色素内镜在电子结肠镜中应用价值研究

目的:结肠镜下应用色染料或色素可增强病变的定位和特征,有利于发现早期结肠肿瘤,且对于内镜下治疗有帮助,采用普通和放大内镜结合染色对于结病变的发现和性质诊断与病理结果进行对照,评价色素内镜的临床价值。方法:对2007年1月至7月在内镜中心拟作内镜下息肉切除的病例81例,117个息肉,分别采用普通结肠镜和放大镜下结合结合0·4%靛胭脂染色采用按工藤分类法进行分类,预测其病理类型,对于不能分类者再采用0·2%甲酚紫染色进行分类,然后行息肉电切后全部送病理活检,将病理结果与内镜下预测对比,分析色素内镜的临床价值。结果:普通电子镜采用靛兰胭脂红染色后所有息肉清晰显示其形态和边界,明显优于染色前。放大肠镜靛胭脂染色对64例87个息肉按工藤分类法进行分类,17例30个息肉靛兰胭脂红染色无法分类,采用0·2%的甲酚紫染色分类,其中Ⅰ型11个,Ⅱ型27个,Ⅲ型46个,Ⅳ型25个,Ⅴ型8例。与病理结果对比,息肉表面腺管开口为Ⅰ、Ⅱ型的的38例病变中全部为增生性息肉,Ⅲ型46个中ⅢL1型33个,管状腺瘤28个,管状绒毛腺瘤5个,ⅢL2型13个,管状腺瘤11个,管状绒毛腺瘤2个,本组未发现现Ⅲs型息肉。Ⅳ型25个中绒毛管状腺瘤15个,绒毛腺瘤8个,灶性癌变2个。Ⅴ型8例,Ⅴ1型3个,ⅤN型5均为腺癌。普通电子肠镜结合色素内镜发现息肉的能力优于普通电子肠镜,对于表面腺管开口的识别靛胭脂染色对ⅢL型,Ⅳ型,Ⅴ型腺管开口有较好的识别能力,明显优于普通电子肠镜,但是对于Ⅰ型、Ⅱ型的鉴别能力差。染色结合放大镜能较好地区分各型,腺管开口的类型对于肿瘤与非肿瘤的鉴别与病理类型有良好的一致性。结论:①普通肠镜结合色素内镜能提高发现结肠息肉敏感性,对于早其肿瘤的诊断与鉴别诊断有价值。②放大肠镜结合色素内镜能清晰显示病变表面结构和腺管开口,对于肿瘤与非肿瘤的鉴别诊断接近病理诊断,对于早期癌的发现有很高的价值,值得更进一步研究与推广应用。     

Value of chromoendoscopy and magnification endoscopy in the evaluation of duodenal abnormalities: a prospective,randomized comparison

BACKGROUND AND STUDY AIMS: Endoscopic staining methods are increasingly being used to evaluate lesions in the esophagus and colon. The aim of this prospective study was to investigate chromoendoscopy and magnification endoscopy for the evaluation of mucosal lesions in the duodenum. PATIENTS AND METHODS: Consecutive patients were randomly assigned to undergo conventional endoscopy without staining (group A) or intravital staining of the duodenal mucosa with indigo carmine and evaluation with a conventional video endoscope (group B) or a magnification endoscope (group C). Visible lesions were characterized before and after staining, and biopsies were taken for histological assessment. RESULTS: A total of 118 patients was examined. Chromoendoscopy detected significantly more lesions in the duodenal bulb (98 vs. 28; P = 0.0042) in more patients (29 vs. 15; P = 0.0025) compared with conventional endoscopy (group A). After mucosal staining, there was no difference between video endoscopy and magnification endoscopy with regard to the number or extent of the lesions identified. Significantly more targeted biopsies were possible after intravital staining. The most commonly identified lesions on targeted biopsies included (staining/control groups): gastric metaplasia (14/3), hyperplastic Brunner's glands (6/3), inflammatory changes (7/6), villous atrophy (1/3), adenoma (1/0). CONCLUSIONS: Intravital staining of the duodenum with indigo carmine may be useful for detecting mucosal abnormalities, delineating their extent, and allowing targeted biopsies. Magnification endoscopy, when used in addition to chromoendoscopy, does not appear to further increase the diagnostic yield for detecting duodenal abnormalities.     

