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Accuracies of Endoscopic Diagnosis of Helicobacter pylori-Gastritis: Multicenter Prospective Study Using White Light Imaging and Linked Color Imaging.

Ono S1, Dohi O2, Yagi N3, Sanomura Y4, Tanaka S5, Naito Y2, Sakamoto N6, Kato M7

Digestion. 2019 Jul 23:1-7. doi: 10.1159/000501634. [Epub ahead of print]

Introduction: The diagnosis of Helicobacter pylori infection status with white light imaging (WLI) is difficult. We evaluated the accuracies of using WLI and linked color imaging (LCI) for diagnosing H. pylori-active gastritis in a multicenter prospective study setting.

Methods: Patients who underwent esophagogastroduodenoscopy were prospectively included. The image collection process was randomized and anonymous, and the image set included 4 images with WLI or 4 images with LCI in the corpus that 5 reviewers separately evaluated. Active gastritis was defined as positive when there was diffuse redness in WLI and crimson coloring in LCI. The H. pylori infection status was determined by the urea breath test and the serum antibody test. Cases in which both test results were negative but atrophy or intestinal metaplasia was histologically confirmed were defined as past infections. The primary endpoint was the diagnostic accuracies of WLI and LCI, and the secondary endpoint was inter-observer agreement.

Results: Data for 127 patients were analyzed. The endoscopic diagnostic accuracy for active gastritis was 79.5 (sensitivity of 84.4 and specificity of 74.6) with WLI and 86.6 (sensitivity of 84.4 and specificity of 88.9) with LCI (p = 0.029). LCI significantly improved the accuracy in patients with past infections over WLI (36.8 in WLI and 78.9 in LCI, p < 0.01). The κ values were 0.59 in WLI and 0.70 in LCI.

Conclusions: LCI is useful for endoscopic diagnosis of H. pylori-active or inactive gastritis, and it is advantageous for patients with past infections of inactive gastritis.

1 Department of Gastroenterology, Hokkaido University Hospital, Sapporo, Japan
2 Department of Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Kyoto, Japan
3 Department of Gastroenterology, Asahi University Hospital, Gifu, Japan
4 Department of Endoscopy, Hiroshima Prefectural Hospital, Hiroshima, Japan
5 Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
6 Department of Gastroenterology and Hepatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
7 Department of Gastroenterology, National Hospital Organization Hakodate Hospital, Hakodate, Japan


Diagnostic utility of linked color imaging in the evaluation of colonic mucosal inflammation in ulcerative colitis: a pilot study.

Kanmura S1, Hamamoto H1, Tanaka A1, Arima S1, Sasaki F1, Tanoue S1, Nasu Y1, Hashimoto S1, Higashi M2, Ido A1.

Endosc Int Open. 2019 Aug;7(8):E937-E943. doi: 10.1055/a-0810-0398. Epub 2019 Jul 24.

Background and aims: Recent studies recommend histological mucosal healing of intestinal tissue as a treatment goal in ulcerative colitis (UC). Linked-color imaging (LCI) is a new endoscopy system that enhances the color differences of the gastrointestinal mucosa. We investigated the efficacy of LCI in the evaluation of intestinal activity, including the histological activity in UC.

Method: A total of 21 UC patients who were evaluated by the LASEREO system (FUJIFILM Co., Tokyo, Japan) were enrolled from August to December in 2016. All of the target points were observed by conventional white-light imaging (WLI) and LCI and biopsied from the region of interest in each view. We quantified the color tones of 73 biopsied points on WLI and LCI using the Lab* color value (WLI-L, WLI-a, WLI-b, and LCI-L, LCI-a, LCI-b). We then investigated the relationships among the Lab* color values, endoscopic findings, and histological healing.

Results: The average LCI-a and LCI-b values of patients with high mucosal activity disease were significantly higher than in those with mucosal healing ( P  < 0.01), and only LCI-a was significantly correlated with the score for histological healing. With regard to the other color values (LCI-L and all WLI values), there were no statistically significant differences in terms of average color value and correlation between patients with high mucosal activity and those with mucosal healing. In addition, the difference in the average color values with LCI and WLI was 7.1 and 3.1, respectively.

Conclusion: LCI is more useful than WLI for the visualization and evaluation of mucosal inflammation in UC.

1 Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
2 Department of Pathology, Field of Oncology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan


Blue Light Imaging and Linked Color Imaging for the Characterization of Mucosal Changes in Chronic Gastritis: A Clinicians View and Brief Technical Report.

