Introduction

Mucosal redness (so called Map-like redness) after Helicobacter pylori (H. pylori) eradication therapy reflects intestinal metaplasia clarified by changes of intra-gastric condition and repairs for gastric mucosa. It is difficult to distinguish Map-like redness and gastric cancer. Map-like redness is a high risk condition for post H. pylori eradicated gastric cancer. Consideration about histopathological findings of mucosal redness after H. pylori eradication therapy are not enough.

Aims & Methods

Image-enhanced endoscopy plays an important role in the detection and further examination of gastritis and early gastric cancer (EGC). LCI is also useful for detecting and evaluating gastritis, gastric intestinal metaplasia as a pre-cancerous lesion, and EGC. To investigate correlation between the color difference and immuno-histochemical findings for mucosal redness (map-like redness; intestinal metaplasia) detected by white light and LCI in patients with successful H. pylori eradication history. We get the endoscopic images by conventional white light image (WLI) and LCI with LASEREO system (FujiFilm, Tokyo, Japan), and evaluate color values (CIE L*a*b* color space and color analysis by Adobe Photoshop C54). Furthermore, we evaluate intestinal metaplasia histopathologically with the immuno-staining by MUC2/MUC5AC/HID-AB; phenotype (Gastro-intestinal Mixed type or Intestinal type, Incomplete type or Complete type) and relationship between color differences and phenotype of intestinal metaplasia.

Results

(1) Objects are 36 patients (24 males, range 56-87yo, median 71yo) and 43 lesions after successful H.pylori eradication therapy; cancer group 15 patients (20 lesions), non-cancer group 21 patients (23 lesions)
(2) Type of intestinal metaplasia in the cancer group and the non-cancer group: GI Mixed type 14/7(cancer group/non-cancer group), p<0.01, Incomplete type 14/6(cancer group/non-cancer group), p<0.01.
(3) In the cancer group, color differences Δa (Green to Red) with LCI between the lesion and the surrounding mucosa is significantly high compared with the non-cancer group (16.0±6.6 vs 11.8±7.0;p<0.05).
(4) Compared severe intestinal metaplasia with none/mild/moderate intestinal metaplasia, color value b (Blue to Yellow) with LCI is significantly low (20.4±9.5 vs 25.9±8.0; p<0.05)
(5) Compared GI mixed type with intestinal type of intestinal metaplasia, color values b (Blue to Yellow) with LCI is significantly low (19.2±8.6 vs 26.4±8.5; p=0.008).

Conclusion

In this study, we observed differences in LCI color values of map-like redness appearing after H. pylori eradication depending on the type of intestinal metaplasia. In particular, the gastric cancer group has a high rate of Gastro-intestinal Mixed Type with a high risk of carcinogenesis. This suggests the usefulness of image enhancement by LCI as a marker for the high-risk group of gastric cancer.

References

Umegaki, E. et al. Linked Color Imaging for Stomach. Diagnostics 2023, 13, x. https://doi.org/10.3390/xxxxx

Introduction

Linked color imaging (LCI), a unique image-enhanced endoscopy technique, expands the color range to enhance the recognition of subtle mucosal differences, facilitating early lesion detection. Recently, the advantage of LCI in cancer visibility and detection has been reported especially in Helicobacter pylori (H. pylori)-negative gastric cancer including cases post-eradication.¹ However, the correlations between the color of LCI’s visualized mucosa and histological findings have not been thoroughly investigated.

Aims & Methods

This study aimed to investigate relationships between color values and histological findings visualized by LCI in H. pylori-negative gastric cancer.
Thirty-two patients with H. pylori-negative, differentiated-type intramucosal gastric cancer (≤20 mm) who underwent endoscopic submucosal dissection were retrospectively reviewed. Images captured with LCI and white light imaging (WLI) were analyzed using the CIE1976 (L^*a^*b^*) color space, as defined by the International Commission on Illumination (CIE).² Three regions of interest, each measuring 10 × 10 pixels, were set on the malignant tumor and adjacent mucosa to the border. The values of a^*(red-green) and b^* (yellow-blue) and the color difference (ΔE), which represents the overall difference between the two colors, were calculated. Histopathological evaluation using Hematoxylin-Eosin stained specimens was performed to highlight the demarcation between cancerous and noncancerous mucosa in a width of 1.0 mm inside and outside the lesion. Vascular density, glandular density, mucosal thickness, and the degrees of intestinal metaplasia (IM) were measured. Vascular density was calculated as the percentage of the occupied blood vessels in an area up to 200 μm from the surface. And the proportion of IM relative to the glands was measured and classified as the severe IM (≥60%), moderate IM (≥30% and <60%), or mild IM (<30%) groups.

