Enhanced Magnification Endoscopy Research Articles

Magnified and enhanced computed virtual chromoendoscopy in gastric neoplasia: A feasibility study

To evaluate the feasibility of a new computed virtual chromoendoscopy (CVC) device (M i-scan) in the diagnosis of gastric neoplasia. Patients with superficial lesions no larger than 1.0 cm found during high definition endoscopy were included. Those with advanced or obviously protruded or depressed lesions, lesions larger than 1.0 cm and/or lesions which were not amenable to observation by zoom function were excluded. The endoscopist was required to give the real-time descriptions of surface pit patterns of the lesions, based on surface pattern classification of enhanced magnification endoscopy. According to previous reports, types I-III represent non-neoplastic lesions, and types IV-V represent neoplastic lesions. Diagnosis with M i-scan and biopsy was performed before histopathological diagnosis. Magnified images of gastric lesions with and without enhancement were collected for further analysis. The diagnostic yield of real-time M i-scan and effects on magnification image quality by tone enhancement (TE), surface enhancement (SE) and color enhancement (CE) were calculated. The selected images were sent to another endoscopist. The endoscopist rated the image quality of each lesion at 3 levels. Ratings of image quality were based on visualization of pit pattern, vessel and demarcation line. One hundred and eighty-three patients were recruited. Five patients were excluded for advanced gastric lesions, 1 patient was excluded for poor preparation and 2 patients were excluded for superficial lesions larger than 1.0 cm; 132 patients were excluded for no lesions found by high definition endoscopy. In the end, 43 patients with 43 lesions were included. Histopathology revealed 10 inflammation, 14 atrophy, 10 metaplasia, 1 low grade dysplasia (LGD), 5 high grade dysplasia (HGD) and 3 cancers. For 7 lesions classified into type I, histopathology revealed 6 atrophy and 1 metaplasia; for 10 lesions classified into type II, histopathology revealed 2 inflammation, 7 atrophy and 1 metaplasia; for 10 lesions classified into type III, histopathology revealed 1 inflammation, 8 metaplasia and 1 LGD; for 9 lesions classified into type IV, histopathology revealed 4 inflammation, 1 atrophy and 4 HGD; for 7 lesions classified into type V, histopathology revealed 3 inflammation, 1 HGD and 3 cancers. A total of 172 still images, including 43 images by white light (MWL) and 129 images by M i-scan (43 with TE, 43 with SE and 43 with CE), were selected and sent to the endoscopist who did the analysis. General image quality of M i-scan with TE and SE was significantly better than that of MWL (TE, 4.55 ± 1.07; SE, 4.30 ± 1.02; MWL, 3.25 ± 0.99; P < 0.001). Visualization of pit pattern was significantly improved by M i-scan with SE (1.93 ± 0.25 vs 1.50 ± 0.50, P < 0.001). Microvessel visualization was significantly improved by M i-scan with TE (1.23 ± 0.78 vs 0.76 ± 0.73, P < 0.001). Demarcation line visualization was improved by M i-scan with both TE and SE (TE, 1.75 ± 0.52; SE, 1.56 ± 0.59; MWL, 0.98 ± 0.44; P < 0.001). M i-scan with CE did not show any significant improvements of image quality in general or in the 3 key parameters. Although M i-scan with TE and SE slightly increased the diagnostic yield of MWL, there was no significant difference (P > 0.1). Although digital enhancement improves the image quality of magnification endoscopy, its value in improving the diagnostic yield seems to be limited.

