Normal White Light Endoscopy Research Articles

S2146 To Remove or Not to Remove? A Case of Appendiceal Inversion and Its Diagnostic Challenges

Introduction: Appendiceal inversion occurs when the appendix is pulled into the lumen of the cecum, and can be an uncommon incidental finding on colonoscopy. When found, they may present as a diagnostic challenge to the endoscopist, as they may be mistaken as a colon polyp or even a neoplasm due to its appearance. Case Description/Methods: A 75-year-old woman with a history of hysterectomy, hypertension, and reported hemorrhoids presented to gastroenterology clinic for evaluation after being found to have a positive Cologuard test. She subsequently underwent colonoscopy, where she was found to have a large polypoid lesion protruding from the appendiceal orifice. Biopsies of the lesion revealed normal mucosa. Given the concerning appearance of the lesion despite normal biopsies, the patient was referred for repeat colonoscopy for endoscopic removal. Repeat endoscopy re-demonstrated a 5 by 10 millimeter non-bleeding, non-ulcerated, finger-like projection from the appendiceal orifice. Normal appearing mucosa of the lesion and its surroundings was observed under narrow band imaging. These findings were suggestive of an appendiceal inversion. The decision was made to not remove the lesion. The patient subsequently underwent CT imaging, where no significant underlying pathology was identified (Figure). Discussion: At present, there are no definitive guidelines on the workup of suspected appendiceal inversions. Appendiceal inversion may occur iatrogenically after open appendectomy or they may be congenital. These are benign causes that would not require further intervention. However, they may be associated with conditions including endometriosis, adenomas, and neoplasms. Anecdotally, there have been reports of peritonitis or significant bleeding with removal of these lesions. A careful approach is thus imperative to prevent unnecessary complications. A thorough surgical history should be taken as history of prior open appendectomy may increase suspicion for appendiceal inversion. Endoscopically, evaluation for surrounding inflammation and use of narrow band imaging to identify abnormal mucosa should be considered. Biopsy of the lesion may also be considered, but should be performed with caution. CT imaging may help exclude any underlying malignancy. Prior case reports have reported identification of mucinous neoplasms on CT following colonoscopy if the lesion cannot be determined to be an appendiceal inversion on endoscopy. In this patient, CT did not reveal any underlying malignancy.Figure 1.: Endoscopic appearance of an appendiceal inversion both under normal white light endoscopy (A) and narrow band imaging (B).

Endoscopic severe mucosal atrophy indicates the presence of gastric cancer after Helicobacter pylori eradication -analysis based on the Kyoto classification

BackgroundGastric cancer after Helicobacter pylori (HP) eradication is a crucial clinical challenge today as HP eradication therapy is widely performed. Detecting gastric cancer after HP eradication tends to be difficult with normal white-light endoscopy. In the present study, we aimed to identify easily-evaluated endoscopic findings that indicate the presence of gastric cancer after HP eradication so that endoscopists can consider additional detailed examinations at the site.MethodsWe analyzed the endoscopic images of 43 patients who underwent endoscopic submucosal dissection for early gastric cancer after HP eradication and 119 patients with an HP eradication history who underwent esophagogastroduodenoscopy for a medical checkup. Endoscopic findings were evaluated according to the Kyoto classification of gastritis (atrophy, intestinal metaplasia, enlarged folds, nodularity, and diffuse redness) and map-like redness.ResultsPatients with gastric cancer had significantly higher total Kyoto risk scores; more atrophy, intestinal metaplasia, and diffuse redness; and a significantly higher prevalence of map-like redness compared with those without gastric cancer, in the univariate analyses. We used logistic regression analysis with forward selection based on the likelihood ratio to develop a model using atrophy and diffuse redness. Receiver operating characteristic analysis showed that a score of A2 in the Kyoto classification of gastritis (open-type atrophic pattern in the Kimura–Takemoto classification) was an endoscopic marker for the presence of post-HP-eradication gastric cancer.ConclusionsEndoscopic severe gastric mucosal atrophy is useful to screen patients for gastric cancer after HP eradication.

Linked Color Imaging Can Improve Detection Rate of Early Gastric Cancer in a High-Risk Population: A Multi-Center Randomized Controlled Clinical Trial.