Results

LCI significantly increased ΔE between the cancer and surrounding mucosa compared with WLI (P < 0.001); however, no significant differences in Δa^* and Δb^* were observed between LCI and WLI. Moderate correlations were observed between LCI a^* values and vascular density (ρ = 0.39, P < 0.001) and between LCI b^* values and the proportion of IM (ρ = −0.49, P < 0.001). Furthermore, the vascular density of cancer in the 0−100 μm depth showed a moderate correlation with the LCI a^* values (ρ = 0.41, P < 0.001). Severe IM significantly decreased the LCI b^* values compared with mild and moderate IM (P = 0.02, P < 0.001).

Conclusion

LCI quantitatively visualizes the superficial vascularity of cancer lesions and the presence of IM of the background mucosa in H. pylori-negative patients. It is a potential noninvasive tool for gastric cancer risk stratification and early detection.

References

1. Kato M, Ono S, Kawada K et al. Diagnostic performance of linked color imaging for gastric cancer by Helicobacter pylori infection status: a subanalysis of the large-scale, multicenter randomized controlled trial LCI-FIND. Helicobacter 2024; 29: e1308.
2. Kuehni RG. Color-tolerance data and the tentative CIE 1976 L a b formula. J Opt Soc Am 1976; 66: 497–500.

Disclosure

Shoko Ono has received lecture and/or consulting fees from Fujifilm.

Introduction

Repeated endoscopy is recommended to detect early-stage cancer or Barrett's oesophagus known as a precancerous lesion at the gastro-oesophageal junction (GOJ) in GERD patients. Transnasal endoscopy is considered suitable for this repeated endoscopy because of less discomfort in the throat compared to conventional (peroral) endoscopy. Thus, improvement of imaging technique at the GOJ by transnasal endoscopy is one of important issues.

Aims & Methods

To evaluate the usefulness of trasnasal endoscopy equipped with high-resolution imaging, blue laser imaging (BLI) bright and linked color imaging (LCI) for the detection short-segment Barrett’s oesophagus (SSBO). We analyzed 300 images at the GOJ acquired from 100 consecutive endoscopies performed at our medical check-up center. Each endoscopy includes white light imaging (WLI), BLI bright and LCI. Ten endoscopists independently interpreted the images on SSBO and endoscopic findings related Barrett’s oesophagus, including palisade vessels of squamo-columnar junction (SCJ) oral side (PV-O), palisade vessels of anal side (PV-A), squamous island (SI) and columnar island (CI). The quality of images for visualization was judged as: excellent visibility (score of 4), good visibility (3), fair visibility (2), or not detectable (1) were evaluated.

Results

The detection rates of each image were as follows (WLI, BLI bright and LCI respectively): SSBO 28.3%, 32.7% and 38.8%; PV-O 88.5%, 83.1% and 90.5%; PV-A 47.3%, 51.1% and 63.2%; SI 9.2%, 9.5% and 9.8%; CI 18.4%, 28.7% and 28.7%. The detection rates of LCI were significantly higher than that of WLI on SSBO, PV-O, PV-A, SI and CI, and that of BLI-bright on PV-A and PV-O. The mean visibility scores (± standard deviation) were as follows: SSBO 1.59 ± 1.02, 1.65 ± 1.03 and 1.86 ± 1.18; PV-O 3.23 ± 1.05, 3.00 ± 1.15 and 3.36 ± 1.01; PV-A 1.99 ± 1.18, 1.98 ± 1.13 and 2.40 ± 1.25; SI 1.18 ± 0.60, 1.21 ± 0.66 and 1.20 ± 0.63; CI 1.43 ± 0.95, 1.74 ± 1.19 and 1.84 ± 1.43. The visibility scores for LCI were significantly higher than that for WLI and BLI-bright on SSBO and all items of related findings (<0.001). Moreover, PV-A showed the strongest correlation with SSBO on visibility score among endoscopic findings related to SSBO (R=0.500; p<0.001).

Conclusion

These results suggest that LCI with transnasal endoscopy is quite effective for the observation GOJ and detecting SSBO.