Magnifying endoscopy for diagnosis of residual/local recurrent gastric neoplasms after previous endoscopic treatment

Incomplete resection of gastric neoplasms by endoscopic treatment could lead to residual/local recurrence, which may be difficult to identify. This study aimed to evaluate the usefulness of magnifying endoscopy for identifying and demarcating residual/local recurrent gastric neoplasms after endoscopic treatment. Between December 2004 and November 2010, magnifying endoscopy was performed in 15 patients with residual/local recurrent gastric neoplasms. All patients underwent conventional magnifying endoscopy (CME) and enhanced-magnification endoscopy with acetic acid instillation (EME) after conventional endoscopy (CE). Eleven patients additionally underwent magnifying endoscopy using narrow-band imaging (NBI-ME) and a combination of narrow-band imaging and acetic acid instillation (NBI-EME). For each procedure, it was recorded whether the location and circumferential demarcation of the lesions were identified. All lesions were resected by endoscopic submucosal dissection. Eleven lesions were identified using CE. However, two and four additional lesions were identified using CME and EME, respectively. In 11 cases, NBI-ME and NBI-EME were performed and all lesions were identified. Three lesions, which were identified by CME, were not demarcated circumferentially. All 15 lesions were well demarcated by EME and 11 by NBI-ME and NBI-EME. Of the resected specimens, histopathology indicated that ten lesions were differentiated tubular adenocarcinomas and five lesions were adenomas. The histopathological diagnosis of the location and demarcation of all neoplasms corresponded to endoscopic findings. Magnifying endoscopy techniques (CME, EME, NBI-ME, and NBI-EME) may be useful for identifying and demarcating residual/local recurrent gastric neoplasms after previous endoscopic treatment.

The role of endoscopy in the management of patients with diarrhea

The role of endoscopy in the management of patients with diarrhea

Ease of early gastric cancer demarcation recognition: A comparison of four magnifying endoscopy methods

Various techniques using magnifying endoscopy (ME) have been developed to enhance images of early gastric cancer (EGC) demarcations, which are often obscure. We investigated four ME methods to determine which is most effective in enhancing the recognition of EGC demarcations: conventional ME (CME), ME with narrow band imaging (NBI-ME), enhanced-magnification endoscopy with acetic acid (EME), and ME with NBI and acetic acid (NBI-EME). Thirty-seven successive patients having a total of 40 EGCs participated in the investigation. The endoscope was fixed and magnification images of EGC demarcations in each patient were recorded using four different ME methods (CME, NBI-ME, EME and NBI-EME). Eight experts and eight non-experts scored each of the four images of each lesion for ease of recognition of demarcation (1 to 4, with 4 being easiest). The mean scores of expert and non-expert judges, respectively, for images acquired using each technique were: CME 1.23, 1.24; NBI-ME 2.61, 2.95; EME 2.62, 2.32 and NBI-EME 3.54, 3.50. There were significant differences between the mean scores for the four techniques (P < 0.0001) using one-way repeated-measures anova. In a Bonferroni's multiple comparison, the average scores (expert and non-expert) of images acquired using NBI-EME were significantly higher than those acquired using other methods; images acquired by NBI-ME or EME also scored significantly higher than those by CME. Non-experts also scored NBI-ME images significantly higher than CME and EME images. Early gastric cancer demarcations were recognized most easily using NBI-EME, and more easily using EME or NBI-ME than CME.

Esophageal sebaceous glands diagnosed after endoscopic mucosal resection

A 57-year-old man without any symptoms or signs of illness underwent upper-GI endoscopy for a routine health evaluation. Esophagoscopy revealed a small hiatal hernia and multiple 0.5-mm to 5-mm diameter yellow-whitish granular nodules scattered throughout the middle and lower esophagus, resembling xanthomata (A). These lesions stained slightly with Lugol iodine solution, and enhanced-magnification endoscopy with narrow-band image system revealed that they were encircled by slightly stretched microvessels (B). When autofluorescence image system was used, the intervening esophageal mucosa was green, whereas the granular lesions were pink or violet (C). To obtain sufficient tissue for a histopathologic diagnosis, we performed EMR with a ligating device (EMRL). We successfully resected the lesion without any complications. His clinical course after EMRL was uneventful and he was discharged. Histology revealed the lesions to be esophageal ectopic sebaceous glands without hair follicle (D, H&E, orig. mag. 20). The glands consisted of units of large polyhedral cells with clear vacuolated cytoplasm, accompanied by an excretory duct.