Weigt J1, Malfertheiner P1, Canbay A1, Haybaeck J2, Bird-Lieberman E3, Link A2.

Dig Dis. 2019 Jul 23:1-6. doi: 10.1159/000501265. [Epub ahead of print]

Background: Blue light imaging (BLI) and linked color imaging (LCI) are new imaging modalities for the endoscopic evaluation of mucosal changes within the digestive tract. There is little experience with these modalities in the characterization of chronic gastritis (CG) intestinal metaplasia (IM) and atrophy in the stomach.

Aims and methods: In a single-center observational pilot study, we correlated endoscopic findings with histology in selected patients.

Results: Findings from 29 patients were included in the analysis. Six patients had macroscopically normal gastric mucosa at endoscopy, and this was confirmed histologically in 5 of them. At endoscopy, 15 patients had the presence of IM in the antrum predicted, and this was confirmed histologically in 11 (73%). In the corpus, we predicted the presence of IM in 14 patients, and this was confirmed in 11 (78%) at histology. Eleven patients had the endoscopic suspicion of atrophy in antrum, which was confirmed in 9 patients (82%). In total, 14 patients had endoscopic suspicion of atrophy in corpus mucosa at endoscopy, but only 10 were confirmed in histology (71%). The concordance of endoscopic classification and histology was 93% for antrum and 88% for corpus. The positive predictive value and negative predictive value for IM were 0.74 and 0.83 and for atrophy 0.63 and 0.97, respectively.

Conclusions: LCI and BLI are helpful in characterization of mucosal changes in CG. The ability to rule out premalignant conditions by endoscopy only reflects the clinical use and harbors significant clinical implications.

1 Department of Gastroenterology, Hepatology and Infectious Diseases, Magdeburg, Germany
2 Department of Pathology, Otto von Guericke University Magdeburg, Magdeburg, Germany
3 Translational Gastroenterology Unit and NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK


Linked Color Imaging and the Kyoto Classification of Gastritis: Evaluation of Visibility and Inter-Rater Reliability.

Takeda T1, Asaoka D1, Nojiri S4, Nishiyama M1, Ikeda A1, Yatagai N1, Ishizuka K1, Hiromoto T1, Okubo S1, Suzuki M1, Nakajima A1, Nakatsu Y2, Komori H1, Akazawa Y1, Nakagawa Y1, Izumi K1, Matsumoto K1, Ueyama H1, Sasaki H1, Shimada Y3, Matsumoto K1, Osada T2, Hojo M1, Kato M5, Nagahara A1

Digestion. 2019 Jul 12:1-10. doi: 10.1159/000501534. [Epub ahead of print]

Background & aims: To compare white light imaging (WLI) with linked color imaging (LCI) and blue LASER imaging (BLI) in endoscopic findings of Helicobacter pylori presently infected, previously infected, and uninfected gastric mucosae for visibility and inter-rater reliability.

Methods: WLI, LCI and BLI bright mode (BLI-bright) were used to obtain 1,092 endoscopic images from 261 patients according to the Kyoto Classification of Gastritis. Images were evaluated retrospectively by 10 experts and 10 trainee endoscopists and included diffuse redness, spotty redness, map-like redness, patchy redness, red streaks, intestinal metaplasia, and an atrophic border (52 cases for each finding, respectively). Physicians assessed visibility as follows: 5 (improved), 4 (somewhat improved), 3 (equivalent), 2 (somewhat decreased), and 1 (decreased). Visibility was assessed from totaled scores. The inter-rater reliability (intraclass correlation coefficient) was also evaluated.

Results: Compared with WLI, all endoscopists reported improved visibility with LCI: 55.8% for diffuse redness; LCI: 38.5% for spotty redness; LCI: 57.7% for map-like redness; LCI: 40.4% for patchy redness; LCI: 53.8% for red streaks; LCI: 42.3% and BLI-bright: 80.8% for intestinal metaplasia; LCI: 46.2% for an atrophic border. For all endoscopists, the inter-rater reliabilities of LCI compared to WLI were 0.73-0.87.

Conclusion: The visibility of each endoscopic finding was improved by LCI while that of intestinal metaplasia was improved by BLI-bright.