Magnification endoscopy diagnosis of Barrett's esophagus with methylene blue and acetic acid

Intestinal metaplasia of Barrett's esophagus is pre-cancerous lesion and it is important to diagnose intestinal metaplasia by endoscopic examination. Predefined 4 quadrant sampling technique is popular in western countries. However, chromoendoscopy or magnification endoscopy have been tried to diagnose intestinal metaplasia. We have carried out magnification endoscopy with methylene blue and magnification endoscopy with acetic acid. In magnification endoscopy with methylene blue, intestinal metaplasia showed blue-staining area with tubulaous or cavernous pattern. In magnification endoscopy with acetic acid, all of epithelium of Barrett's esophagus changed to whitening surface and it was easy to observe the structure of each epithelium. Intestinal metaplasia showed tubulaous or villous, although fundic type showed pits of small round and cardiac type showed oval pattern with central-slit pits.     

染色结肠镜对大肠隆起性黏膜病变的应用价值

目的：探讨普通结肠镜、染色结肠镜在大肠隆起性黏膜病变中临床应用价值。方法：对90例结肠镜检查发现的黏膜隆起性病变,分别行普通结肠镜、染色结肠镜诊断。所有病变均作病理学检查。比较普通结肠镜、染色结肠镜诊断结果与病理学诊断结果。结果：共发现192个隆起性黏膜病变,普通结肠镜诊断为炎性息肉、管状腺瘤、绒毛状腺瘤、大肠癌与病理诊断的符合率分别为68.8%、76.9%、66.7%和80.0%,总病理符合率为73.4%;染色结肠镜分别为86.7%、87.5%、85.7%和90.9%,总病理符合率为87.5%。结论：染色结肠镜能有效提高大肠隆起性黏膜瘤性与非瘤性病变的鉴别能力,具有较高的临床应用价值。     

Chromoendoscopic diagnosis of Barrett's esophagus

Some kinds of chromoendoscopy have been reported to survey the cases with Barrett's esophagus more effectively, since random biopsy as a gold standard is not an ideal method from the viewpoint of safety, labor or cost effectiveness. Methylene blue (MB) chromoendoscopy has been reported that a targeted biopsy is possible to limit because MB only stains non-dysplastic Barrett's mucosa but not dysplastic one. However, many of supplementary studies have not agreed this recommendation. Crystal violet (CV) chromoendoscopy clearly stains Barrett's mucosa and makes a detailed observation of pit pattern possible. The availability of this method is required a further mass survey although CV chromoendoscopy has been reported to be effective in Barrett's screening. Other chromoendoscopic methods using indigo carmine or fluorescence dye also have been reported to be effective for discovering a dysplastic lesion by some investigator, but the efficacy has not been sufficiently evidenced. Conclusively, chromoendoscopic diagnosis of Barrett's esophagus has not yet got a consensus in the availability for Barrett's surveillance at present in Barrett's Esophagus Chicago Workshop 2003 of AGA.     

染色结肠镜和染色放大结肠镜在结直肠隆起性黏膜病变中临床应用价值的研究

目的 探讨普通结肠镜、染色结肠镜、染色放大结肠镜在结直肠隆起性黏膜病变中临床应用价值。方法 对30例结肠镜检查发现黏膜隆起性病变的病人，先作普通结肠镜诊断，再作染色结肠镜诊断，最后用放大结肠镜作出诊断。所有病变作病理学检查。将普通结肠镜、染色结肠镜、染色放大结肠镜的诊断结果与病理学诊断结果进行比较分析。结果 共发现64个隆起性黏膜病变，普通结肠镜诊断为炎性息肉、管状腺瘤、绒毛状腺瘤、结直肠癌与病理诊断的符合率分别为68，8％、76．9％、66．7％和80％，总病理符合率为73．4％；染色结肠镜分别为86．7％、87．5％、85．7％和90．9％，总病理符合率为87-5％：染色放大结肠镜分别为93．3％、91．7％、92．9％和90．9％，总病理符合率为92.2％。结论 普通结肠镜不能有效鉴别结直肠隆起性黏膜瘤性与非瘤性的改变，需要依赖病理组织学判断性质。染色结肠镜与染色放大结肠镜均能有效提高对结直肠隆起性黏膜瘤性与非瘤性病变的鉴别能力，具有较高的临床应用价值。染色结肠镜应列为常规检查以提高早期结肠肿瘤的检出率。     