Surface pattern classification by enhanced-magnification endoscopy for identifying early gastric cancers

The correlation between fine surface patterns of gastric mucosal lesions and early gastric cancer is not sufficiently clear. To evaluate the efficacy of surface pattern classification by enhanced-magnification endoscopy (EME) for identifying early gastric cancers. Observational study. All procedures were performed at Mie University Hospital. A total of 380 consecutive patients who underwent EGD by using magnification endoscopy. Among these subjects were found 250 newly detected lesions suspected of being gastric cancer. Conventional magnification endoscopy (CME), magnification chromoendoscopy (MCE), and EME were performed, and surface patterns of lesions were classified into 5 types: type I, small round pits of uniform size and shape; type II, slit-like pits; type III, gyrus and villous patterns; type IV, irregular arrangement and size; and type V, destructive pattern. Biopsy specimens were obtained from all lesions. Correlation between surface pattern classification by EME and histopathologic findings of early gastric cancer. Surface patterns were evident by CME/MCE in only 66.4% (166/250) of lesions but in 100% (250/250) of lesions by EME. Classification by EME was as follows: type I, 52 lesions; type II, 12; type III, 146; type IV, 32; and type V, 8. By histopathologic examination, 16 early gastric cancers were detected between type IV or V lesions. Thus, classification of types IV-V strongly correlated with the presence of gastric cancer (sensitivity 100%, specificity 89.7%). Single-center study. Surface pattern classification by EME may be useful for identifying early gastric cancers.

Classification of villous atrophy with enhanced magnification endoscopy in patients with celiac disease and tropical sprue

Intestinal lesions in celiac disease (CD) and tropical sprue (TS) can be patchy. Improved endoscopic identification of affected areas may increase the diagnostic yield of biopsy specimens. Enhanced magnification endoscopy [EME] combines magnification endoscopy with 3% acetic acid instillation. This study describes endoscopic findings associated with villous atrophy during EME. Patients underwent EME with a magnifying endoscope with acetic-acid application. Surface mucosal patterns were characterized before and after acetic-acid spraying. Observed surface patterns were compared with histologic results obtained from a single targeted biopsy specimen. Policlinica Metropolitana in Caracas, Venezuela. Patients with diagnosed but untreated CD or TS. Fifty-two biopsy specimens were obtained from 27 patients (17 men, 10 women; mean age 50.5 years; range, 24-76 years; 12 with CD and 15 with TS). EME of the duodenum revealed 4 different mucosal patterns: I, normal; II, stubbed; III, ridged; and IV, foveolar. Three of the 4 patterns were strongly associated with the presence of villous atrophy (pattern I, 1/18 [5.5%]; II, 16/17 [94%]; III, 12/12 [100%]; and IV, 5/5 [100%]). EME was more sensitive than standard endoscopy for detecting villous atrophy, 100% versus 58% in CD and 93% versus 20% in TS. Furthermore, EME identified patchy areas of partial villous atrophy in 16 patients (5 CD and 11 TS) in whom standard endoscopy was normal. EME identifies 3 characteristic endoscopic patterns that correlate with the presence of villous atrophy. EME could help identify patchy areas of partial mucosal atrophy, potentially reducing the need for blind biopsies.

Depressed-type early duodenal carcinoma (carcinoma in situ) observed by enhanced magnification endoscopy

Early primary nonampullary duodenal carcinoma is an extremely rare disease. We observed the features of depressed-type early duodenal carcinoma by enhanced magnification endoscopy (EME).

Enhanced Magnification-Directed Biopsies Do Not Increase the Detection of Intestinal Metaplasia in Patients with GERD