Early diagnosis of gastric cancer is difficult in China due to the lack of a valid method for endoscopic screening. Early gastric cancer, especially flat gastric cancer, lacks specific endoscopic features. Many cases appear to be similar to ordinary gastritis cases under normal white light endoscopy, which can lead to misdiagnosis. In order to find a new method to improve detection rate of early gastric cancer in China, we designed a trial to validate linked color imaging (LCI) for screening of early gastric cancer in a high-risk population, as compared to white light imaging (WLI). Subjects were randomly allocated to either the LCI + WLI or WLI group and then subjected to gastroscopy and all endoscopies were made after special preparation. All endoscopists had knowledge of this experiment. The main indicator was the rate of detection of gastric neoplastic lesions. The difference in the detection rate between the two groups is reported. The detection rate was 4.31% in the WLI group and 8.01% in the LCI + WLI group. This is a difference of 3.70% with a P value < 0.001 and an OR (95% CI) of 1.934 (1.362, 2.746). The lower limit of the 95% CI was greater than 0, and the superiority margin was 1%. The detection rate of gastric neoplastic lesions was higher in the LCI + WLI group than in the WLI group, LCI might be an effective method for screening early gastric cancer.

Effect of narrow-band imaging (NBI) combined with magnifying endoscopy in early diagnosis of gastric cancer

Objective To explore the effect of narrow-band imaging (NBI) combined with magnifying endoscopy (ME) in early diagnosis of gastric cancer, and to observe whether it is helpful for inexperienced endoscopists to diagnose. Methods From April 2015 to October 2017, a total of 480 lesions were selected as research objects which were detected in the normal white light endoscopy (WLE). Pathological examination was used as the gold standard for diagnosis. 3 experienced doctors were selected to read the endoscopy films. 40 intern endoscopy doctors were selected to read the endoscopy filins at the same time after simple training. 80 WLE images and narrowband imaging technology combined with magnifying endoscopy (ME-NBI) images were randomly selected to hold a film reading meeting. Real-time voting was used to judge the nature of lesions. Results The accuracy, sensitivity, specificity false positive rate and false negative rate of ME-NBI were 97.9%(470/480), 96.8%(120/124), 98.3%(350/356), 1.7%(6/356), 3.2%(4/124). And WLE values were 91.7%(440/480), 80.6%(100/124), 89.9%(320/356), 10.1%(36/356), 19.4%(24/124), respectively. The diagnostic accuracy, sensitivity and specificity of ME-NBI were significantly higher than those of WLE (χ2=18.989, 16.104, 15.859, P<0.05), and the false positive rate and false negative rate were significantly lower than those of WLE (χ2=22.772, 16.104, P<0.05). The diagnostic results of ME-NBI of 40 endoscopy interns were significantly better than those of WLE (t=11.467, 16.188, P<0.05). The diagnostic results of NBI by 40 interns were significantly better than that of WLE (t=11.467, 16.188, P<0.05). Conclusions The accuracy of ME-NBI in screening early gastric cancer is satisfactory, and it has certain diagnostic value for inexperienced doctors. Key words: Stomach neoplasms; Early detection of cancer; Gastroscopy

The use of narrow band imaging for the detection of benign lesions of the larynx.

In the cases of uncertainty, even if the patient has no complaints about his voice quality, sometimes, benign vocal fold mass lesions are removed to exclude malignancy with the risk of resultant dysphonia. Narrow Band Imaging (NBI) enables a specific visualization of vessel structures in the superficial tissue. Benign lesions of the larynx are frequently characterized by abnormal vessel configuration or an absence of vessels in the area of the lesion. It was hypothesized that, in the primary diagnosis of patients with these benign lesions, the combination of white light and NBI endoscopy enables a better detection compared with white light endoscopy alone. Twenty-nine patients (eight patients with a cyst on a vocal fold, eight with a polyp, seven with a Reinke´s edema, two with a leukoplakia, one with a carcinoma, one with a granuloma, and two without any pathologic finding) were examined with normal white light and NBI endoscopy. 87 video sequences (29 white, 29 NBI, and 29 white/NBI) were generated and randomized and presented to 20 otolaryngologists who rated the videos in terms of the suspected diagnosis. Results were compared with the histopathologic findings of microlaryngoscopy. The probability of detecting benign lesions of the vocal folds was higher using NBI in combination with white light endoscopy compared with white light endoscopy alone. For vocal fold cysts, this difference was statistically significant. NBI endoscopy in combination with normal white light endoscopy improves the detection rate of benign lesions of the larynx, especially of vocal fold cysts.

Endoscopic ultrasound of the larynx.

Endoscopic ultrasound (EUS) of the larynx is a vertical endoscopic imaging technique that gives further information about the extension of a lesion apart from normal white light endoscopy, chromoendoscopy, as well as palpation. It combines the advantages of ultrasound and endoscopy. Miniprobes or ultrasound endoscopes with 10-20 MHz are applied. The present review is focused on the use of EUS in the larynx especially in the management of laryngeal cancer. At present, the larynx is routinely assessed by computed tomography and MRI. Alternatively, endoscopic endoluminal application of miniprobes enables the laryngologist to predict the exact extension of a laryngeal tumor larger than 3 mm during microlaryngoscopy before surgery is performed. Generally, tumors are hypoechoic and can easily be differentiated from the surrounding tissue especially in the hyperechoic supraglottic structures. Thyroid cartilage infiltration can be detected by the interruption of the hyperechoic inner perichondrium. EUS proved to be a reliable imaging tool for the investigation of laryngeal lesions and can easily be used during microlaryngoscopy. It offers a higher image resolution compared with computed tomography and MRI and allows a complete sonographic evaluation of the larynx as well as its pathological changes, especially laryngeal cancer. VIDEO FILE LINK: http://links.lww.com/COOH/A19.

