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Competing Interests: Disclosure The following authors disclosed financial relationships: K. K. Das: Patent with Interpace Biosciences; food and beverage compensation from Medtronic, Inc. D. Chen: Food and beverage compensation from Ambu Inc. V. S. Akshintala: Board member for Origin Endoscopy Inc; consultant for Dragonfly Endoscopy Inc; research support from Abbvie, Boston Scientific Corporation, and Medtronic; travel compensation from Mauna Kea Technologies, Inc; food and beverage compensation from Mauna Kea Technologies, Inc, Boston Scientific Corporation, and AbbVie Inc. Y.-I. Chen: President of Chess Medical; consultant for Boston Scientific Corporation. A. Kahn: Consultant for MiMedx. G. Mishra: Consultant for Pentax of America, Inc and Cook Medical LLC; travel compensation from Pentax of America, Inc; food and beverage compensation from Pentax of America, Inc, Cook Medical LLC, Ambu Inc, Boston Scientific Corporation, and Wilson Cook Medical Incorporated. V. Raman Muthusamy: Consultant for Medtronic and Boston Scientific Corporation; research support from Boston Scientific Corporation; stock options and equity in Capsovision; advisory board for Endogastric Solutions and Motus GI; travel compensation from Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation, Steris Corporation, Medtronic, Inc, Apollo Endosurgery US Inc, Endogastric Solutions, Inc, Cook Medical LLC, Pentax of America, Inc, and Olympus America Inc. J. V. Obando: Shareholder with Surgenly LLC. F. U. Onyibma: Food and beverage compensation from Endogastric Solutions, Inc and Medtronic, Inc. S. Pawa: Consultant for Boston Scientific Corporation. T. Rustagi: Consultant for Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Merit Medical Systems Inc. S. Sakaria: Food and beverage compensation from AbbVie Inc. G. Trikudanathan: Consultant for Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation. R. Law: Consultant for ConMed Corporation, Boston Scientific Corporation, Medtronic USA Inc, and Olympus America Inc; royalties from UpToDate; food and beverage compensation from Olympus America Inc, Boston Scientific Corporation, and Ethicon Inc. All other authors disclosed no financial relationships.

Background and Aims: EMR and endoscopic submucosal dissection (ESD) are minimally invasive endoscopic techniques, developed for the removal of benign and early malignant lesions throughout the GI tract. Submucosal injection of a marking agent can help to identify lesions during surgery. Endoscopic resection frequently involves "lifting" of the lesions by injection of a substance within the submucosal space to create a cushion for safe resection. This review summarizes the current techniques and agents available for endoscopic marking and lifting of GI tract lesions., Methods: The MEDLINE database was searched through April 2023 for relevant articles related to the lifting and marking aspect of EMR by using key words such as "endoscopy" or "endoscopic" combined with "marking," "tattoo," and "lifting." The report was drafted, reviewed, and edited by the American Society for Gastrointestinal Endoscopy Technology Committee and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy., Results: This technology review describes the techniques for endoscopic tattoo placement and submucosal lifting, along with currently available agents, safety, and costs., Conclusions: Endoscopists performing EMR and ESD have several choices in submucosal injection materials for lifting and marking agents for tattoos. These may be commercially prepared agents or off-the-shelf materials with or without additives to facilitate visualization. A thorough understanding of the indications, techniques, properties of various agents, costs, and adverse events is necessary in choosing the appropriate materials and technique to optimize lesion resection in EMR and ESD., Competing Interests: Disclosure The following authors disclosed financial relationships: A. Bhatt: Consultant for Medtronic, Inc, US Endoscopy, Olympus Corporation, and Intuitive Surgical Inc; patent-holder for a commercial device licensed to Medtronic, Inc. V. S. Akshintala: Board member for Origin Endoscopy Inc; consultant