The diagnosis of Barrett's esophagus (BE) requires histologic confirmation of specialized intestinal metaplasia (SIM) through biopsy, a technique prone to sampling error. One method designed to improve the yield of biopsy uses acetic acid with magnification endoscopy: enhanced magnification endoscopy (EME). This technique identifies several mucosal surface patterns, and of these, pattern types III and IV have been associated with SIM. We conducted a prospective, randomized trial to compare EME-directed biopsies and standard endoscopy with random biopsies in patients with symptoms of gastroesophageal reflux disease. Patients in the standard endoscopy group with evidence of BE had four-quadrant random biopsies taken every 2 cm. If there was no BE, four-quadrant biopsies were taken at the SCJ. Patients in the EME group had the mucosa at the SCJ classified as type I-IV based on published criteria. Biopsies targeted to type III and IV were compared to random biopsies. One hundred thirty-seven patients enrolled (68 randomized to EME, 69 to standard endoscopy). Fifty-six (41%) had endoscopic evidence of BE (20 standard endoscopy [29%] vs 36 EME [53%]). Of the patients with apparent BE, standard endoscopy with random biopsies confirmed SIM in 12 (60%) compared to 11 of 18 (61%) patients with EME targeted biopsies of patterns type III or IV (p = 1.0). Patients without apparent BE (N = 81) had SIM of the SCJ confirmed in 16% (8 of 49) with standard endoscopy and random biopsies compared with 8% (1 of 12) using EME-directed biopsy of pattern III or IV (p = 0.67). Random biopsies of endoscopically apparent BE and a normal SCJ yield SIM at the same rate as targeted biopsies with EME in patients with pattern types III or IV. This calls into question the utility of this technique in reducing sampling error to identify SIM.

Features of early gastric cancer and gastric adenoma by enhanced-magnification endoscopy

Changes to the mucosal surface of early gastric carcinomas and gastric adenomas as viewed by enhanced-magnification endoscopy with acetic acid have not been investigated thoroughly. Using this technology, we investigated the appearance of the gastric surface patterns of neoplastic and surrounding nonneoplastic mucosa. Forty-seven consecutive patients with early gastric carcinomas or gastric adenomas underwent enhanced-magnification endoscopy following 1.5% acetic acid instillation. All biopsy specimens were taken from the area at which the enhanced-magnified endoscopic image was obtained. Surface patterns of gastric tumors and the surrounding mucosa were classified into five types: type I, small round pits of uniform size and shape; type II, slit-like pits; type III, gyrus and villous patterns; type IV, irregular arrangements and sizes of pattern types I, II and III; type V, destructive patterns of types I, II and III. The predominant pattern of the surrounding mucosa was type III, and most type III mucosa had characteristics of intestinal metaplasia. Although all elevated adenomas showed type II or type III surface patterns, both depressed adenomas showed type IV. Elevated carcinomas showed type III (42.9%) or type IV (57.1%) surface patterns, while depressed carcinomas showed type IV (70%) or type V (30%). Although differentiated tubular adenocarcinomas showed type III (10.3%), type IV (86.2%), or type V (3.5%) surface patterns, all of the signet-ring cell carcinomas and poorly differentiated tubular adenocarcinomas showed type V. Enhanced-magnification endoscopy may be useful for identifying gastric tumors and determining the extent of horizontal spread, especially in tumors of the depressed type.

Enhanced Magnification Directed Biopsies Do Not Increase the Detection of Intestinal Metaplasia in Patients with GERD

Background: The diagnosis of Barrett's esophagus (BE) requires histologic confirmation of specialized intestinal metaplasia (SIM) through biopsy, a technique prone to sampling error. One method designed to improve the yield of biopsy uses acetic acid with magnification endoscopy: Enhanced Magnification Endoscopy (EME). This technique identifies several mucosal surface patterns and of these, pattern types III and IV have been associated with SIM. Methods: We conducted a prospective, randomized trial to compare EME directed biopsies and standard endoscopy with random biopsies in patients with symptoms of GERD. Patients in the standard endoscopy group with evidence of BE had 4 quadrant random biopsies taken every 2 cms. If there was no BE, 4 quadrant biopsies were taken at the SCJ. Patients in the EME group had the mucosa at the SCJ classified as Type I to IV based on published criteria. Biopsies targeted to type III and IV were compared to random biopsies. Results: 137 patients enrolled (68 randomized to EME, 69 to standard endoscopy). 56 (41%) had endoscopic evidence of BE [20 standard endoscopy (29%) vs. 36 EME (53%)]. Of the patients with apparent BE, standard endoscopy with random biopsies confirmed SIM in 12 (60%) compared to 11 of 18 (61%) of patients with EME targeted biopsies of patterns type III or IV (p = 1.0). Patients without apparent BE (N = 81) had SIM of the SCJ confirmed in 16% (8/49) with standard endoscopy and random biopsies compared with 8% (1/12) using EME directed biopsy of pattern III or IV (p = 0.67). Conclusions: Random biopsies of endoscopically apparent BE and a normal SCJ yield SIM at the same rate as targeted biopsies with EME in patients with pattern types III or IV. This calls into question the utility of this technique in reducing sampling error to identify SIM.

