Narrow band imaging with magnification for the diagnosis of lesions in the upper gastrointestinal tract

Endoscopy plays an important role in the diagnosis and management of gastrointestinal(GI)tract disorders.Chromoendoscopy has proven to be superior to white light endoscopy for early detection of various GI lesions.This has however been fraught with problems.The use of color stains,time taken to achieve an effect and the learning curve associated with the technique has been some of the pitfalls.Narrow band imaging(NBI)particularly in combination with magnifying endoscopy may allow the endoscopist to accomplish a fairly accurate diagnosis with good histological correlation similar to results achieved with chromoendoscopy.Such enhanced detection of pre-malignant and early neoplastic lesions in the gastrointestinal tract should allow better targeting of biopsies and could ultimately prove to be cost effective.Various studies have been done demonstrating the utility of this novel technology.This article will review the impact of NBI in the diagnosis of upper gastrointestinal tract disorders.     

Neue endoskopische Methoden zur Schleimhautbeurteilung im Gastrointestinaltrakt

Technical innovations in endoscopy aim at enhanced detection and characterization of lesions of the gastrointestinal tract. High resolution endoscopy has become part of routine endoscopy and has been associated with higher detection rates in some but not all trials. Optical or software-based methods of surface contrast enhancement (e.g. NBI, i-scan, FICE) are mainly used for detailed characterization of lesions. Chromoendoscopy by topical application of intravital dyes still plays a role in detection and characterization of suspicious mucosal areas. Microscopic endoscopy methods, such as endomicroscopy and endocytoscopy not only try to predict the histology but are able to visualize pathologies at cellular and sub-cellular levels.     

Magnifying chromoendoscopy for the detection of premalignant gastrointestinal lesions

The prognosis for patients with malignancies of the gastrointestinal tract is strictly dependent on the early detection of premalignant and malignant lesions. At present, endoscopy can be performed with new, powerful high-resolution or magnifying endoscopes. Comparable to the rapid development in chip technology, the optic features of the newly designed endoscopes offer resolutions that allow new mucosal surface details to be seen. In conjunction with chromoendoscopy, the newly discovered tool of video endoscopy is much easier to use and more impressive than previously used fibreoptic endoscopy. This review summarises the value of magnifying endoscopy in the upper and lower gastrointestinal tract and focuses on gastroesophageal reflux disease and early gastric and colorectal cancer.     

Endoscopic detection of early upper GI cancers

The detection of early-stage neoplastic lesions in the upper GI tract is associated with improved survival and the potential for complete endoscopic resection that is minimally invasive and less morbid than surgery. Despite technological advances in standard white-light endoscopy, the ability of the endoscopist to reliably detect dysplastic and early cancerous changes in the upper GI tract remains limited. In conditions such as Barrett's oesophagus, practice guidelines recommend periodic endoscopic surveillance with multiple biopsies, a methodology that is hindered by random sampling error, inconsistent histopathological interpretation, and delay in diagnosis. Early detection may be enhanced by several promising diagnostic modalities such as chromoendoscopy, magnification endoscopy, and optical spectroscopic/imaging techniques, as these modalities offer the potential to identify in real-time lesions that are inconspicuous under conventional endoscopy. The combination of novel diagnostic techniques and local endoscopic therapies will provide the endoscopist with much needed tools that can considerably enhance the detection and management of early stage lesions in the upper GI tract.     

MAGNIFYING ENDOSCOPIC OBSERVATION OF THE UPPER GASTROINTESTINAL TRACT

Recent advances in technology enable us to obtain more detailed information during endoscopic procedures. Diagnosis of the pit pattern or microvascular architecture allow the earlier detection of neoplastic lesions in the gastrointestinal tract. These advances have led to the enhanced selection of appropriate treatments. Cancers that are discovered at an early stage can be treated by mucosal resection, whereas advanced cancers are treated with surgery. Recently, some groups have tried to acquire direct in vivo histological images of gastrointestinal mucosa (virtual histology or optical biopsy). Now optical coherence tomography (OCT), confocal laser endoscopy and endo‐cytoscopy systems enable this conception. However, none of these techniques has been proven, although some investigators have been able to use them to enhance cancer detection, and have reported the usefulness of these techniques. The present review assesses the strengths and weaknesses of these technologies, and describes the magnifying observations of the upper gastrointestinal tract using magnifying endoscopy equipment available on the market as well as newly developed endo‐cytoscopy systems. Published and unpublished data for this review were identified by searches of MEDLINE, Register of Cancer Trials: National Cancer Institute ( http://cancertrials.nci.nih.gov/ ) and references from relevant articles. We also contacted researchers. The authors’ own database of references was also used. The search items were as follows: magnifying endoscopy, endo‐cytoscopy system, confocal endoscopy, optical coherence tomography, contact endoscopy, esophageal cancer, Barrett’s esophagus, Barrett’s esophageal cancer, gastric cancer, colon cancer, chromoendoscopy, methylene blue etc.     