Narrow Band Imaging

Narrow band imaging (NBI) is supposed to be a technique for a better visualization of vessel structures in superficial tissue as it selects the wavelengths of hemoglobin. It was hypothesized that, in the regular follow-up examination of patients with recurrent laryngeal papillomatosis, NBI enables a better detection of laryngeal papillomatosis in contrast to normal white light endoscopy. Eleven patients, 10 with a known recurrent papillomatosis (8 with a relapse, 2 without) and 1 with a primary diagnosis of papillomatosis, were examined with normal white light and NBI endoscopy. Twenty-six video sequences (11 white, 11 NBI, 4 doubled for validity) were generated and randomly presented to 20 otolaryngologists who rated the videos in terms of lesions seen and number of lesions identified. Results were compared with the histopathologic findings of microlaryngoscopy. Detection of papillomatosis and the correct number of lesions identified were more accurate with NBI than with normal white light endoscopy. There was a significantly higher probability of detecting laryngeal papillomata with NBI. NBI endoscopy enables a more accurate detection of laryngeal papillomatosis than white light endoscopy.

PTU-033 Narrow-band imaging demonstrates abnormalities in nerd: the ‘linear furrow sign’

<h3>Introduction</h3> Two-thirds of patients with reflux symptoms will have a normal white light endoscopy (WLE). Using high definition narrow-band imaging (NBI), however, we found abnormalities in the distal oesophagus correlating with histologic findings of reflux. A common appearance was noted in patients referred for investigation of reflux (where endoscopy was otherwise normal). This was termed the ‘linear furrow’ sign (LFS) as it comprised of linear, alternating lighter and darker ‘ridges’ of mucosa resembling furrows in a ploughed field. This observational cohort study was conducted prospectively to establish the relevance of the LFS. <h3>Method</h3> Consecutive patients referred for investigation of reflux underwent endoscopy (BH or AH) to the institution protocol: a pair of routine, non-targetted distal and mid-esophageal biopsies were taken to examine for microscopic changes of reflux and to exclude eosinophilic esophagitis (EoE). Prior to biopsies, the oesophagus was examined using NBI. The endoscopist’s opinion as to whether the LFS was present was recorded in the routine report and digital still images captured. Histology was reported in the routine clinical service, then reviewed by a single experienced Histopathologist (HAA), blinded to endoscopic findings. Positive biopsies were those initially reported as “findings compatible with reflux”, but in each case the reviewing Histopathologist recorded the changes contributing to this overall impression. Sensitivity and specificity of the LFS was calculated using biopsies as the gold standard. <h3>Results</h3> n = 31 with normal WLE were examined (13F; mean age 44.3 ± 15.0 yrs). The LFS was present (LFS+) in 25 patients, extending approximately 4–5 cm above the squamocolumnar junction. Histologic examination of biopsies from this region demonstrated changes consistent with reflux in 23/25. 6 patients were LFS-, with normal histology in 5. Mid-esophageal biopsies were positive in only three patients. In one, diagnostic criteria for EoE were met (responding completely to acid suppression). Magnification endoscopy with NBI demonstrated that the changes seen arise from the impression of a ridged appearance to the mucosal surface – most likely reflecting elongation of papillae and basal cell hyperplasia. Spongiosis (dilated intercellular spaces; DIS) was demonstrable in 75% of LFS+. Although reflux symptoms were not systematically evaluated, a self-reported response to PPI was noted in 70% of such patients (LFS+, DIS+) and only 10% of those without (LFS-, DIS-; p &lt; 0.01). <h3>Conclusion</h3> The LFS was detected in 80% of patients, achieving diagnostic accuracy of 90% and appears to relate to self-reported symptomatic response to PPI. A further prospective study is under way to determine the clinical significance of this finding. <h3>Disclosure of interest</h3> None Declared.

