FFP (11.1%) were given to patients who were not actively bleeding and had a pre-INR of <2. Six patients did not get the planned procedure done and received 25 units (5.2%) of FFP. Of 15 patients who received FFP as pre-procedure prophylaxis with INR <2, only one (6.6%) had normalized post-transfusion INR (post-INR), 5 (33.3%) had post-INR of <1.5 and none had any bleeding complications. Inappropriate use of FFP in this study was noted to be 23.7% (114/479 units of FFP). Mean improvement in INR per unit of FFP for all transfusion episodes (n=114) was 0.36, with mean pre-INR of 3.28 (range 1.5 to >10) and mean post-INR of 1.72 (range 1.2 to 4.2). Mean improvement in INR/FFP in patients with pre-INR <2 vs. those with pre-INR 2 or higher was 0.22 vs. 0.42 respectively (p=0.021). Mean improvement in INR/FFP was significantly higher in patients with warfarin related coagulopathy vs. in those secondary to other causes (0.46 vs. 0.33, p=0.001). Patients who received vitamin K concurrently with FFP had higher mean improvement in INR/FFP than those who did not receive vitamin K (0.45 vs. 0.17, p=0.001). It was also noted that timing of post-INR check was very heterogeneous. Two patients developed an allergic reaction needing stoppage of transfusion and further treatment. Approximately $6,840 were wasted in direct costs ($60 per unit) in just 3 months for only medical in-patients excluding indirect costs (estimated at $100 per unit= $11,400) such as technician, nursing time; transfusion sets, pre-medication, etc. CONCLUSION: Inappropriate use of FFP remains high even among medical in-patients. This study is consistent with previous studies in finding warfarin reversal as the major indication of FFP use and higher the pre-INR, higher was the improvement in INR. Especially, high percentage of use of FFP for pre-procedural prophylaxis with mild elevation of INR is alarming; therefore, studies evaluating restrictive vs. liberal use of FFP are needed. *ICU=Intensive care unit, PCU= Progressive care unit, ER= Emergency room, GMF= General medical floor. Disclosures: No relevant conflicts of interest to declare.