Barrett’s esophagus specialist clinic: what difference can it make?

A 'Barrett's specialist clinic' was set up in our institution consisting of a specialist nurse, research fellow, and a consultant gastroenterologist. The aim of our study was to examine the impact of this clinic in the management of patients with Barrett's esophagus (BE). Patients with the diagnosis of BE seen in the outpatient departments or in the endoscopy unit were referred to this clinic. Guidelines were introduced modelling the American College of Gastroenterology recommendation. Patients were assessed based on their comorbidity and willingness to undergo surveillance. Reflux symptom control and acid suppression was addressed. All patients were invited to undergo high-resolution enhanced magnification endoscopy (EME) and targeted biopsy to confirm the diagnosis and to form a management plan. During the appointment in the clinic, patients were given an option to fill a questionnaire that inquired about the information given to them regarding BE. One hundred and forty-three patients (92 men, mean age: 62 years) with a diagnosis of BE were seen in the specialist clinic. In 16 patients surveillance was stopped. In 25 patients treatment was changed due to poor control of reflux symptoms. Sixty-five patients (51%) answered the questionnaire. Seventy-five patients (58%) underwent high resolution EME. Twelve patients, had a histological upgrade after EME, in spite of a short mean screening interval (5.5 months). The 'Barrett's specialist clinic' introduced a more structured approach in our institution and changed the way these patients were managed. Our results indicate the need for local guidelines and Barrett's specialist clinics in the UK, and perhaps in the rest of the Western world, wherein the burden of this condition is increasing.

Acetic acid‐enhanced magnification endoscopy in the diagnosis of specialized intestinal metaplasia, dysplasia and early cancer in Barrett's oesophagus

Barrett's surveillance is prone to sampling error. Aim To determine whether enhanced magnification endoscopy using acetic acid instillation improves diagnostic accuracy of specialized intestinal metaplasia/dysplasia in Barrett's oesophagus. We examined the detection rate of the specialized intestinal metaplasia/dysplasia in 64 consecutive patients with Barrett's oesophagus using acetic acid to enhance mucosal pit patterns. Histology was compared with the previous findings at recent conventional surveillance in 62 patients. We also examined the inter-/intra-observer agreement in the assessment of the enhanced magnification endoscopy pit pattern findings. Histology revealed columnar-lined oesophagus in six (9%) patients, specialized intestinal metaplasia in 49 (77%), low-grade dysplasia in five (8%), high-grade dysplasia in one (2%), and adenocarcinoma in three (5%). There was discordance between the histologic findings from conventional surveillance with random biopsy. Fifteen patients (24%) had a histological upgrade with enhanced magnification endoscopy. There was a high detection rate of specialized intestinal metaplasia even in short segment Barrett's oesophagus (74%), and additionally, there were two cancers, one with 2-cm Barrett's oesophagus and one ultra-short (1 cm). The mean kappa values for inter- and intra-observer agreement in assessing the pit patterns were 0.571 (0.041) and 0.709 (0.038), respectively. Enhanced magnification endoscopy allows clear visualization of the epithelial pit patterns within Barrett's oesophagus, and targeted biopsy results in a high yield of specialized intestinal metaplasia and dysplasia.