Introduction

The prevalence of Helicobacter pylori (H.pylori) positive patients has gradually decreased in Japan due to eradication therapy, and H.pylori-uninfected gastric cancer (HPUGC) is expected to increase relatively. Recently, HPUGC, such as gastric adenocarcinoma of fundic-gland type (GAFG), gastric adenocarcinoma of foveolar-type (GAFV), adenocarcinoma of differentiated type (DGA) and signet ring cell carcinoma (SRCC) has been increasingly reported. Since the detection and endoscopic diagnosis of HPUGC is considered to be difficult [1]. The effective observation methods in screening endoscopy to detect HPUGC. In this context, a new image enhancement technology called Texture and Color Enhancement Imaging (TXI; Olympus Medical Systems Corporation) which optimizes the three elements: structure (texture) enhancement, color tone, and brightness correction was developed in 2020. There have been several reports on the usefulness of TXI for the detection and endoscopic diagnosis of mucosal atrophy or gastric neoplasm [2-6]. However, the usefulness of TXI for the detection of HPUGC has been investigated.

Aims & Methods

The aim of the study is to investigate whether the visibility of HPUGC improved using TXI and NBI compared with WLI as a single-center retrospective clinical study. We enrolled 40 HPUGC lesions endoscopically imaged with WLI, TXI-1, TXI-2, and NBI in our facility between October 2020 and March 2023. In addition, the visibility of HPUGCs was analyzed for each factor, such as histological type, coloration, and macroscopic type. Ten endoscopists (5 experts and 5 non-experts) evaluated the images, and visibility changes were scored by endoscopists as follows: 5, improved; 4, somewhat improved; 3, equivalent; 2, somewhat decreased; and 1, decreased. The total visibility score of ≥40 in all endoscopists and /≥20 in each of the 5 endoscopists was defined as improved visibility, 21-39/11-19 as unchanged visibility, and 20≤/10≤ as decreased visibility. The intraclass correlation coefficients (ICC) were calculated and evaluated for inter-rater agreement.

Results

The histological types were classified as GAFG (n=24), GAFV (n=9), DGA (n=4), and SRCC (n=3). There were 17 reddish lesions and 23 whitish lesions. In the macroscopic type, there were type 0-Ⅰ (n=11), type 0-Ⅱa (n=13), type 0-Ⅱb (n=11), and type 0-Ⅱc (n=5) lesions. The visibility improvement rate for all endoscopists in all HPUGCs was TXI-1: 55%, TXI-2: 29.7%, and NBI: 7.5%. The overall ICCs were TXI-1: 0.86, TXI-2: 0.84, and NBI: 0.90, which were almost perfect. GAFG (all/experts/trainees: 79/54/79%) and SRCC (all/experts/trainees: 67/67/67%) showed improved visibility with TXI-1. In contrast, GAFV and DGA did not improve the visibility. The whitish lesions (all/experts/trainees: 74/52/74%) showed improved the visibility with TXI-1, but the reddish lesions did not improve visibility. Among the macroscopic type , type 0-Ⅱa (overall/experts/trainees: 85/54/85%) and type 0-Ⅱb (overall/experts/trainees: 73/64/73%) showed improved visibility with TXI-1. The all ICCs of each factor were above 0.7, which indicated generally good correlations.

Conclusion

The usefulness of TXI-1 compared with WLI led to the improved visibility of the whitish lesions such as GAFG and SRCC for both experts and trainees when evaluated subjectively and objectively.

References

1. Ishibashi, F., et al., Exploring quality indicators for the detection of Helicobacter pylori-naïve gastric cancer: a cross-sectional nationwide survey. Clinical Endoscopy, 2023. Apr 4. doi: 10.5946/ce.2022.167.
2. Abe, S., et al., Emerging texture and color enhancement imaging in early gastric cancer. Dig Endosc, 2022. 34(4): p. 714-720.
3. Sugimoto, M., et al., Efficacy of high-vision transnasal endoscopy using texture and colour enhancement imaging and narrow-band imaging to evaluate gastritis: a randomized controlled trial. Ann Med, 2022. 54(1): p. 1004-1013.
4. Abe, S., et al., Visibility of early gastric cancer in texture and color enhancement imaging. DEN Open, 2022. 2(1): p. e46.
5. Ishikawa, T., et al., Efficacy of Texture and Color Enhancement Imaging in visualizing gastric mucosal atrophy and gastric neoplasms. Sci Rep, 2021. 11(1): p. 6910.
6. Kawasaki, A., et al., Usefulness of third-generation narrow band imaging and texture and color enhancement imaging in improving visibility of superficial early gastric cancer: A study using color difference. DEN Open, 2022. 3(1): p. e186.