Recent Advances in Light-Induced Fluorescence Endoscopy (LIFE) of the Gastrointestinal Tract

Abstract: Gastrointestinal (GI) cancer continues to be a significant malignant disease. It is well recognized that early detection of dysplastic changes prior to invasive growth may have a pronounced effect on the clinical efficacy of treatment and subsequent patient survival. Standard white-light endoscopic visualization of such early lesions is often difficult and many premalignant lesions remain undetected during routine screening procedures. Additionally, dysplastic lesions are usually not distinguished against surrounding normal tissue, and visible non-adenomatous lesions such as hyperplastic polyps are often indistinguishable from adenomatous polyps. However, recent developments in endoscopic technology have led to the development of more sensitive endoscopic screening methods. Fluorescence-based endoscopic imaging or spectroscopy of the gastrointestinal tract may offer a novel and alternative means of detecting and identifying premalignant and malignant lesions otherwise occult to conventional white-light endoscopy. The purpose of this review is to present a general overview of the current developments and possible clinical roles of light-induced fluorescence endoscopy (LIFE) as an adjunct to conventional diagnostic endoscopy for screening and surveillance for premaligant and malignant gastrointestinal lesions. (Dig Endosc 1999; 11: 108–118)     

Ultraslim endoscopy with flexible spectral imaging color enhancement for upper gastrointestinal neoplasms

AIM:To conduct a preliminary study on the effect of flexible spectral imaging color enhancement (FICE) used in combination with ultraslim endoscopy by focusing on the enhanced contrast between tumor and non-tumor lesions. METHODS: We examined 50 lesions of 40 patients with epithelial tumors of the upper gastrointestinal tract before endoscopic submucosal dissection using ultraslim endoscopy with conventional natural color imag ing and with FICE imaging. We retrospectively invest igated the effect of the use of FICE on endoscopic diagn osis in comparison with normal light. RESULTS: Visibility of the epithelial tumors of the upper gastrointestinal tract with FICE was superior to normal light in 54% of the observations and comparable to normal light in 46% of the observations. There was no lesion for which visibility with FICE was inferior to that with normal light. FICE visualized 69.6% of hyperemic lesions and 58.8% of discolored lesions better than conventional endoscopy with natural color imaging. FICE sign if icantly improved the visibility of lesions with hyp ere mia or discoloration compared with normocolored lesions. CONCLUSION: This study suggests that the use of FICE would improve the ability of ultraslim endoscopy to detect epithelial tumors of the upper gastrointestinal tract.     

Adenocarcinoma of the stomach in Fanconi's anemia

A case of Fanconi's anemia presenting for the first time at the age of 23 years is described. He died of adenocarcinoma of the stomach 4 months later. As far as the authors are aware, this is the second case of adenocarcinoma of the stomach occurring in Fanconi's anemia. As Fanconi's anemia is known to predispose to malignancy, all patients need detailed evaluation of the gastrointestinal tract by endoscopy as well as radiology for the early detection of gastrointestinal lesions.     

Narrow-band imaging with magnifying endoscopy for the evaluation of gastrointestinal lesions

Narrow band imaging(NBI) endoscopy is an optical image enhancing technology that allows a detailed inspection of vascular and mucosal patterns, providing the ability to predict histology during real-time endoscopy. By combining NBI with magnification endoscopy(NBI-ME), the accurate assessment of lesions in the gastrointestinal tract can be achieved, as well as the early detection of neoplasia by emphasizing neovascularization. Promising results of the method in the diagnosis of premalignant and malignant lesions of gastrointestinal tract have been reported in clinical studies. The usefulness of NBI-ME as an adjunct to endoscopic therapy in clinical practice, the potential to improve diagnostic accuracy, surveillance strategies and cost-saving strategies based on this method are summarized in this review. Various classification systems of mucosal and vascular patterns used to differentiate preneoplastic and neoplastic lesions have been reviewed. We concluded that the clinical applicability of NBI-ME has increased, but standardization of endoscopic criteria and classification systems, validation in randomized multicenter trials and training programs to improve the diagnostic performance are all needed before the widespread acceptance of the method in routine practice. However, published data regarding the usefulness of NBI endoscopy are relevant in order to recommend the method as a reliable tool in diagnostic and therapy, even for less experienced endoscopists.     