Evaluation of sensitivity and inter- and intra-observer variability in the detection of intestinal metaplasia and dysplasia in Barrett's esophagus with enhanced magnification endoscopy

Objective. Magnification endoscopy with acetic acid or dye for diagnosis of Barrett's esophagus is presently undergoing clinical evaluation. Current studies report good accuracy in predicting specialized intestinal metaplasia. To date, however, there is no definitive information on the inter- and intra-observer variability of these methods applied to the diagnosis of normal and dysplastic Barrett's mucosa. Material and methods. Sixty patients with endoscopically suspected Barrett's esophagus were investigated prospectively with the zoom endoscope after contrast enhancement of the mucosa with 1.5% acetic acid. Two hundred and twenty-three enlarged and histologically investigated areas of gastric, cardiac, normal and dysplastic Barrett's mucosa were photodocumented and in randomized sequence presented to 4 endoscopists in a blinded manner (2 with and 2 without experience of zoom endoscopy for evaluation). The reference for the first evaluation (A1) was standard endoscopic photographs of the respective, histologically confirmed mucosal entity. In a second evaluation (A2), the pictures were again interpreted by the same blinded investigators, but this time a modified pit-pattern classification as proposed by Sharma et al. was employed as the evaluation reference. Results. The diagnostic sensitivity for specialized intestinal metaplasia and dysplasia in Barrett's esophagus calculated for the A1 evaluation ranged – investigator dependently – from 54.9% to 80.7% and for A2 from 42.2% to 81.5%. The inter- and intra-observer variability for the evaluation procedure A1 and A2 was high (all kappa values <0.4). In particular, the inexperienced investigators demonstrated high intra-observer variability and low sensitivity in comparison with the experienced investigators. Conclusions. The diagnosis of Barrett's mucosa using enhanced magnification endoscopy after acetic acid instillation is associated with a high level of interobserver variability. One reason is a frequent mismatch between cardiac mucosa and non-dysplastic Barrett's mucosa.

Features of Early Gastric Cancer and Gastric Adenoma by Enhanced-Magnification Endoscopy

Features of Early Gastric Cancer and Gastric Adenoma by Enhanced-Magnification Endoscopy

Inter- and Intra-Observer Consistency in Recognizing Pit Patterns in Barrett's Esophagus Using the Enhanced Magnification Endoscopy Technique