Introduction

There are several reports about the diagnosis of early gastric cancers (EGCs) using artificial intelligence (AI) systems, but satisfactory data for sensitivity and specificity are not yet available. Linked color imaging (LCI) produces high color contrast between malignant lesions and surrounding mucosa compared to white light imaging (WLI). Therefore, LCI combined with AI (LCI-AI) has the potential to further improve the diagnosis of gastric cancer compared with WLI combined with AI (WLI-AI). We developed three new LCI-AI models to determine their sensitivity and specificity for the diagnosis of EGCs.

Aims & Methods

Three models including a convolutional neural network (CNN) model (high resolution net (HRNet)), a transformer model (Segformer) and a hybrid (combined CNN and transformer) model (Uniformer), were based on MMSegmentation. When each model recognized a gastric cancer lesion from test image data, it was shown with the existing position as a blue area on WLI images and green area on LCI images. Non-neoplastic mucosa was shown as a black area on both images. Endoscopic images using WLI and LCI (LASEREO 7000 system series and scopes of EG-L600ZW and EG-L600ZW7, Fujifilm Corporation, Tokyo, Japan) were collected from patients with EGCs from January 2015 to December 2018 at Jichi Medical University Hospital. A total of 1970 images including 1179 WLI and 791 LCI images of 236 EGCs were used for training the three LCI-AI models. Another set of 414 EGC images was selected for validation from 43 cases. Primary and secondary endpoints were the sensitivity and specificity of each AI model, respectively.
The image-based performance metric was based on Dice loss, calculated by subtracting the mean Dice similarity score. A Dice score >20% was defined as the correct diagnosis of cancer because EGCs sometimes have unclear demarcation lines. The correct diagnosis of a non-malignant lesion was defined as no reactive black areas in surrounding mucosae. Each case had from four to 21 images. Therefore, the median Dice score was used as a representative value in each case to evaluate performance. All three models’ programming and data analysis were supported by AI Medical Service Inc. (Tokyo, Japan).

Results

Analysis of lesions in all EGC images showed both sensitivity (82.8%) and specificity (83.4%) with LCI-AI to be high and similar to those with WLI-AI (83.1% and 84.3%, respectively). Sensitivities of LCI-AI/ WLI-AI among HRNet, SegFormer and UniFormer were 80.9%/81.6% (p=0.625), 83.8%/83.8% (p=0.224) and 83.8%/83.8% (p=0.450), respectively and specificities were 80.0%/86.0% (p=0.120), 86.4%/84.8% (p=0.672) and 86.8%82.0%/ (p=0.214), respectively. Representative Dice values among cases with EGCs showed sensitivities for LCI-AI using HRNet, SegFormer and UniFormer to be extremely high, at 92.7% 90.9% and 93.0%, respectively, although not significantly different when compared to those using WLI-AI, 84.6% (p=0.67), 85.4% (p=0.15) and 80.5% (p=0.19), respectively. Higher sensitivities were found regardless of lesion size, morphology, and Helicobacter pylori status. All sensitivities using LCI-AI were higher than 80% whereas those using WLI-AI varied from 64% to 89%.

Conclusion

LCI-AI showed high sensitivity and specificity for the diagnosis of EGCs using all three models tested, suggesting potential for practical clinical use in the near future.

Disclosure

Hiroyuki Osawa and Hironori Yamamoto have consultant relationships with Fujifilm Corporation and have received honoraria, grants and royalties from the company. Hiroyuki Osawa has a consultant relationship with AI Medical survice inc. and has recieved honoraria.This study received no funding from Fujifilm Corporation and AI Medical survice inc. nor any other funding source.

Introduction

Data evaluating the utility of Blue light Imaging (BLI) and Linked Color Imaging (LCI) in the diagnosis of gastric intestinal metaplasia (IM) and atrophic gastritis (AG) is limited.