Chromoendoscopy of the colon

Chromoendoscopy is a technique that uses tissue stains to better characterize, delineate, or highlight the gastrointestinal mucosa.Chromoendoscopy of the colon has the potential to significantly aid the endoscopist in the recognition and identification of mucosal abnormalities ranging from inflammation to neoplasia.     

Histology of Barrett's esophagus and dysplasia

This article explores issues related to the diagnosis of Barrett's esophagus (BE) in endoscopic biopsies and dysplasia in Barrett's epithelium. The definitions of BE, including long- and short-segment BE, are reviewed, with an emphasis on the significance of intestinal metaplasia (IM). IM of the gastroesophageal junction and cardia is reviewed and problems in its distinction from short-segment BE are discussed. In addition, the article reviews the classification of dysplasia in Barrett's mucosa, with reference to problematic areas, such as sampling error and interobserver variability. Biomarkers and their role in the diagnosis of dysplasia and stratification of risk are summarized.     

Chromoendoscopy using indigo carmine dye spraying with magnifying observation is the most reliable method for differential diagnosis between non-neoplastic and neoplastic colorectal lesions: a prospective study

BACKGROUND AND AIMS: Differential diagnosis between non-neoplastic and neoplastic lesions is very important at colonoscopy, since removal or biopsy of non-neoplastic polyps wastes time and resources. We therefore conducted a prospective study to examine whether indigo carmine dye spraying with and without magnification is more reliable than the conventional method for differential diagnosis. PATIENTS AND METHODS: 122 patients with 206 lesions of 10 mm or smaller were recruited into this study. All lesions detected on colonoscopy were first diagnosed using the conventional view, then at chromoendoscopy using 0.2 % indigo carmine, and finally at chromoendoscopy with magnification. The diagnosis at each step were recorded consecutively. All lesions were finally categorized as neoplastic or non-neoplastic according to pit pattern; non-neoplastic lesions were biopsied for histological evaluation, and all the neoplastic ones were removed endoscopically. The accuracy rate of each type of endoscopic diagnosis was evaluated, using histological findings as reference. RESULTS: Histologically, 46 lesions (22 %) were non-neoplastic and 160 (78 %) were neoplastic. The overall diagnostic accuracies by conventional view, chromoendoscopy, and chromoendoscopy with magnification were 84.0 % (173/206), 89.3 % (184/206) and 95.6 % (197/206), respectively. CONCLUSION: Chromoendoscopy with magnification is the most reliable method for determining whether a colorectal lesion is non-neoplastic or neoplastic.     

NBI magnifying endoscopic classification using crystal violet staining

NBI magnifying imaging with crystal violet (CV-NBI magnifying imaging) makes recognition of micro-vascular pattern and grandular structure in the gastric mucosa better. NBI image emphasizes micro-vascular structure in mucosal surface. Magnification endoscopy with crystal violet staining delineates surface grandular structure better than without it. Crystal violet stained epithelium is clearly observed as cobalt green with NBI imaging. In the classification of CV-NBI magnification findings, 71% of differentiated type lesion was classified into ILL (intralobular loop pattern), and the rest (29%) was diagnosed as FNP (fine network pattern) which was originally advocated by Nakayoshi, et al. ILL is the new category of magnifying endoscopy. ILL corresponded mainly to differentiated-type adenocarcinoma, but it also includes undifferentiated-type adenocarcinoma. Corkscrew pattern is corresponding well to undifferentiated-type adnocarcinoma (Nakayoshi, et al). CV-NBI magnifying classification is considered to be related to tissue characterization in gastric cancer.     