Endoscopic detection of early lower gastrointestinal cancer

The prognosis for patients with malignancies of the lower gastrointestinal tract is strictly dependent on early detection of premalignant and malignant lesions. What should an ideal screening and surveillance colonoscopy be able to accomplish? The technique should allow detection of large but also discrete mucosal alterations. Ideally, endoscopic discrimination between neoplastic and non-neoplastic lesions would be possible during the ongoing procedure. At present, endoscopy can be performed with powerful new endoscopes. Comparable to the rapid development in chip technology, the optical features of the newly designed endoscopes offer resolutions, which allow new surface details to be seen. In conjunction with chromoendoscopy, the newly discovered tool video colonoscopy is much easier and more impressive today than with the previously used fibre-optic endoscopes. Recently, new endoscopic technologies such as narrow band imaging, endocytoscopy, or confocal laser endoscopy have allowed the discovery of a whole new world of image details which will surely improve the diagnostic yield in the field of early malignancies. This review summarises newly available technologies and clinical data about the diagnosis of early lower gastrointestinal cancers.     

消化内镜技术在消化道黏膜病变中的应用和进展

内镜是消化道疾病常用的的检查方法，传统的白光内镜对黏膜病变的发现存在局限性，容易漏诊、误诊，先进的内镜技术则有利于提高病灶与周围黏膜的视觉效果，使黏膜表面及微血管的细小变化更容易被发现，本文就胃镜技术在上消化道黏膜病变中的临床诊断应用进行综述。     

CT仿真内镜与电子内镜诊断胃肠道疾病的对照研究

目的对比分析CT仿真内镜(CTVE)与电子内镜对胃肠道疾病的诊断价值。方法对84例可疑胃肠道疾病患者行CTVE检查,同时行电子胃镜或电子结肠镜检查,其中47例经内镜及手术病理证实,24例经内镜下病理活检确定诊断。结果84例中胃癌17例,结直肠癌48例,以手术及病理确诊为标准,内镜和CTVE对肿瘤的诊断符合率均为98.46%(64/65),CTVE还检出胃肠外转移病灶29例;内镜下检出结直肠息肉20例,其中CTVE检出15例,符合率为75%;CTVE对炎症性肠病及溃疡性病变的检出率为40%(2/5)。结论CTVE是一种无创的胃肠道检查新技术,对于胃肠道肿瘤的诊断与电子内镜同样有高度敏感性,并能完整显示胃肠道及肠外病灶,但对于小息肉的敏感性不高,对炎症性及扁平病灶的检出率相对较低。     

上消化道胶囊内镜发展与创新北大核心CSCD

上消化道疾病高发,传统插管式胃镜是检查上消化道疾病最常用的检查方法和"金标准"。为了更舒适无创的检查上消化道黏膜,多项研究提出了上消化道胶囊内镜的概念,但是由于上消化道各部位解剖与生理结构的差异,目前可以使用的胶囊内镜如单纯被动式、磁控式、线控式、磁控联合线控式以及侧视胶囊内镜都存在一定的局限性,无法实现对上消化道整体黏膜情况的观察。文章试图通过介绍适用于食管、胃以及十二指肠检测的胶囊内镜,分析各内镜的诊断效能及其不足,探讨未来上消化道胶囊内镜可能的发展方向。     

Gastrointestinal cytomegalovirus manifestations in AIDS

Cytomegalovirus (CMV) infection is one of the most important intestinal opportunistic infections in AIDS. In severe cases ulcerations and colitis are the commonest manifestations. 184 HIV positive patients with gastrointestinal symptoms were investigated by endoscopy of the gastrointestinal tract. While culture, immunohistochemical staining and histology from biopsies were performed, the results of all three methods were compared. In one third the cases CMV associated lesions could be found by endoscopy. Erosions or ulcerations are the most frequent tissue lesions. In 95% the culture was positive. In addition, immunohistochemical staining in 75% and histology in 61.7% were positive in patients with more serious manifestations. For early diagnosis endoscopy of the gastrointestinal tract and histological, histochemical and microbiological investigations of biopsies are essential.     