Introduction: Specialized intestinal metaplasia and dysplasia in Barrett's Esophagus (BE) is not readily identifiable by standard endoscopy. Enhanced magnification endoscopy involves the combined use of acetic acid instillation and zoom endoscopy (1). This technique aids to obtain detailed views of the pit patterns within BE and thus allows the endoscopist to target biopsies from areas of interest. Aim: To evaluate the inter- and intra observer agreement in the assessment of enhanced magnification endoscopy pit patterns in BE. Methods: A total of 215 enhanced magnification endoscopy digital images of BE were selected from a consecutive series of 60 patients. The pictures were randomly displayed twice to seven experienced endoscopists (average >2000 gastroscopies) at interval of 1 week. Prior to this all endoscopists had a session of tutorial in recognising the pit patterns. Each image was assessed for the predominant pit pattern by using a modified Guelrud classification which we use in our unit. This classification system was created by using the Olympus Lucera CV260 processor and high-resolution magnifying endoscope (GIF-Q240Z; Olympus) with ×115 magnification: Type I, round or slit-like pits, Type II; linear, Type III; villous, Type IV; tubular or cerebriform, and Type V; distorted pits. Kappa statistics were used to estimate inter- and intra observer variation. A kappa value < 0.4 was regarded as poor agreement, 0.4-0.75 was considered to show good agreement, and > 0.75 was regarded as demonstrating excellent agreement. Results: The mean (standard deviation) inter- and intra-observer kappa values were 0.571 (0.041), and 0.709 (0.037), respectively. The accuracy of predicting the pit pattern was: Type I 79.4% (67.44%-97.6%), Type II 74.37% (62.7%-81.4%), Type III 63.48% (47.8%-81.1%), Type IV 65.4% (50-88%), and Type V 86.1% (38.8%-100%). Conclusion: For experienced endoscopists, the inter and intra observer agreement of the classification of pit patterns in BE using the enhanced magnification endoscopy technique is good. With appropriate training, expertise in this technique can be achieved to acceptable levels. Reference: 1. Guelrud M, Herrera I, Essenfeld H, Castro J. Enhanced magnification endoscopy: a new technique to identify specialized intestinal metaplasia in Barrett's esophagus. Gastrointest Endosc 2001;53:559-65. Introduction: Specialized intestinal metaplasia and dysplasia in Barrett's Esophagus (BE) is not readily identifiable by standard endoscopy. Enhanced magnification endoscopy involves the combined use of acetic acid instillation and zoom endoscopy (1). This technique aids to obtain detailed views of the pit patterns within BE and thus allows the endoscopist to target biopsies from areas of interest. Aim: To evaluate the inter- and intra observer agreement in the assessment of enhanced magnification endoscopy pit patterns in BE. Methods: A total of 215 enhanced magnification endoscopy digital images of BE were selected from a consecutive series of 60 patients. The pictures were randomly displayed twice to seven experienced endoscopists (average >2000 gastroscopies) at interval of 1 week. Prior to this all endoscopists had a session of tutorial in recognising the pit patterns. Each image was assessed for the predominant pit pattern by using a modified Guelrud classification which we use in our unit. This classification system was created by using the Olympus Lucera CV260 processor and high-resolution magnifying endoscope (GIF-Q240Z; Olympus) with ×115 magnification: Type I, round or slit-like pits, Type II; linear, Type III; villous, Type IV; tubular or cerebriform, and Type V; distorted pits. Kappa statistics were used to estimate inter- and intra observer variation. A kappa value < 0.4 was regarded as poor agreement, 0.4-0.75 was considered to show good agreement, and > 0.75 was regarded as demonstrating excellent agreement. Results: The mean (standard deviation) inter- and intra-observer kappa values were 0.571 (0.041), and 0.709 (0.037), respectively. The accuracy of predicting the pit pattern was: Type I 79.4% (67.44%-97.6%), Type II 74.37% (62.7%-81.4%), Type III 63.48% (47.8%-81.1%), Type IV 65.4% (50-88%), and Type V 86.1% (38.8%-100%). Conclusion: For experienced endoscopists, the inter and intra observer agreement of the classification of pit patterns in BE using the enhanced magnification endoscopy technique is good. With appropriate training, expertise in this technique can be achieved to acceptable levels. Reference: 1. Guelrud M, Herrera I, Essenfeld H, Castro J. Enhanced magnification endoscopy: a new technique to identify specialized intestinal metaplasia in Barrett's esophagus. Gastrointest Endosc 2001;53:559-65.

Enhanced Magnification Directed Biopsies for Detection of Intestinal Metaplasia in Patients with GERD

Background: The diagnosis of Barrett's esophagus (BE) requires histologic confirmation of specialized intestinal metaplasia (SIM) through biopsy, a technique prone to sampling error. A promising method to improve the yield of biopsy uses acetic acid with magnification endoscopy: Enhanced Magnification Endoscopy (EME). This technique identifies mucosal surface patterns and of these, pattern types III and IV have been associated with SIM. Methods: We conducted a prospective, randomized trial to evaluate EME directed biopsies and standard endoscopy with random biopsies in patients with symptoms of GERD. Patients in the standard endoscopy group with evidence of BE had 4 quadrant random biopsies taken every 2 cms. If there was no BE, 4 quadrant biopsies were taken at the SCJ. Patients in the EME group had the mucosa at the SCJ classified as Type I) round pits, Type II) reticular, III) villous or IV) ridged based on published criteria. In some cases, the visualized pattern did not fall into one of these categories and was labeled Type V. Biopsies were taken from each pattern type. Results: 93 patients enrolled (44 with EME, 49 with standard endoscopy). 36 (39%) had endoscopic evidence of BE (12 standard endoscopy, 24 EME). The yield of SIM using EME for each pattern type is shown (table). Of the 12 patients with apparent BE on standard endoscopy, random biopsies confirmed SIM on a per patient basis in 6 (50%) and in 6 (25%) for the 24 with EME directed biopsies. Overall, the prevalence of SIM was higher in the standard endoscopy group (50%) vs. EME (25%), but if pattern type III or IV were identified, EME confirmed SIM in 75% (6/8 patients). Patients without apparent BE (57) had SIM of the SCJ confirmed in 16% (6/37) with standard endoscopy and random biopsies compared with 5% (1/20) using magnification endoscopy. Conclusions: Random biopsies of endoscopically apparent BE yield SIM at slightly lower rates than targeted biopsies with EME in patients with pattern types III or IV. However, overall it appears that the yield of biopsy confirming SIM using these two techniques is similar. This calls into question the utility of this technique in reducing sampling error to identify SIM.

