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Radiation beams precisely directed at a tumor can attenuate the radiation to contiguous tissues. Image-guided radiation therapy using fiducials allows accurate delineation of tumor location. Traditionally, fiducials in the prostate have been placed by urologists or radiation oncologists. With the evolution of endoscopic ultrasound (EUS), fiducials have been successfully placed under the EUS guidance in different organs. In this case series, fiducials were placed in 3 patients with prostate cancer. All patients completed their radiation therapy, and no complications were reported except mild dysuria in one case. EUS-guided fiducial placement is safe and offers a new modality for fiducial placement in the prostate.

Distal biliary stricture secondary to pancreatic cancer or primary biliary cancer such as cholangiocarcinoma, gallbladder cancer, carcinoma of the ampulla of Vater, or metastatic disease caries poor prognosis mainly due to lack of initial symptoms and advanced stage prognosis. Every year more then 40,000 new patients are diagnosed with pancreatic cancer. Pancreatic cancer is responsible for almost 90% of distal biliary obstruction. The main symptom is painless jaundice, but patients may also present with weight loss, anorexia, epigastric pain, and back pain. Different imaging modalities are required for the differential and final diagnosis; computed tomography (CT), magnetic resonance (MRI), endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound (EUS) are few of the modalities used for diagnosing and staging in cases of distal biliary strictures. In this chapter we will review the epidemiology, natural history, clinical presentation, diagnosis, and curative and palliative treatment of distal bilary strictures.

Gastric varices (GV) manifest in almost one-fifth of the patients with portal hypertension. Although primary pharmacological prevention of esophageal varices has been identified, there are limited therapeutic options that are optimal for GV bleeding. Recently, the use of endoscopic ultrasound (EUS)-guided angiotherapy [cyanoacrylate (CA) and coils] was introduced for the treatment of GV. Although CA injection is the recommended first-line therapeutic modality, it is associated with systemic, life-threatening embolization as well as technical instrumental challenges. Recently, EUS-guided coiling for GV was used with high safety profile.This is a review of the current literature on the treatment of GV, focusing on the role of EUS-guided angiotherapy in the treatment of GV. We performed a Medline/PubMed search, and 37 relevant studies were extracted and examined.EUS-guided angiotherapy has shown a consistent favorable result among the several reports throughout the literature, with better safety and efficacy profile toward EUS-guided coiling; however, a combination treatment with EUS-guided coiling followed by glue injection has shown as well to reduce the embolization adverse events associated with glue injection.EUS-guided angiotherapy and specifically EUS-guided coiling is an emerging promising technique and should be considered as a first-line therapeutic option for bleeding GV.

Endoscopic ultrasound (EUS)-guided fine needle aspiration with or without biopsy (FNA/FNB) are the primary diagnostic tools for gastrointestinal submucosal tumors. EUS-guided fine needle aspiration (EUS-FNA) is considered a first line diagnostic method for the characterization of pancreatic and upper gastrointestinal lesions, since it allows for the direct visualization of the collection of specimens for cytopathologic analysis. EUS-FNA is most effective and accurate when immediate cytologic assessment is permitted by the presence of a cytopathologist on site. Unfortunately, the accuracy and thus the diagnostic yield of collected specimens suffer without this immediate analysis. Recently, a EUS-FNB needle capable of obtaining core samples (fine needle biopsy, FNB) has been developed and has shown promising results. This new tool adds a new dimension to the diagnostic and therapeutic utility of this technique. The aim of the present review is to compare the efficacy of EUS-FNA to that afforded by EUS-FNB in the characterization of pancreatic masses and of upper and lower gastrointestinal submucosal tumors.