Chromoendoscopy with indigocarmine improves the detection of adenomatous and nonadenomatous lesions in the colon.

BACKGROUND AND STUDY AIMS: Depressed early cancers and flat adenomas have a high potential for malignancy with possible infiltrating growth, despite the small size of the lesion. Japanese investigators have shown that early diagnosis and classification of these lesions is possible with the help of chromoendoscopy. The aim of this study, therefore, was to evaluate the usefulness of chromoendoscopy during routine colonoscopy. PATIENTS AND METHODS: During routine colonoscopy, vital staining with indigocarmine solution (0.4 %, 1 - 10 ml) was performed on all visible lesions in 100 consecutive patients without visible inflammatory changes. If findings on macroscopic examination were unremarkable, the sigmoid colon and rectum were stained with indigocarmine over a defined segment (0 - 30 cm ab ano) and inspected for lesions visible only after staining. Each lesion was classified with regard to type (polypoid, flat, or depressed), position and size. The staining pattern was classified according to the pit pattern classification. RESULTS: A total of 52 patients had 105 visible lesions (89 polypoid, 14 flat and two depressed). The mean size of the lesions was 1.4 cm. Among the 48 patients with mucosa of normal appearance, 27 showed 178 lesions after staining (176 flat, two depressed) with a mean size of 3 mm. On histological investigation, 210 lesions showed hyperplastic or inflammatory changes, 67 were adenomas and six were cancers. Use of the pit pattern system to classify lesions (adenomatous, pit patterns III-V; nonadenomatous, pit patterns I-II) was possible, with a sensitivity of 92 % and a specificity of 93 %. Lesions with pit patterns III - V showed higher rates of dysplasia. CONCLUSIONS: Chromoendoscopy allows easy detection of mucosal lesions in the colon and facilitates visualization of the margins of flat lesions. This technique unmasks multiple mucosal lesions which are not identified by routine video colonoscopy. The pit pattern seen after staining allows differentiation between hyperplastic and adenomatous lesions which may have consequences with regard to the endoscopic interventions needed.     

Novel endoscopic therapies for gastrointestinal malignancies: endoscopic mucosal resection and endoscopic ablation

Gastrointestinal malignancies are often detected at advanced stages when the prognosis is poor. Screening guidelines that vary accord-ing to the regional disease prevalence are needed. High-resolution endoscopy, magnification endoscopy, chromoendoscopy, light autofluorescence endoscopy, and optical coherence tomography are new technologies designed to improve endoscopic detection.Once detected, lesions must be accurately staged, including depth of mucosal penetration and lymph node involvement, to determine endoscopic resectability. Widely applicable, relatively safe, and minimally invasive alternatives to surgery are needed. Endoscopic mucosal resection and endoscopic ablation are potentially curative for malignancies limited to the mucosa, obviating the need for surgery in these patients.     

High-resolution chromoendoscopy in the esophagus

The major role for chromoendoscopy in the esophagus is the identification of premalignant or early cancerous lesions. In combination with high-resolution or magnification endoscopes, chromoendoscopy can potentially increase the diagnostic yield of clinically relevant lesions. Preliminary data have indicated a good correlation of findings using this technique to histopathologic readings.The ultimate goal of chromoendoscopy in combination with high resolution/magnification endoscopy is the determination of histology without obtaining tissue samples. In this article we review the different stains, the technical aspects, and current data in esophageal chromoendoscopy. We summarize possible clinical applications of these techniques and future directions of their use in esophageal diseases.     