Mo1133 Narrow-Band Imaging Demonstrates Abnormalities in NERD: The ‘Linear Furrow Sign’

Introduction Two-thirds of patients with reflux symptoms will have a normal white light endoscopy (WLE). Using high definition narrow-band imaging (NBI), however, we found abnormalities in the distal oesophagus correlating with histologic findings of reflux. A common appearance was noted in patients referred for investigation of reflux (where endoscopy was otherwise normal). This was termed the ‘linear furrow’ sign (LFS) as it comprised of linear, alternating lighter and darker ‘ridges’ of mucosa resembling furrows in a ploughed field. This observational cohort study was conducted prospectively to establish the relevance of the LFS. Method Consecutive patients referred for investigation of reflux underwent endoscopy (BH or AH) to the institution protocol: a pair of routine, non-targetted distal and mid-esophageal biopsies were taken to examine for microscopic changes of reflux and to exclude eosinophilic esophagitis (EoE). Prior to biopsies, the oesophagus was examined using NBI. The endoscopist’s opinion as to whether the LFS was present was recorded in the routine report and digital still images captured. Histology was reported in the routine clinical service, then reviewed by a single experienced Histopathologist (HAA), blinded to endoscopic findings. Positive biopsies were those initially reported as “findings compatible with reflux”, but in each case the reviewing Histopathologist recorded the changes contributing to this overall impression. Sensitivity and specificity of the LFS was calculated using biopsies as the gold standard. Results n = 31 with normal WLE were examined (13F; mean age 44.3 ± 15.0 yrs). The LFS was present (LFS+) in 25 patients, extending approximately 4–5 cm above the squamocolumnar junction. Histologic examination of biopsies from this region demonstrated changes consistent with reflux in 23/25. 6 patients were LFS-, with normal histology in 5. Mid-esophageal biopsies were positive in only three patients. In one, diagnostic criteria for EoE were met (responding completely to acid suppression). Magnification endoscopy with NBI demonstrated that the changes seen arise from the impression of a ridged appearance to the mucosal surface – most likely reflecting elongation of papillae and basal cell hyperplasia. Spongiosis (dilated intercellular spaces; DIS) was demonstrable in 75% of LFS+. Although reflux symptoms were not systematically evaluated, a self-reported response to PPI was noted in 70% of such patients (LFS+, DIS+) and only 10% of those without (LFS-, DIS-; p Conclusion The LFS was detected in 80% of patients, achieving diagnostic accuracy of 90% and appears to relate to self-reported symptomatic response to PPI. A further prospective study is under way to determine the clinical significance of this finding. Disclosure of interest None Declared.

Value of fluorescence endoscopy for the early diagnosis of laryngeal cancer and its precursor lesions

Fluorescence endoscopy is used for the early detection and delineation of laryngeal cancer and its precursor lesions. No systematic review of these promising imaging techniques has yet been performed. A systematic review of the published literature and meta-analysis of data extracted from 16 included studies were performed. A total of 1000 laryngeal lesions were examined by autofluorescence endoscopy (AFE), 318 mucosal changes by induced fluorescence endoscopy (IFE), and 679 laryngeal pathologies underwent normal white light endoscopy (WLE). In identifying precancerous and cancerous lesions of the larynx, sensitivity (91% vs 73%), specificity (84% vs 79%), and accuracy (88% vs 77%) of AFE were superior to WLE alone, whereas IFE showed an even higher sensitivity (95% vs 73%) at the expense of specificity (62% vs 79%). Therefore, AFE also achieved a higher specificity (84% vs 62%) and accuracy (88% vs 76%) than did IFE in detecting these kinds of lesions. However, the sensitivity (91% vs 95%) did not differ significantly between both methods. This meta-analysis confirms that fluorescence endoscopy is highly effective in the early diagnosis of laryngeal cancer and its precursor lesions. Thus, AFE can be used immediately without drug administration or possible side effects, whereas IFE is more suited for the detection of recurrent disease following initial surgery.

Validation of Fujinon intelligent chromoendoscopy withhigh defnition endoscopes in colonoscopy

To validate high definition endoscopes with Fujinon intelligent chromoendoscopy (FICE) in colonoscopy. The image quality of normal white light endoscopy (WLE), that of the 10 available FICE filters and that of a gold standard (0.2% indigo carmine dye) were compared. FICE-filter 4 [red, green, and blue (RGB) wavelengths of 520, 500, and 405 nm, respectively] provided the best images for evaluating the vascular pattern compared to white light. The mucosal surface was best assessed using filter 4. However, the views obtained were not rated significantly better than those observed with white light. The "gold standard", indigo carmine (IC) dye, was found to be superior to both white light and filter 4. Filter 6 (RGB wavelengths of 580, 520, and 460 nm, respectively) allowed for exploration of the IC-stained mucosa. When assessing mucosal polyps, both FICE with magnification, and magnification following dye spraying were superior to the same techniques without magnification and to white light imaging. In the presence of suboptimal bowel preparation, observation with the FICE mode was possible, and endoscopists considered it to be superior to observation with white light. FICE-filter 4 with magnification improves the image quality of the colonic vascular patterns obtained with WLE.