Aims & Methods

We aimed to evaluate and compare the diagnostic accuracy of BLI and LCI without magnification for the detection of IM and AG.
Single centre prospective study involving consecutive patients aged ≥18 years undergoing diagnostic upper gastrointestinal endoscopy (UGIE), endoscopic follow-up of intestinal metaplasia or gastric cancer screening. Exclusion criteria: previous gastrectomy, contraindication to UGIE due to comorbidities, no gastric mucosal biopsies, refusal of consent. Endoscopy was initially performed with white light image (WLI), followed by BLI and LCI. Standardized photodocumentation of stomach was performed with WLI, BLI and LCI. Imaging features suggestive of IM: lavender color sign and whitish flat elevation with LCI, and light blue crest and white opaque substance with BLI. EGGIM and Kimura-Takamoto Classification (KTC) were applied when IM and AG were suspected. Systematic random biopsies of the antrum, incisura angularis and corpus along with targeted biopsies of suspicious gastric mucosal lesions were obtained. Histology was considered gold standard. Performance of endoscopic imaging in the detection of IM, AG and EGC was evaluated.
Initially, 134 patients were evaluated and 64 were excluded: previous gastrectomy-22, pending histology-20, non-BLI imaging-15, intolerance to UGIE-3, refusal of consent-1, esophageal stenosis-1 and contra-indication to biopsies-2. Final sample included 70 patients.
Qualitative data expressed as percentage were compared with Chi-square test. A p value of <0.05 was considered significant.

Results

Median age was 56 (19-86), with 49 (63%) female. There was family history of gastric cancer in 12(15%) and history of smoking in 35 (44%).
Histological AG was found in 15 (19%) and IM in 20 (26%) patients. WLI was suggestive of IM in 14(20%), confirmed histologically in 9 (64%). IM was suspected by LCI and BLI in 24 (34%) and 23 (32%) cases, confirmed by histology in 16 (67%) and 17 (74%), respectively.
WLI classified 56 (71%) as EGGIM 0 and after LCI and BLI, 10 (18%) and 8 (15%) of these cases had EGGIM 1 or 2. In 10 patients, EGGIM 1-2 with WLI, only 1 was upgraded to EGGIM 3-4 with LCI and BLI. In 3 (4%) EGGIM 3-4 with WLI, after LCI and BLI,1 had extensive IM (EGGIM 6). Among 19(24%) patients EGGIM 1-2 with LCI, 3(16%) had EGGIM 0 with BLI.
Atrophy was suspected by WLI and LCI in 9(12%) and 15(21%) patients, confirmed by histology in 6(67%) and 8(53%) cases, respectively. According to KTC, 5 (6%) were classified as C1, 2 (3%) as C2 and 4 (5%) as O3 with WLI. With LCI images, 8 (10%) were classified as C1, 3(4%) as C2 and 4(5%) as O3. The sensitivity (Sens), specificity (Spec), accuracy, positive predictive value (PPV), negative predictive value (NPV) of WLI, BLI and LCI in detecting AG and IM are shown in table 1.


Table 1. Sens, Spec, accuracy, PPV and NPV in detecting AG and IM with WLI, LCI and BLI.

Conclusion

Both BLI and LCI are promising advanced endoscopic imaging techniques with BLI having higher accuracy than LCI in detection of IM.

References

1. Chen H, Liu Y, Lu Y, Lin X, Wu Q, Sun J, et al. Ability of blue laser imaging with magnifying endoscopy for the diagnosis of gastric intestinal metaplasia. Lasers Med Sci. 2018 Nov 1;33(8):1757–62.
2. Ono S, Abiko S, Kato M. Linked color imaging enhances gastric cancer in gastric intestinal metaplasia. Vol. 29, Digestive Endoscopy. Blackwell Publishing; 2017. p. 230–1.
3. Ono S, Kato M, Tsuda M, Miyamoto S, Abiko S, Shimizu Y, et al. Lavender Color in Linked Color Imaging Enables Noninvasive Detection of Gastric Intestinal Metaplasia. Digestion. 2018 Nov 1;98(4):222–30.
4. Zhang G, Zheng J, Zheng L, Yu S, Jiang C, Lin W, et al. Gastric intestinal metaplasia assessment between linked color imaging based on endoscopy and pathology. Scand J Gastroenterol. 2021;56(1):103–10.
5. Shu X, Wu G, Zhang Y, Wang Y, Zheng Y, Guo Q, et al. Diagnostic value of linked color imaging based on endoscopy for gastric intestinal metaplasia: a systematic review and meta-analysis. Ann Transl Med. 2021 Mar;9(6):506–506.
6. Esposito G, Pimentel-Nunes P, Angeletti S, Castro R, Libânio D, Galli G, et al. Endoscopic grading of gastric intestinal metaplasia (EGGIM): A multicenter validation study. Endoscopy. 2019;51(6):515–21.