Gastroparesis is a debilitating progressive disease that significantly impacts a patient's life with limited and challenging treatments available. Although the pathogenesis is multifactorial, pylorospasm is believed to have a major underlying role. Several therapeutic interventions directed to the pylorus have been developed over the last decade, including intra-pyloric injections of botulinum toxin, transpyloric stenting, and surgical pyloroplasty. All of these treatment options had limited and disappointing results. More recently, gastric peroral endoscopic myotomy (G-POEM) has been reported as a treatment for refractory gastroparesis. In this review article, we provide an overview on gastroparesis with a focus on the therapeutic interventions. In addition, we provide a literature summary and pool analysis of the clinical efficacy, scintigraphic efficacy, and safety profile of all studies that evaluated G-POEM in gastroparesis. Overall, seven studies have reported on the use of G-POEM in gastroparesis, and the pooled analysis of these studies showed a technical success of 100%, with clinical efficacy as assessed by the Gastroparesis Cardinal Symptoms Index of 81.5%, gastric emptying scintigraphy normalization in approximately 55.5% of the cases, perioperative complications in 7.6%, and intraoperative complications in 6.6%. This suggests that G-POEM is a new promising therapeutic intervention for the treatment of gastroparesis with durable effect and limited potential adverse events.

Venous thromboembolism (VTE) in cirrhotic patients is an increasingly encountered problem in the daily clinical practice; there is still a debate on the ideal measures to be followed for prophylaxis and treatment of VTE among this population. Although traditionally, liver cirrhosis has been considered a disease with hypocoagulability state and increasing bleeding tendency due to severe homeostatic disruption in liver disease, until recently there is increasing awareness and evidence that cirrhotic patients are not completely protected from thrombotic events although they have an elevated international normalized ratio and auto anticoagulation. Furthermore, hypercoagulability is now an increasingly recognized aspect of chronic liver disease (CLD), and the bleeding risk of VTE prophylaxis and treatment remains unclear. In this review, we provide an updated discussion on the mechanisms involved in hemostasis in CLD as well as on the benefits and complications of anticoagulant therapy in cirrhotic patients. Overall, sufficient evidence exists, promoting the use of anticoagulation in cirrhotic patients for both VTE prophylaxis and treatment in carefully selected patients after consideration of pharmacologic or endoscopic variceal bleeding prophylaxis.

Drug-induced liver injury (DILI) is a rare but potentially life threatening adverse drug reaction. DILI may mimic any morphologic characteristic of acute or chronic liver disease, and the histopathologic features of DILI may be indistinguishable from those of other causes of liver injury, such as acute viral hepatitis. In this review article, we provide an update on causative agents, clinical features, pathogenesis, diagnosis modalities, and outcomes of DILI. In addition, we review results of recently reported genetic studies and updates on pharmacological and invasive treatments.

Drug-induced liver injury (DILI) accounts for approximately 10 percent of all cases of acute hepatitis. The patterns of acute injury include any form of hepatic injury, but the most common problems are cholestasis, hepatocellular damage, or a mixed type. DILI is often re- versible, and discontinuation of the offending agent usually results in a complete recovery; however, some cases may lead to chronic liver injury, cirrhosis, and even death. Temozolomide (TMZ) is an alkylating, anti-neoplastic agent used for the treatment of refractory anaplastic astrocytoma, newly-diagnosed Glioblastoma multiforme (GBM) and metastatic melanoma. Levetiracetam (LEV) is an established second-generation antiepileptic drug and is most com- monly approved as adjunctive treatment of partial-onset seizures with or without secondary generalization. When administered separately each of these drugs is considered to be relatively safe and only few cases of severe liver injury can be found throughout the literature; however, LEV and TMZ are commonly used together in the treatment of brain malignancies. We report three patients who presented with jaundice during treatment with TMZ and LEV, and propose a mechanism for liver sensitization by LEV for TMZ-induced injury.