1 Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
2 Department of Gastroenterology, Juntendo University Urayasu Hospital, Chiba, Japan
3 Department of Gastroenterology, Juntendo Sizuoka Hospital, Shizuoka, Japan
4 Department of Medical Technology Innovation Center Juntendo University School of Medicine, Tokyo, Japan
5 Department of Gastroenterology, National Hospital Organization Hakodate National Hospital, Hakodate, Japan


Impact of linked-color imaging on colorectal adenoma detection.

Dos Santos CEO1, Malaman D1, Pereira-Lima JC2, de Quadros Onófrio F2, Ribas Filho JM3.

Gastrointest Endosc. 2019 Jul 11. pii: S0016-5107(19)32052-8. doi: 10.1016/j.gie.2019.06.045. [Epub ahead of print]

Background and aims: Linked-color imaging (LCI) is a new technology that emphasizes changes in mucosal color by providing clearer and brighter images, thus allowing red and white areas to be more clearly visualized. We investigated whether LCI increases the detection of colorectal adenomas when compared with white-light imaging (WLI) and blue-laser imaging (BLI)-bright.

Methods: Consecutive patients undergoing colonoscopy were randomized (1:1:1) into examination by WLI, BLI-bright, or LCI during withdrawal of the colonoscope. The adenoma detection rate (ADR), mean number of adenomas per patient, and withdrawal time were evaluated. The lesions were evaluated according to size, morphology, location, and histology.

Results: A total of 379 patients were randomized, and 412 adenomas were detected. ADR was 43.2%, 54.0%, and 56.9% for WLI, BLI-bright, and LCI, respectively, being significantly higher in the LCI group than in the WLI group (P=0.03). No significant difference was observed between LCI and BLI-bright (P=0.71) or BLI-bright and WLI (P=0.09). The mean number of adenomas per patient was 0.82, 1.06, and 1.38 for WLI, BLI-bright, and LCI, respectively, with a significant difference between LCI and WLI (P=0.03). Withdrawal time did not differ between groups. A total of 102 adenomas were detected by WLI, 131 by BLI-bright, and 179 by LCI. LCI provided a higher rate of detection of adenomas ≤ 5 mm in size than WLI (P=0.02), with a borderline significance for a higher detection of sessile serrated adenomas (P=0.05). Nonpolypoid adenomas were more commonly located in the right colon segment and polypoid adenomas in the left colon segment, with a significant difference only between BLI-bright (P<0.01) and LCI (P=0.03).

Conclusions: Our findings show that LCI increases the detection of colorectal adenomas during colonoscopy.

1 Department of Endoscopy and Gastroenterology, Santa Casa de Caridade Hospital, Bagé, RS, Brazil.
2 Department of Gastroenterology and Endoscopy, Santa Casa Hospital, Porto Alegre, RS, Brazil.
3 Postgraduate Program in Principles of Surgery, Faculdade Evangélica do Paraná, Curitiba, PR, Brazil.


Linked color imaging identifies important risk factors associated with gastric cancer after successful Helicobacter pylori eradication.

Majima A1,2, Dohi O1, Takayama S1, Hirose R1, Inoue K1, Yoshida N1, Kamada K1, Uchiyama K1, Ishikawa T1, Takagi T1, Handa O1, Konishi H1, Naito Y1, Itoh Y1.

Gastrointest Endosc. 2019 Jul 9. pii: S0016-5107(19)32047-4. doi: 10.1016/j.gie.2019.06.043. [Epub ahead of print]

Background & aims: Limited studies have evaluated the risk factors of gastric cancer (GC) after Helicobacter pylori eradication using endoscopic findings. We aimed to investigate GC detection-related endoscopic findings after H pylori eradication using linked color imaging (LCI), a novel image-enhanced endoscopy.

Methods: This single-center, cross-sectional study evaluated background mucosa-associated endoscopic findings described in the Kyoto classification of gastritis in patients with newly detected GC after H pylori eradication (CA group, n=109) and those without GC (NC group, n=85) using white-light imaging (WLI) and LCI.

Results: Severe atrophy and map-like redness were significantly more frequent in the CA group than in the NC group using WLI (79.8% vs 63.5%; P=0.01 and 61.5% vs 37.7%; P=0.001, respectively) and LCI (79.8% vs 63.5%; P=0.01 and 78.0% vs 45.9%; P<0.0001, respectively). Regular arrangement of collecting venules (RAC) was significantly less frequent in CA than in NC using WLI (40.3% vs 64.7%; P=0.0009) and LCI (37.6% vs 62.4%; P=0.0006). Map-like redness was an independent positive risk finding (WLI: odds ratio, 2.05; 95% CI, 1.09-3.87; P = .03; LCI: odds ratio, 3.62; 95% CI, 1.88-6.97; P<0.001), whereas RAC was an independent negative risk finding (WLI, 0.42, 0.21-0.82; P = .01; LCI, 0.46, 0.23-0.93; P=0.03) of GC detection after H pylori eradication.