for Dragonfly Endoscopy Inc; research support from Abbvie, Boston Scientific Corporation, and Medtronic. Y. Chen: President of Chess Medical; consultant for Boston Scientific Corporation. K. K. Das: Consultant for Olympus Medical Systems Corporation; patent-holder with Interpace Biosciences. A. Kahn: Consultant for MiMedx. K. Krishnan: Consultant for Boston Scientific Corporation and Olympus Corporation of the Americas. G. Leung: Consultant for Boston Scientific Corporation, Steris Corporation, AI Medical Service, and Mirai Medical. D. R. Lichtenstein: Consultant for Olympus Corporation of the Americas and Boston Scientific Corporation; speaker for Olympus Corporation of the Americas and Boston Scientific Corporation; Clinical Events Committee for Boston Scientific Corporation (chair) and SafeHeal; advisory board and research committee for Iterative Health; GI boards committee for the American Board of Internal Medicine. G. Mishra: Consultant for Pentax of America, Inc and Cook Medical LLC. V. Raman Muthusamy: Consultant for Medtronic and Boston Scientific Corporation; research support from Boston Scientific Corporation; stock options/equity in Capsovision; advisory board for Endogastric Solutions and Motus GI. J. V. Obando: Shareholder with Surgenly LLC. S. Pawa, T. Rustagi, G. Trikudanathan: Consultant for Boston Scientific Corporation. M. Saumoy: Consultant for Becton, Dickinson and Company and Intuitive Surgical, Inc. A. J. Trindade: Consultant for Pentax of America, Inc, Boston Scientific Corporation, Lucid Diagnostics, and Exact Science. J. Yang: Consultant for Cook Medical, Interscope, and Steris. R. Law: Consultant for Conmed Corporation, Boston Scientific Corporation, Olympus America Inc, and Medtronic USA Inc; royalties from UpToDate. All other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Gastric variceal bleeding occurs less commonly than bleeding from esophageal varices (EVs), although it is associated with higher morbidity and mortality. Bleeding from gastroesophageal varices type 1 (GOV1) is treated like EVs. In contrast, other forms of gastric variceal bleeding, including gastroesophageal varices type 2 (GOV2) and isolated gastric varices types 1 (IGV1) and 2 (IGV2), are treated with varying endoscopic approaches. Nonendoscopic methods include transjugular intrahepatic portosystemic shunt (TIPS) or balloon-occluded retrograde transvenous obliteration (BRTO). This technology report focuses on endoscopic management of gastric varices (GVs)., Methods: The MEDLINE database was searched through August 2022 for relevant articles by using key words such as gastric varices, glue, cyanoacrylate, thrombin, sclerosing agents, band ligation, topical hemostatic spray, coils, EUS, TIPS, and BRTO. The article was drafted, reviewed, and edited by the American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee and approved by the Governing Board of the ASGE., Results: Endoscopic injection with cyanoacrylate (CYA) glue has been the primary endoscopic method to treat GVs. EUS-guided angiotherapy with CYA glue and coil embolization has emerged as an alternative method enabling improved detection of GVs with a high technical success for targeting and obliterating GVs. Combining CYA glue with coil therapy allows the coil to act as a scaffold for the glue, reducing the risk of glue embolization and improving outcomes. Alternative injectates or topical treatments have been described but remain poorly studied., Conclusions: The mainstay paradigm for the endoscopic management of gastric variceal bleeding is the injection of CYA glue. The published success of EUS-guided angiotherapy using CYA glue with or without embolization coils has increased our treatment armamentarium., Competing Interests: Disclosure The following authors disclosed financial relationships: G. Trikudanathan: Consultant for Boston Scientific Corporation. A. Bhatt: Consultant for Medtronic, Inc, US Endoscopy, Olympus Corporation, and Intuitive Surgical Inc; patent-holder for a commercial device licensed to Medtronic, Inc. V. Chandrasekhara: Consultant for Covidien LP and Boston Scientific Corporation; research support from Microtech Endoscopy; shareholder with Nevakar, Inc. A. Kahn: Consultant for