Diagnosis of depressed-type early gastric cancer using small-caliber endoscopy with flexible spectral imaging color enhancement.

BACKGROUND AND AIM: Small-caliber endoscopy has lower resolution than normal-caliber endoscopy, limiting its use in routine outpatient practice. Flexible spectral imaging color enhancement (FICE) strengthens the color contrast of depressed-type early gastric cancer without magnification. The aim of the present study was to evaluate the detection of depressed-type early gastric cancer using small-caliber endoscopy with the FICE system. METHODS: Eighty-two patients diagnosed with depressed-type early gastric cancer by standard endoscopy and biopsy were evaluated by small-caliber endoscopy. FICE images and conventional images were compared. Color differences in all 82 lesions were measured between malignant lesions and the surrounding mucosa using the Commission Internationale de L'Eclairage (CIE) 1976 color space. RESULTS: Most cancers were readily detected as reddish lesions on FICE images. Lines of demarcation between the malignant lesion and the surrounding mucosa were easily identified with FICE images, as such cancers could be clearly distinguished from the surrounding atrophic mucosa. Greater median color differences between malignant lesions and the surrounding mucosa were present in FICE images compared with conventional images, resulting in images with better contrast (27.2 vs 18.7, P<0.0001). CONCLUSIONS: Small-caliber endoscopy with the FICE system provides better color contrast of depressed-type early gastric cancers than conventional small-caliber endoscopy, and the FICE system may facilitate the diagnosis of this type of cancer as a new endoscopic modality.

Non-steroidal anti-inflammatory drug-induced small bowel injuries identified by double-balloon endoscopy.

AIM: To clarify clinical features of the NSAID-induced small bowel lesions using a new method of endoscopy. METHODS: This is a retrospective study and we analyzed seven patients with small bowel lesions while taking NSAIDs among 61 patients who had undergone double-balloon endoscopy because of gastro-intestinal bleeding or anemia between September 2000 and March 2004, at Jichi Medical School Hospital in Japan. Neither conventional EGD nor colonoscopy revealed any lesions of potential bleeding sources including ulcerations. Double-balloon endoscopy was carried out from oral approach in three patients, from anal approach in three patients, and from both approaches in one patient. RESULTS: Ulcers or erosions were observed in the ileum in six patients and in the jejunum in one patient, respectively. The ulcers were multiple in all the patients with different features from tiny punched out ulcers to deep ulcerations with oozing hemorrhage or scar. All the patients recovered uneventfully and had full resolution of symptoms after suspension of the drug. CONCLUSION: NSAIDs can induce injuries in the small bowel even in patients without any lesions in both the stomach and colon.

Diagnosis of gastric antral vascular ectasia by transnasal flexible spectral imaging color enhancement.

The endoscopic appearance of gastric antral vascular ectasia (GAVE) can be easily misinterpreted as inflammatory changes of gastric mucosa. We report on a case of GAVE that had been missed by conventional transnasal endoscopy but was diagnosed by flexible spectral imaging color enhancement (FICE) with a transnasal endoscope. A 45-year-old woman with severe anemia presented with a 1-month history of increasing fatigue. She was previously diagnosed as having acute antral gastritis by conventional transnasal endoscopy (EG 530N2) because of the presence of reddish mucosal changes on the entire antral rugal fold. However, the FICE images produced using a combination of new processor system (VP4450) and new small-caliber endoscope (EG 530NW), did not show reddish mucosal changes on the entire rugal fold, but gave a clear image of dilated vessels associated with GAVE distinct from the surrounding normal mucosa on the same fold. These findings are useful to differentiate GAVE from ordinary gastritis. The lesions of GAVE were managed with a combination of focal pulse and spray-painting techniques to obliterate the bulk of the disease in two sessions of argon plasma coagulation therapy. Three months later, the patient recovered from iron deficiency anemia with an oral medication of iron tablets.

Diagnosis of small flat early gastric cancer by flexible spectral imaging color enhancement.

Current conventional endoscopy often misses flat early gastric cancers (0-IIb) because they are sometimes invisible. We experienced a case of small flat early gastric cancer that had been missed by normal-caliber conventional endoscopy. By small-caliber endoscope, conventional endoscopy showed a subtle reddish change of gastric mucosa, but the image with flexible spectral imaging color enhancement clearly showed a flat reddish lesion with 10 mm diameter, distinct from the surrounding mucosa. Flat early gastric cancer was suspected even though the lesion was not clearly described by conventional endoscopy. Histological examination of biopsy specimen revealed atypical glands. Endoscopic submucosal dissection of the lesion was performed. Pathological examination of the resected specimen confirmed well-differentiated adenocarcinoma localized in the mucosal layer without any depression or protrusion compared with the surrounding mucosa, consistent with the endoscopic finding. The small flat early gastric cancer became clearly visible with the new endoscopic technology.

Endoscopic submucosal dissection of esophageal lymphangioma: a case report with a review of the literature.

Esophageal lymphangioma is a very rare disease. We report a case of esophageal lymphangioma successfully treated with endoscopic submucosal dissection (ESD), which yielded definitive histological diagnosis and symptom relief. ESD offers a better option for definitive diagnosis as well as complete resection of large esophageal lymphangiomas with flat configuration.