自体荧光内镜诊断消化道恶性肿瘤和癌前病变的临床初探

背景：自体荧光内镜应用于临床已十余年,但对其诊断消化道恶性肿瘤和癌前病变的价值仍存在争议。目的：探讨自体荧光内镜在消化道恶性肿瘤和癌前病变中的诊断价值。方法：对2010年6月～2013年3月于上海交通大学医学院附属仁济医院确诊或高度怀疑消化道恶性肿瘤以及随访癌前病变患者的170例离体手术标本和30例在体受试者进行自体荧光内镜检查,以组织病理学检查结果作为金标准。结果：自体荧光内镜诊断消化道恶性肿瘤和癌前病变的总体准确性、敏感性、特异性、阳性预测值（PPV）和阴性预测值（NPV）分别为94．0％、94．6％、93．5％、92．6％和95．3％。自体荧光内镜与组织病理学诊断结果一致性较高（κ=0．880）。离体试验中,癌前病变和早期癌与进展期癌的检出率无显著差异（88．2％对95．8％,P=0．238）,分化型癌与未分化型癌的检出率差异显著（97．9％对86．8％,P=0．009）;在体试验中,分化型癌与未分化型癌的检出率无显著差异（94．1％对80．0％,P=0．373）。结论：自体荧光内镜对于消化道恶性肿瘤和癌前病变具有较高的诊断价值,有望成为诊断早期消化道恶性肿瘤的重要手段。     

The pathology of epithelial pre-malignancy of the gastrointestinal tract

This chapter deals with pre-malignant epithelial lesions of the gastrointestinal tract that have the potential to become cancers. Pre-malignant lesions are divided into two types: those characterized by dysplastic mucosa and those without dysplasia. Examples of the two types are present in the oesophagus, stomach and intestine.In the oesophagus, dysplasia of the squamous epithelium is a precursor to squamous carcinoma. There are differences in interpretation between Western and Japanese pathologists in the diagnosis of oesophageal squamous lesions. Dysplasia in Barrett's oesophagus is regarded as a precursor of adenocarcinoma. The goal of endoscopic surveillance in Barrett's mucosa is the detection of high-grade dysplasia. There are several problems with our current knowledge of high-grade dysplasia and controversies regarding its management. There are differences in the interpretation of biopsies of gastric epithelial dysplasia between Japanese and Western pathologists. In the colon, pre-malignant lesions include dysplasia seen in inflammatory bowel disease and colonic adenomas. The most significant predictor of the risk of malignancy in patients with inflammatory bowel disease is the presence of dysplasia in colonic biopsies.Because of the similarity of neoplasia throughout the gastrointestinal tract, there have been attempts to unify its classification, terminology and diagnostic criteria internationally, the most recently proposed modified classification of gastrointestinal neoplasia being the Vienna classification. Dysplasia of the columnar mucosa has a similar appearance in Barrett's oesophagus, the stomach and the colon. Criteria for its histological diagnosis and grading are reviewed, with an emphasis on areas of diagnostic difficulty such as interobserver variation, and discrepancies between Western and Japanese pathologists. Implication of the presence of dysplasia that are specific to each organ site are discussed, highlighting weaknesses and controversies in current knowledge.     

Endoscopic photodynamic diagnosis: oral aminolevulinic acid is a marker of GI cancer and dysplastic lesions.

BACKGROUND: Dysplasia and early cancer of the upper gastrointestinal (GI) tract often are undetected at white-light endoscopy. We describe oral administration of 5-aminolevulinic acid for the in vivo photodynamic diagnosis of premalignant and malignant lesions during endoscopy. METHODS: Four patients with known gastric adenoma (n = 1), macroscopically undetected but histologically proven esophageal squamous cell cancer (n = 1), suspected early cancer of the esophagus (n = 1), and multiple duodenal adenomas (n = 1) were sensitized with 5-aminolevulinic acid administered orally (15 mg/kg body weight). Photodynamic diagnosis was conducted after a retention time of 6 to 7 hours with a special light source capable of delivering either white or violet-blue light. Red fluorescence was detected through the gastroscope with an image-intensifying camera. RESULTS: All malignant lesions exhibited red or bluish fluorescence during photodynamic diagnosis. Fluorescence-negative mucosal areas proved to be histologically benign. CONCLUSION: Fluorescence induced with 5-aminolevulinic acid might be useful for the endoscopic detection of dysplasia and early carcinoma in the upper GI tract. Further investigations are needed to evaluate the sensitivity and specificity of photodynamic diagnosis for different tumor entities.     