Objectives Pancreatic intraepithelial neoplasia lesions can appear as chronic pancreatitis-like changes on endoscopic ultrasound (EUS). The aim of our study was to determine if BRCA2 mutation carriers were more likely than noncarriers to demonstrate chronic pancreatitis-like changes on EUS. Methods Patients with BRCA2 mutations referred for EUS were identified (cases) from an endoscopy database. Controls were matched with cases in a 2:1 ratio for sex, date EUS was performed, endoscopist, and echoendoscope. Data were extracted from medical records, EUS reports, and EUS images. Rosemont classification was used to categorize chronic pancreatitis-like changes. Results During the study period, 37 BRCA2 mutation carriers and 92 controls underwent EUS. Compared with controls, BRCA2 mutation carriers had a higher prevalence of solid pancreas lesions (16.2% vs 1.08%; P = 0.005), pancreatic cysts (21.6% vs 6.1%; P = 0.01), Rosemont "consistent with chronic pancreatitis" definition changes (13.5% vs 1%; P = 0.002), and Rosemont "suggestive of chronic pancreatitis" definition changes (16.2% vs 2.1%; P = 0.003). After adjusting for age, alcohol use, and smoking, BRCA2 mutation carriers were almost 25 times more likely to demonstrate chronic pancreatitis-like changes. Conclusions Chronic pancreatitis-like changes, along with solid and cystic pancreatic lesions, were significantly more common in BRCA2 mutation carriers than in noncarriers.

Approximately 5%–10% of common bile duct (CBD) stones cannot be removed by conventional methods because of altered anatomy. Percutaneous transhepatic cholangioscopic lithotomy has been cited as a viable alternative. A 69-year-old woman with a history of Roux-en-Y was found to have a lesion obstructing the CBD. A cholangioscope was advanced through a percutaneous transhepatic sheath and demonstrated an obstructing stone in the CBD that was removed with lithotripsy. The rate of successful stone removal with percutaneous transhepatic cholangioscopic lithotomy is 90%, with complication rates similar to endoscopic retrograde cholangiopancreatography and is an option in patients with altered surgical anatomy.

1Department of Medicine, Hebrew University-Hadassah Medical Center, Jerusalem, Israel 2Division of Gastroenterology, Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215, USA *Corresponding author: Mizrahi Meir, MD Division of Gastroenterology Center for Advanced Endoscopy Beth Israel Deaconess Medical Center and Harvard Medical School 330 Brookline Ave, Boston MA 02215, USA E-mail: mmizrahi@bidmc.harvard.edu

Fatty pancreas is a newly recognized condition which is poorly investigated until today as compared to nonalcoholic fatty liver disease. It is characterized by pancreatic fat accumulation and subsequent development of pancreatic and metabolic complications. Association of fatty pancreas have been described with type 2 diabetes mellitus, acute and chronic pancreatitis and even pancreatic carcinoma. In this review article, we provide an update on clinical implications, pathogenesis, diagnosis, treatment and outcomes.

Percutaneous endoscopic gastrostomy (PEG) tubes are commonly utilized as a method of enteral feeding in patients unable to obtain adequate oral nutrition. Although some studies have shown improved mortality in select populations, the safety and effectiveness of PEG insertion in patients with dementia compared with those with other neurological diseases or head and neck malignancy remains less well defined. To evaluate the nutritional effectiveness, rate of rehospitalization, and risk of mortality among patients with dementia compared with patients with other neurological diseases or head and neck cancers who undergo PEG placement. We conducted a retrospective analysis from a prospective database of patients who underwent PEG placement at an academic tertiary center between 2008 and 2013. The following data were collected: indication for PEG, patient demographics, biochemical markers of nutritional status rehospitalization, and survival rates. During the study period, 392 patients underwent PEG tube placement. Indications for PEG were dementia (N=165, group A), cerebrovascular accident (N=124, group B), and other indications such as oropharyngeal cancers and motor neuron disease (N=103, group C). The mean follow-up time after PEG was 18 months (range, 3 to 36 mo). No differences in baseline demographics were noted. PEG insertion in the dementia (group A) neither reduced the rehospitalization rate 6 months' postprocedure compared with groups B and C (2.45 vs. 1.86 and 1.65, respectively; P=0.05), nor reduced the mortality rate within the first year post-PEG placement (75% vs. 58% and 38% for groups A, B, and C, respectively, P=0.001), as well, it did not improve survival at 1 month after the procedure (15% vs. 3.26% and 7.76%, for groups A, B, C, respectively, P