Introduction

Atrophy and intestinal metaplasia (IM) are well-defined preneoplastic conditions and their endoscopic appearance may be subtle. The importance of their identification lies in the fact that it allows the recognition of a high-risk population, enabling an appropriate follow-up.¹ The stigmata of chronic gastritis have been extensively studied and validated with Narrow Band Imaging (NBI) worldwide, while European studies with Blue Light Imaging (BLI) are still limited.^2,3

Aims & Methods

The primary aim of this study is to evaluate the applicability of BLI in characterizing chronic gastritis (CG), atrophy and IM comparing it to the gold-standard histology.
All patients undergoing upper digestive endoscopy requiring gastric biopsies, between November 2023 and March 2024, who agreed to participate after written informed consent, were prospectively included. Gastric mucosa was endoscopically evaluated using white light (WL), Linked Colour Imaging (LCI) and BLI, documenting findings and performing biopsies for mapping. Patients with history of gastric surgery were excluded. Statistical analysis was performed using IBM SPSS Statistics version 26®.

Results

A total of 169 patients were included, 55.6% female, with a mean age of 60.2±15.2 years. At the time of the endoscopy, most of the patients had never been tested for Helicobacter pylori (74.0%), 12.4% had confirmed eradication, 7.1% had previous negative tests and 6.5% had active infection. There was a family history of gastric cancer in 14.2% of patients. Of all endoscopies, 53.8% were performed without any type of sedation. For the evaluation of CG, BLI, LCI and WL were similar (sensitivity = 91.8% vs 92.6% vs 90.2%; specificity = 16.3% vs 14.0% vs 18.6%; positive predictive value (PPV) = 75.7% vs 75.3% vs 75.9%; negative predictive value (NPV) = 41.2% vs 40.0% vs 40.0%; area under ROC curve (AUROC) = 0.54 vs 0.53 vs 0.54, respectively; BLI vs WL p-value 0,87; LCI vs WL p-value 0,54; BLI vs LCI p-value 0,54), as well as for atrophy (sensitivity = 85.9% vs 85.9% vs 84.4%; specificity = 25.7% vs 25.7% vs 31.7%; PPV = 42.3% vs 42.3% vs 43.9%; NPV = 74.3% vs 74.3% vs 76.2%; AUROC = 0.56 vs 0.56 vs 0.58, respectively; BLI vs WL p-value 0.17; LCI vs WL p-value 0.12; BLI vs LCI p-value 1.0). On the other hand, the diagnostic accuracy of BLI was superior to LCI, and both were superior to WL for IM, although at the expense of a higher rate of false positives (sensitivity = 65.9% vs 50.5% vs 34.1%; specificity = 77.2% vs 82.2% vs 85.6%; PPV = 39.5% vs 39.0% vs 34.8%; NPV = 91.0% vs 88.1% vs 85.2%; AUROC = 0.72 vs 0.66 vs 0.60, respectively; BLI vs WL p-value <0.001; LCI vs WL p-value 0.01; BLI vs LCI p-value 0.009). Considering those who underwent endoscopy without any type of sedation, only BLI showed superiority when compared to WL (p-value 0.045) but not to LCI (p-value 0.41). Also, in this subgroup, LCI was not superior to WL. However, in the subgroup who underwent sedation, the diagnostic accuracy of BLI was even better than the global results (AUROC = 0.79; BLI vs WL p-value <0.001; BLI vs LCI p-value 0.006). There were eleven visible lesions identified, three of which were detected only with BLI assessment (two with low-grade and one with high-grade dysplasia).

Conclusion

BLI appears to increase the diagnostic accuracy of IM when compared to LCI and WL, and LCI when compared to WL. Regarding the assessment of CG and atrophy, there seems to be an overestimation of findings due to the high rate of false positives. Given the focal nature of IM, sedation is vital for adequate identification and targeted tissue sampling.

References

1. Pimentel-Nunes P, et al.; Management of epithelial precancerous conditions and lesions in the stomach (MAPS II): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG), European Society of Pathology (ESP), and Sociedade Portuguesa de Endoscopia Digestiva (SPED) guideline update 2019. Endoscopy. 2019 Apr;51(4):365-388.
2. Jochen Weigt, et al.; Blue Light Imaging and Linked Color Imaging for the Characterization of Mucosal Changes in Chronic Gastritis: A Clinicians View and Brief Technical Report. Dig Dis 8 January 2020; 38 (1): 9–14.
3. Castro, R., et al.; Reliability and accuracy of blue light imaging for staging of intestinal metaplasia in the stomach. Scandinavian Journal of Gastroenterology, 54(11), 1301–1305.