Inter-Observer Variability with Enhanced Magnification Endoscopy of the Squamocolumnar Junction

Background: Enhanced Magnification Endoscopy (EME) is an endoscopic technique that combines the application of acetic acid to the surface of the esophagus and endoscopic imaging with a magnifying endoscope. This technique has been identified as highly accurate in predicting specialized intestinal metaplasia (SIM) in Barrett's esophagus based on surface pattern types. Previous investigators have noted that there is high inter-observer variability in identifying pattern types that may limit the utility of this technique.

Enhanced magnification endoscopy in the upper gastrointestinal tract.

In diseases such as Barrett's esophagus and celiac disease, the mucosal abnormality is patchy or irregular, highlighting the need for targeted biopsies. Enhanced magnification endoscopy is an effective, readily available method that can be used to assist in target biopsies and endoscopic diagnosis leading to an endoscopic classification system. The technique is not difficult and adds only an additional 5 to 10 minutes to a standard endoscopic procedure;however, most endoscopists never receive instruction in magnification endoscopy during their training. The value of this technique is still being explored, but the improvement in diagnostic accuracy will have an impact on decreasing morbidity and mortality without a large increase in cost. Increased use of this technique will aid in the diagnosis of celiac disease and simplify the classification system for Barrett's esophagus. Using enhanced magnification endoscopy at multiple centers in studies will help to determine the intra- and inter-observer variability, define the endoscopic criteria for dysplasia and early neoplastic changes, and standardize the visualized mucosal patterns more clearly.

Detection of intestinal metaplasia in distal esophagus and esophagogastric junction by enhanced-magnification endoscopy

Background Standard videoendoscopy identifies columnar-lined esophagus but cannot distinguish intestinal metaplasia from other types of epithelium. Enhanced-magnification endoscopy identifies different mucosal pit patterns. A preliminary study suggested that a type 3 pattern is associated with the presence of intestinal metaplasia. This study assesses the value of enhanced-magnification endoscopy for the detection of intestinal metaplasia in the distal esophagus and esophagogastric junction in patients undergoing diagnostic EGD. Methods Patients undergoing diagnostic endoscopy for upper-GI symptoms underwent enhanced-magnification endoscopy after instillation of 1.5% acetic acid. The enhanced-magnification endoscopy mucosal pattern was classified into 3 types: 1, normal pits; 2, slit-reticular pattern; and 3, gyrus-villous pattern. Preliminary studies indicated that the type 3 pattern was related to intestinal metaplasia. One to 6 biopsies were targeted to areas having a type 3 pattern in columnar-appearing mucosa in the distal esophagus or esophagogastric junction. In the absence of type 3 pattern, one to 8 biopsies were targeted to areas with a type 2 pattern in columnar-appearing mucosa in the distal esophagus or esophagogastric junction. Results The overall frequency of intestinal metaplasia in the esophagus and esophagogastric junction was 38.8% (26/67 patients). There was a good correlation between the type 3 pattern and intestinal metaplasia in targeted biopsy specimens (sensitivity 88.5%, specificity 90.2%, positive predictive value 85.2%, negative predictive value 92.5%, overall accuracy 90.0%). Conclusions Enhanced-magnification endoscopy is useful for detection of intestinal metaplasia in distal esophagus and esophagogastric junction.