MiMedx. K. Krishnan: Consultant for Boston Scientific Corporation and Olympus Corporation of the Americas. N. A. Kumta: Consultant for Apollo Endosurgery US Inc, Boston Scientific Corporation, Safeheal, and Olympus Corporation of the Americas. D. R. Lichtenstein: Consultant for Olympus Corporation of the Americas and Boston Scientific Corporation; speaker for Olympus Corporation of the Americas and Boston Scientific Corporation; Clinical Events Committee for Boston Scientific Corporation (chair) and SafeHeal; advisory board and research committee for Iterative Health; GI boards committee for the American Board of Internal Medicine. J. V. Obando: Shareholder with Surgenly LLC. R. Pannala: Consultant for HCL Technologies; scientific advisory board for Bluestar Genomics and Nestle HealthCare Nutrition Inc; research support from Erbe USA Inc; Medical Director (AZ Chapter) for the National Pancreas Foundation. M. Saumoy: Consultant for Becton, Dickinson and Company and Intuitive Surgical, Inc. A. J. Trindade: Consultant for Pentax of America, Inc, Boston Scientific Corporation, Lucid Diagnostics, and Exact Science. J. Yang: Consultant for Cook Medical, Interscope, and Steris. R. J. Law: Consultant for Conmed Corporation, Boston Scientific Corporation, Olympus America Inc, and Medtronic USA Inc; royalties from UpToDate. All other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Disclosure The following authors disclosed financial relationships: V. S. Akshintala: Board member for Origin Endoscopy Inc; consultant for Dragonfly Endoscopy Inc; educational grants from Abbvie, Boston Scientific Corporation, and Medtronic; travel compensation from Mauna Kea Technologies, Inc; food and beverage compensation from Mauna Kea Technologies, Inc, Boston Scientific Corporation, and AbbVie Inc. D. Chen, S. Sakaria: Food and beverage compensation from Ambu Inc. Y-I. Chen: President of Chess Medical; consultant for Boston Scientific Corporation. K. K. Das: Patent-holder with Interpace Biosciences; food and beverage compensation from Medtronic, Inc. A. Kahn: Consultant for MiMedx. G. Mishra: Consultant for Pentax of America, Inc and Cook Medical LLC; travel compensation Pentax of America, Inc; food and beverage compensation from Pentax of America, Inc, Cook Medical LLC, Ambu Inc, Boston Scientific Corporation, and Wilson Cook Medical Inc. V. Raman Muthusamy: Consultant for Medtronic and Boston Scientific Corporation; research support from Boston Scientific Corporation; stock options/equity in Capsovision; advisory board for Endogastric Solutions and Motus GI; travel compensation from Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation, Steris Corporation, Medtronic, Inc, Apollo Endosurgery US Inc, Endogastric Solutions, Inc, Cook Medical LLC, Pentax of America, Inc, and Olympus America Inc. J. V. Obando: Shareholder with Surgenly LLC. F. U. Onyibma: Food and beverage compensation from Endogastric Solutions, Inc and Medtronic, Inc. S. Pawa: Consultant for Boston Scientific Corporation. T. Rustagi: Consultant for Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Merit Medical Systems Inc. G. Trikudanathan: Consultant for Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation. R. J. Law: Consultant for ConMed Corporation, Boston Scientific Corporation, Medtronic USA Inc, and Olympus America Inc; royalties from UpToDate; food and beverage compensation from Olympus America Inc, Boston Scientific Corporation, and Ethicon Inc.

Endoscopic ultrasound (EUS) technology has evolved dramatically over the past 20 years, from being a supplementary diagnostic aid available only in large medical centers to being a core diagnostic and therapeutic tool that is widely available. Although formal recommendations and practice guidelines have not been developed, there are considerable data supporting the use of EUS for its technical accuracy in diagnosing pancreaticobiliary and gastrointestinal pathology. Endosonography is now routine practice not only for pathologic diagnosis and tumor staging but also for drainage of cystic lesions and celiac plexus neurolysis. In this article, we cover the use of EUS in biliary and pancreatic intervention, ablative therapy, enterostomy, and vascular intervention.