Methylene blue chromoendoscopy for the detection of Barrett's esophagus in a Greek cohort

BACKGROUND AND STUDY AIMS: Specialized columnar epithelium of Barrett's esophagus is a precursor of dysplasia and adenocarcinoma, and methylene blue selectively stains this type of epithelium. The present prospective study examined the detection of short-segment and long-segment Barrett's esophagus using methylene blue chromoendoscopy-directed biopsies, in comparison with biopsies directed using conventional endoscopic criteria. PATIENTS AND METHODS: Biopsies were obtained from macroscopically conspicous areas in the distal esophagus observed during conventional endoscopy in a total of 975 patients. Immediately after conventional biopsies, the distal esophagus was sprayed with methylene blue and directed biopsies were then obtained from the stained regions. All patients with a histologically established Barrett's esophagus underwent a second upper gastrointestinal endoscopy within 1 year in order to assess the reproducibility of the method. RESULTS: In a total of 3,900 conventional biopsy specimens (without staining), 54 specimens (1.4%) were found to show Barrett's esophagus and were confined to 16 of the 975 patients (1.6%). Of the total 130 directed biopsy specimens obtained during chromoendoscopy, 114 (87.7%) revealed Barrett's esophagus (P<0.00001) and were confined to 35 of the 975 patients (3.5%; P < or = 0.001). The findings were confirmed within 1 year in all dye-positive patients. CONCLUSIONS: Chromoendoscopy with methylene blue appears to be an accurate, simple, safe, inexpensive, and reproducible method of detecting specialized columnar epithelium in Barrett's esophagus.     

Endoscopic evaluation and advanced imaging of Barrett's esophagus

Enhanced visualization techniques are available for Barrett's esophagus and have promise in the detection of dysplasia and cancer. Several of these techniques, such as narrow band imaging and chromoendoscopy, are being applied clinically. These techniques will allow the endoscopist to screen the surface of the Barrett's esophagus to detect areas of neoplasia. Once detected, it is hoped that either magnification techniques, such as confocal laser endomicroscopy, or spectroscopic techniques can be of value in allowing in vivo real-time diagnostic capabilities.     

Association of the degree of bronchial epithelial dysplasia to the serum level of non-enzymatic antioxidants

The serum levels of non-enzymatic antioxidants were studied in patients with chronic nonspecific lung diseases with first-to-third-degree dysplasia of the bronchial epithelium (BE) before and after therapeutic correction. The development of BE dysplastic changes was ascertained to cause a considerable reduction in the content of antioxidant vitamin A. During the therapy contributing to reversal of BE dysplastic alterations, there was an increase in the serum levels of vitamin A and uric acid in patients with simple chronic bronchitis with both first- and second-degree dysplasia. If no therapeutic effect occurred, the systemic level of the antioxidants remained unchanged.     

Cytology in Barrett's esophagus

Brush cytology is complementary to endoscopic biopsy and is recommended by some to be part of the routine endoscopic surveillance of patients with BE. Advantages of cytology include the ability to sample a greater area of involved epithelium, preferential exfoliation of the less cohesive dysplastic cells, simplicity, and lower cost. There are clear cytologic criteria for dysplasia, and biomarker studies can be performed on cytologic specimens. Despite these advantages, cytology is used by only 17% of gastroenterologists in the United States today. Limited data are available on the usefulness of cytology in the diagnosis and surveillance of BE. Cytology has good sensitivity for the detection of adenocarcinoma and HGD and good specificity for the detection of IM without dysplasia. Furthermore, cytology may detect abnormalities missed by biopsy. Cytology has problems in the detection of LGD, however. For cytology to become a useful surveillance option, its sensitivity for low-grade lesions must be improved. One potential way to accomplish this is to add biomarkers to routine cytologic specimens to define patients at increased risk of progression to cancer. If simple prognostic biomarkers could be developed and validated in histology and cytologic specimens, this would provide additional support for the utility of cytologic brushings in the surveillance of BE. Cytology could then conceivably accomplish the goals of improved efficiency, risk stratification, and decreased costs in BE surveillance programs.     