Efficacy of endoscopic surveillance of the upper gastrointestinal tract following distal gastrectomy for early gastric cancer

BACKGROUND/AIMS: How endoscopy can be used in the follow-up of the upper gastrointestinal tract in patients who underwent gastrectomy for early gastric cancer remains unclear. METHODOLOGY: Two-hundred and ten patients (137 males and 73 females, aged at initial gastrectomy 27-86, average age 56.5) were followed in the present study. Results of follow-up endoscopy of all patients, pathologic diagnoses of secondary tumors and interval between gastrectomy and detection of secondary tumor were reviewed. Cumulative incidence rate of second tumors in the upper gastrointestinal tract was then analyzed. RESULTS: Secondary tumor was observed by follow-up endoscopy in 7 patients including two gastric, one esophageal, one duodenal carcinoma and 3 gastric adenomas. The interval between initial gastrectomy and diagnosis of secondary tumor ranged from 20 to 71 months (average 51.7 months). All carcinomas were early stage and localized within the mucosa. Three patients with secondary cancer were successfully treated by endoscopic mucosal resection. The cumulative incidence rate of secondary cancer in the gastric remnant, esophagus and duodenum at six years after initial gastrectomy was 1.0, 0.8 and 0.5%, respectively. The overall incidence rate of secondary tumors of the upper gastrointestinal tract at six years after distal gastrectomy was 4.1%. CONCLUSIONS: The present findings indicate that annual follow-up endoscopy of the upper gastrointestinal tract after gastrectomy for early gastric cancer can be introduced to detect carcinoma at an early stage, thus improving the survival rate of gastrectomy patients.     

Photodiagnostic techniques for the endoscopic detection of premalignant gastrointestinal lesions

Considerable attention is given to the clinical diagnosis of gastrointestinal (GI) malignancies as they remain the second leading cause of cancer‐associated deaths in developed countries. Detection and intervention at an early stage of preneoplastic development significantly improve patient survival. High‐risk assessment of asymptomatic patients is currently performed by strict endoscopic surveillance biopsy protocols aimed at early detection of dysplasia and malignancy. However, poor sensitivity associated with frequent surveillance programs incorporating conventional screening tools, such as white light endoscopy and multiple random biopsy, is a significant limitation. Recent advances in biomedical optics are illuminating new ways to detect premalignant lesions of the GI tract with endoscopy. The present review presents a summary report on the newest developments in modern GI endoscopy, which are based on novel optical endoscopic techniques: fluorescence endoscopic imaging and spectroscopy, Raman spectroscopy, light scattering spectroscopy, optical coherence tomography, chromoendoscopy, confocal fluorescence endoscopy and immunofluorescence endoscopy. Relying on the interaction of light with tissue, these ‘state‐of‐the‐art’ techniques potentially offer an improved strategy for diagnosis of early mucosal lesions by facilitating targeted excisional biopsies. Furthermore, the prospects of real‐time ‘optical biopsy’ and improved staging of lesions may significantly enhance the endoscopist's ability to detect subtle preneoplastic mucosal changes and lead to curative endoscopic ablation of these lesions. Such advancements within this specialty will be rewarded in the long term with improved patient survival and quality of life.     

Reassessment of barium radiographic examination in diagnosing gastrointestinal diseases

Gastrointestinalradiography(GIR)hasbeenamajorandfirst-ch0icemethodfordiagnosinggastrointestinaldiseaseswithbariumascontrastmediasinceitsemergenceinl9lO,evenindiagnosingthemasslesionsofthe0rgansoutsidegastrointestinaltract(e.g.,liver,pancreas,etc)indirectly.Thefiberendoscopyinventedinthelate1960scandirectlyobservethechangesonmucosalsurfaceintraluminallyandobtainbi0psiesaswell,thusgreatlyimprovingthedetectionandsensitivityofsmall,shall0w0rtinylesions0riginatedfrommucosa.Thisdisc0veryisabigchall…