Diagnosis of endoscopic Barrett's esophagus by transnasal flexible spectral imaging color enhancement.

BACKGROUND: The diagnosis of endoscopic Barrett's esophagus (BE) has been under discussion for the past decade because palisade vessels may be obscured by inflammation or the location of upper end of gastric fold may be diversely changed. The flexible spectral imaging color enhancement (FICE) system can reconstruct improved spectral images decomposed from ordinary endoscopic images with free selection of three wavelengths, and can provide non-magnified images with high light intensity. METHODS: To evaluate whether the transnasal FICE system enables easier diagnosis of endoscopic BE, 72 patients with endoscopic BE were observed prospectively with a transnasal endoscope using both conventional images and FICE images. The visualization of palisade vessels and the identification of the demarcation between endoscopic BE mucosa and gastric mucosa were compared between FICE images and conventional endoscopic images, and the CIELAB color differences were calculated among palisade vessels, background BE mucosa and gastric folds. RESULTS: Palisade vessels could be more clearly visualized in BE mucosa with transnasal FICE than with conventional endoscopy. Demarcation between whitish BE mucosa and the upper end of the brownish gastric mucosa could be clearly identified using transnasal FICE images. Greater color differences existed with FICE images between palisade vessels and background BE mucosa as well as between BE mucosa and gastric folds than with conventional images, leading to better contrasting images. CONCLUSIONS: The transnasal FICE system enables clear visualization of palisade vessels and provides better contrasting images of the demarcation between the BE mucosa and the gastric mucosa, and thus contributes to easier diagnosis of endoscopic BE.

Phlegmonous gastritis after endoscopic submucosal dissection for early gastric cancer.

A 74-year-old man with diabetic nephropathy developed epigastric pain and high fever after endoscopic submucosal dissection (ESD) for early gastric cancer. Gastroscopy, endoscopic ultrasonography and computed tomography showed ulceration with a purulent lake, thickened entire gastric mucosal layers suggesting focal abscess formation, leading to the diagnosis of phlegmonous gastritis. He underwent total gastrectomy as an emergency. Histological findings of the resected specimen showed severe inflammatory cell infiltration and multiple focal abscess formation spreading to the entire gastric wall. In patients with poorer general conditions, phlegmonous gastritis should be considered as a serious complication after ESD, indicating a requirement of antibiotic prophylaxis.

A case of esophageal stricture due to metastatic breast cancer diagnosed by endoscopic mucosal resection.

Metastasis of breast cancer to the esophagus has been reported but is rare. It is often difficult to diagnose metastases of breast cancer to the esophagus because they are often located in the submucosa and covered with normal mucosa. Although several methods have been reported in order to obtain specimens for pathological diagnosis, the adverse effects including bleeding and perforation were considerable problems. We report a case of a patient with esophageal stricture due to metastatic breast cancer to the esophagus. Pathological diagnosis was successfully obtained using endoscopic mucosal resection of the esophagus.

Technical modification of the double-balloon endoscopy to access to the proximal side of the stenosis in the distal colon.

BACKGROUND: The inability to pass endoscopes beyond strictures is a considerable problem in patients with a colonic stricture. METHODS: In patients with bowel obstruction, we have modified the insertion method for double-balloon endoscopy with a long, transnasal decompression tube. OBSERVATIONS: We have succeeded in reaching the proximal side of the stricture from the oral approach across the entire small bowel in a patient. CONCLUSIONS: This modified double-balloon enteroscopy is useful for patients with bowel obstruction in whom a long decompression tube is already placed.

Clinical outcomes of double-balloon endoscopy for the diagnosis and treatment of small-intestinal diseases.

BACKGROUND & AIMS: A specialized system for a new method for enteroscopy, the double-balloon method, was developed. The aim of this study was to evaluate the usefulness of this endoscopic system for small-intestinal disorders. METHODS: The double-balloon endoscopy system was used to perform 178 enteroscopies (89 by the anterograde approach and 89 by the retrograde approach) in 123 patients. The system was assessed on the basis of the rates of success in jejunal and ileal insertion and the entire examination of the small intestine, diagnostic yields, ability to perform treatment, and complications. RESULTS: Insertion of the endoscope beyond the ligament of Treitz or ileocecal valve was possible in all 178 procedures. It was possible to observe approximately one half to two thirds of the entire small intestine by each approach, and observation of the entire small intestine was possible in 24 (86%) of 28 trials. The source of bleeding was identified in 50 (76%) of 66 patients with GI bleeding, scrutiny of strictures was possible in 23 patients, and a tumor was examined endoscopically in 17 patients. Two complications (1.1%) occurred. Endoscopic therapies in the small intestine including hemostasis (12 cases), polypectomy (1 case), endoscopic mucosal resection (1 case), balloon dilation (6 cases), and stent placement (2 cases) were performed successfully. CONCLUSIONS: Double-balloon endoscopy permits the exploration of the small intestine with a high success rate of total enteroscopy. The procedure is safe and useful, and it provides high diagnostic yields and therapeutic capabilities.