Conclusions: Map-like redness, which was identified more frequently using LCI than WLI, and the absence of RAC were associated with GC detection after H pylori eradication.

1 Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
2 Department of Gastroenterology and Hepatology, Omihachiman Community Medical Center, Omihachiman, Japan


Linked color imaging confers benefits in profiling H. pylori infection in the stomach.

Sun X1,2, Bi Y1, Nong B3, Hu D4, Sun X5, Chen H6, Xu Y1, Liu Y1.

Endosc Int Open. 2019 Jul;7(7):E885-E892. doi: 10.1055/a-0895-5377. Epub 2019 Jul 3.

Background & aims: There is a high prevalence of Helicobacter pylori infection. White light endoscopy (WLE) can be used for evaluating the mucosal lesions, but it does not have high diagnostic efficiency. Linked color imaging (LCI) is a newly developed endoscopic imaging technique. The aim of this study was to compare LCI with WLE in detecting and staging H. pylori infection in the stomach in arandomized controlled clinical trial.

Patients and methods: A total of 253 patients who had indications for gastroduodenoscopy were enrolled and randomized into Group A (n = 127), who underwent WLE followed by LCI, and Group B (n = 126), who underwent LCI followed by WLE. Clinical data were collected and the diagnostic accuracy of WLE and LCI was calculated and compared.

Results: The overall diagnostic accuracy of WLE and LCI for H. pylori infection was 31.5 % (n = 40) and 50.4 % (n = 64) in Group A (P = 0.001), and 36.5% (n = 46) and 49.2% (n = 62) in Group B (P = 0.029). In both groups, LCI had higher sensitivity, specificity, and Youden index scores than WLE. Four stages were defined in the course of H. pylori infection in the stomach. LCI staging results were more highly consistent with pathological staging than were WLE staging results (kappa value 0.772 vs. 0.516). The LCI observations were closely correlated with the pathology.

Conclusions: LCI had a higher diagnostic efficacy for H. pylori infection in the stomach. Endoscopic color features under LCI can help to stage and profile H. pylori-associated gastritis.

1 Department of Gastroenterology, the Fifth Clinical Center of Chinese PLA General Hospital (307 Hospital), Beijing, China
2 Department of Internal Medicine, Clinic of August First Film Studio, Beijing, China
3 Department of Gastroenterology and Hepatology, the People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
4 Department of Gastroenterology, the Second Affiliated Hospital of Soochow University, Suzhou, China
5 Department of Gastroenterology and Hepatology, Shanghai Tenth People’s Hospital, Shanghai, China
6 Department of Gastroenterology, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.


Color information from linked color imaging is associated with invasion depth and vascular diameter in superficial esophageal squamous cell carcinoma.

Kobayashi K1, Miyahara R2, Funasaka K2, Furukawa K2, Sawada T1, Maeda K1, Yamamura T1, Ishikawa T2, Ohno E2, Nakamura M2, Kawashima H2, Nakaguro M3, Okumura Y3, Hirooka Y1, Fujishiro M2.

Dig Endosc. 2019 Jun 20. doi: 10.1111/den.13469.

Objectives: Accurate diagnosis of invasion depth is important for reliable treatment of esophageal squamous cell carcinoma, but it is limited to the muscularis mucosae to slight submucosal invasion (MM/SM1). The diagnostic accuracy of invasion depth is unsatisfactory and remains to be improved. We aimed to investigate the association between the color of the superficial esophageal squamous cell carcinoma and invasion depth using linked color imaging (LCI) under light-emitting diode (LED) light sources.

Methods: Lesions diagnosed as superficial esophageal squamous cell carcinoma were observed using white light imaging and then by LCI. The color values were calculated using Commission international de l’eclariage – Lab* color space, and the color difference was calculated according to invasion depth. The vascular diameters and vascular angles of the intrapapillary capillary loops were pathologically analyzed. Their correlation with mucosal color was also investigated by LCI.