Image analysis for classification of dysplasia in Barrett's esophagus using endoscopic optical coherence tomography

Barrett's esophagus (BE) and associated adenocarcinoma have emerged as a major health care problem. Endoscopic optical coherence tomography is a microscopic sub-surface imaging technology that has been shown to differentiate tissue layers of the gastrointestinal wall and identify dysplasia in the mucosa, and is proposed as a surveillance tool to aid in management of BE. In this work a computer-aided diagnosis (CAD) system has been demonstrated for classification of dysplasia in Barrett's esophagus using EOCT. The system is composed of four modules: region of interest segmentation, dysplasia-related image feature extraction, feature selection, and site classification and validation. Multiple feature extraction and classification methods were evaluated and the process of developing the CAD system is described in detail. Use of multiple EOCT images to classify a single site was also investigated. A total of 96 EOCT image-biopsy pairs (63 non-dysplastic, 26 low-grade and 7 high-grade dysplastic biopsy sites) from a previously described clinical study were analyzed using the CAD system, yielding an accuracy of 84% for classification of non-dysplastic vs. dysplastic BE tissue. The results motivate continued development of CAD to potentially enable EOCT surveillance of large surface areas of Barrett's mucosa to identify dysplasia.     

Endoscopic and histologic diagnosis of Barrett esophagus

Endoscopy plays an important role in the identification, diagnosis, and treatment of Barrett esophagus. Short-segment (<2-3 cm) and traditional long-segment (>2-3 cm) Barrett esophagus are distinguished solely on the length of metaplastic tissue above the esophagogastric junction. The histologic hallmark of intestinal metaplasia is required to confirm diagnosis. Biopsy specimens obtained from tissue of presumed Barrett esophagus or an irregular Z line confirm metaplastic glandular mucosa and permit evaluation of dysplastic or neoplastic changes. In the appropriate clinical setting, the use of adjunctive diagnostic techniques may facilitate the diagnosis of Barrett esophagus and sequelae such as dysplasia. Chromoendoscopy with high-resolution or magnified endoscopy is simple, safe, and desirable for surveillance but requires additional procedural time. The use of light-induced fluorescence endoscopy and light-scattering spectroscopy (i.e., optical biopsy) is appealing for the diagnosis and characterization of suspicious lesions. Adjunctive endoscopic techniques and adherence to a protocol for performing biopsies facilitate the early detection and subsequent surveillance of Barrett esophagus.     

黏膜微细形态类型的可视化判断对早期贲门癌及癌前病变的诊断价值

目的探讨增强放大内镜下早期贲门癌和癌前病变黏膜微细形态分型及其诊断价值。方法应用放大内镜结合乙酸染色观察食管癌高发区的136例贲门黏膜微细形态,并将其分为5种黏膜类型,即A型(圆点状)、B型(短管状或细线状)、C型(绒毛状)、D型(沟槽或脑回状)和E型(不规则状伴异常血管形成)。统计分析各黏膜类型与组织病理学诊断之间的内在联系。结果本组共获得贲门病灶483个,其中炎症293个、肠上皮化生80个、低级别上皮内瘤变66个、高级别上皮内瘤变23个、早期贲门癌(包括黏膜内癌及黏膜下癌)21个。放大内镜观察,A型为胃底腺黏膜小凹类型,所占比率为100%(150/150);B型为贲门腺黏膜小凹类型,比率为87.7%(143/163)。A型和B型主要见于炎症组,C型发生肠上皮化生的比率为74.2%(49/66)与B型和D型比较差异有统计学意义(P<0.01)。D型发生低级别上皮内瘤变的比率为55.9%(38/68),与B型和C型比较差异有统计学意义(P<0.01)。E型发生高级别上皮内瘤变的比率为占41.7%(15/36),与C型和D型比较差异有统计学意义(P<0.01)。21例早期贲门癌的黏膜类型均为E型。5种黏膜类型与贲门病变的病情程度呈正相关(Rs=0.850,P<0.01)。结论贲门黏膜类型与病变的组织病理学诊断关系密切,其中C型可能为肠上皮化生、D型为低级别上皮内瘤变、E型为早期癌的特征性表现。通过增强放大内镜判定黏膜类型,能提高活检的准确率,有助于高发区早期贲门癌及癌前病变的检出。