Background: Intrapancreatic accessory spleen (IPAS) can pose a challenge in the diagnostic workup by mimicking a pancreatic neoplasm. Reports of IPAS identified by endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) are scant in the literature, and increased recognition of this benign entity may reduce misdiagnosis and unnecessary surgical intervention. Here we report 2 cases of IPAS diagnosed by EUS-guided FNA biopsy., Cases: Each patient underwent computed tomographic evaluation for abdominal pain; it revealed a mass or thickening within the tail of the pancreas. Both patients were referred for EUS-guided FNA to further characterize their pancreatic lesions. In both cases, the cytomorphologic appearance of smears and cell blocks demonstrated aggregates of benign splenic tissue characteristic of both white and red pulp. Rare fragments of pancreatic acinar tissue were also identified. One cell block demonstrated benign splenic and pancreatic parenchyma immediately adjacent to one another without an apparent intervening capsule., Conclusion: IPAS can be diagnosed by FNA biopsy. Definitive tissue diagnosis in these 2 cases avoided not only unnecessary surgical intervention but also the need for consideration of a "watch and wait" strategy with further imaging and possible additional biopsy attempts.

Context: Pancreas divisum has been associated with recurrent acute pancreatitis, chronic abdominal pain without elevated pancreatic enzymes, and chronic pancreatitis. Prior studies suggest that endoscopic minor papillotomy benefits certain symptomatic pancreas divisum patients. However, the data are quite limited and there is a lack of long-term follow-up., Objective: To describe a retrospective study of endoscopic minor papillotomy for pancreas divisum., Patients: Eighty-nine adult patients who underwent endoscopic minor papillotomy at our referral center were included in the study. Median follow-up was 29 months., Intervention: We conducted a telephone survey. Fifty-three patients were available for the telephone survey., Results: Thirty-two patients (60.4%) reported immediate improvement: however, symptoms recurred in 17 (53.1% of the immediate responders). Repeat endoscopic interventions were performed in 8 patients, with long-term improvement in two. Overall long-term improvement was achieved in 17 patients (32.1%). Results of minor papillotomy were more favorable for patients with recurrent, well-defined bouts of pancreatitis (immediate improvement: P=0.036; long-term improvement: P=0.064) compared to those with pancreatitis who reported continuous pain and those without clinical evidence of pancreatitis (immediate improvement: 73.3%, 42.9% and 44.4%, respectively; long-term improvement: 43.3%, 21.4%, and 11.1%, respectively)., Conclusions: The long-term benefit from endoscopic minor papillotomy using strict criteria is poorer than suggested from previous studies. However, pancreas divisum patients with well-defined bouts of pancreatitis are more likely to benefit from endoscopic minor papillotomy than those without symptom-free intervals between "attacks" and those with pain that is not associated with elevated pancreatic enzymes.

Heavy iron overload, as occurs in primary and secondary hemochromatosis, may cause fibrosis of parenchymal organs, including the heart, liver, and pancreas, and it is a risk factor for the development of hepatocellular carcinoma. Recent evidence indicates that lesser degrees of hepatic iron deposition are also risk factors for nonhemochromatotic liver disease. For example, several recent studies showed extraordinarily high prevalences (about 60% to 75%) of HFE mutations in patients with porphyria cutanea tarda and significantly increased prevalences of these mutations in patients with nonalcoholic steatohepatitis from Australia and the United States. It is less well established that the prevalence of the HFE mutations is increased in alcoholic liver disease and in chronic viral hepatitis, but in both conditions, patients harboring one of these mutations, especially C282Y, are more likely to have advanced hepatic fibrosis or cirrhosis. Thus, these mutations both incite and exacerbate nonhemochromatotic liver disease. In this review, we summarize current knowledge of these associations and emphasize important unresolved questions that require further study.