Results: In all, 52 lesions from 48 patients were analyzed. On the basis of invasion depth, the color difference between the normal mucosa and the lesion was larger in the MM/SM1 or deeper group than in the epithelium and the lamina propria mucosa (EP/LPM) group using LCI (P = 0.025). The vascular diameter was positively correlated with the b* color value (correlation coefficient = 0.302, P = 0.033).

Conclusion: Observation using LCI under LED light sources may improve the endoscopic diagnosis of the invasion depth of superficial esophageal squamous cell carcinoma. Further research is needed to validate its usefulness. This article is protected by copyright. All rights reserved.

1 Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
2 Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
3 Department of Pathology and Laboratory Medicine, Nagoya University Hospital, Nagoya, Japan


Diagnostic value of blue laser imaging combined with magnifying endoscopy for precancerous and early gastric cancer lesions.

Yang Zhenming 1, Shen Lei 1

Turk J Gastroenterol. 2019 Jun;30(6):549-556. doi: 10.5152/tjg.2019.18210.

Background / Aims: Blue laser imaging (BLI) is a new technique for detailed examination of upper gastrointestinal lesions. This study aimed to evaluate the diagnostic value of BLI combined with magnifying endoscopy for precancerous and early gastric cancer lesions.

Materials and methods: A total of 249 gastric lesions detected via conventional white light endoscopy (WLE) based on assessments of mucosal shape and color were included in this study. The accuracy of diagnosis of precancerous or early cancer lesions white light magnification alone, BLI-contrast magnification, and BLI-bright magnification was determined according to the VS criteria.

Results: For white light magnification alone, BLI-contrast magnification, and BLI-bright magnification, the concordance rates for lesions were 76.7%, 85.1%, and 86.7%, respectively, and the Kappa values were 0.571, 0.730, and 0.760, respectively. For the screening of high-grade intraepithelial neoplasia or early gastric cancer, the diagnostic sensitivities of white light magnification alone, BLI-contrast magnification, and BLI-bright magnification were 72.0%, 92.0%, and 92.0%, respectively; the specificities were 95.5%, 98.2%, and 99.1%, respectively; the consistencies were 93.2%, 97.6%, and 98.4%, respectively; and the Kappa values were 0.642, 0.871, and 0.911, respectively. For diagnoses of high-grade intraepithelial neoplasia or early gastric cancer, the concordance between endoscopic and pathological diagnosis was significantly higher for BLI-contrast and BLI-bright magnification than for white light magnification alone (p<0.05).

Conclusion: BLI combined with magnifying endoscopy may improve diagnostic accuracy for early gastric cancer and precancerous lesions.

1 Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China


Efficacy of linked colour imaging in magnifying chromoendoscopy with crystal violet staining: a pilot study.

Taku Sakamoto1, Kazuya Inoki1, Hiroyuki Takamaru1, Masau Sekiguchi1, Masayoshi Yamada1, Takeshi Nakajima1, Takahisa Matsuda1, Yutaka Saito1

International Journal of Colorectal Disease 2019 Jun 5. doi: 10.1007/s00384-019-03323-0. [Epub ahead of print]

Purpose: Diagnosis of the depth of invasion is crucial in the endoscopic management of early colorectal cancer. Image-enhanced endoscopy (IEE) is a method for easily evaluating the depth of invasion. Linked colour imaging (LCI) is an IEE method that enables clearer identification of neoplastic lesions and mucosal inflammation. The aim of this experimental study was to explore the efficacy of LCI in vessel and pit pattern recognition when used in magnifying chromoendoscopy with crystal violet staining for superficial colorectal neoplasms.

Methods: This was an experimental study. Colour difference (CD) values between the surrounding mucosa and vessels and pits were measured on white light (WLI), blue laser (BLI), and LCI images. The CD values of 10 neoplastic lesions were calculated and compared between WLI and the other techniques.

Results: The CD value was 9.8 (interquartile range, 7.3-12.4) for WLI, 9.7 (6.7-13.4) for LCI, and 6.8 (5.1-9.3) for BLI. The CD value was statistically different between WLI and BLI but not between WLI and LCI. With regard to vessel description, the CD value was 7.5 (4.0-11.0) for WLI, 15.6 (11.6-23.9) for LCI, and 23.3 (15.8-30.4) for BLI.

Conclusions: LCI provides more diagnostic information than other light modes. Further, it is superior to the other techniques in terms of vessel visibility and is comparable to them in terms of pit recognition. These unique features of LCI may lead to its use as an alternative to WLI and BLI for pit and vessel pattern evaluation in the future.

1 Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan