Novel endoscopic findings as visualized by non-magnification endoscopy with linked color imaging are indicative of gastric intestinal metaplasia

Abstract

Background: Gastric intestinal metaplasia (GIM) is generally considered to be the main mucosal background for the development of gastric adenocarcinomas. Using linked color imaging (LCI), we noticed that the color pattern in areas of GIM was purple mixed with white on the epithelium with signs of mist that were detected by the non-magnifying LCI observation. We have termed this endoscopic finding “Purple in Mist” (PIM). The aim of this study was to investigate whether PIM could be a useful optical sign for predicting GIM. Methods: We prospectively evaluated consecutive patients undergoing endoscopy for various indications. The endoscopist used the LCI system to carefully observe the gastric antrum, body and angulus. When a PIM was identified in the surface layer, targeted biopsies were subsequently taken from this part. If the suspected area had no PIM on the surface, targeted biopsies were also taken. Results: Sixty-three consecutive patients were included in this study. The prevalence of intestinal metaplasia (IM) was 29/63 (46%). In PIM-positive patients, the prevalence of IM was 23/26 (89%). Of these patients, 146 biopsy specimens were included in this study. For the diagnosis of IM, compared to histological assessment, the LCI finding had an accuracy of 91.1% (95%CI: 86.5%–95.7%), a sensitivity of 89.8% (95%CI: 81.3%–98.3%), a specificity of 91.8% (95%CI: 86.3%–97.2%), a positive predictive value of 84.6% (95%CI: 74.8%–94.4%), and a negative predictive value of 94.7% (95%CI: 90.1%–99.2%). Conclusions: A positive PIM finding in a suspicious lesion on LCI would complement LCI diagnosis of possible IM because of the positive predictive value of PIM. PIM could be a novel endoscopic marker for IM. Trial registration: ClinicalTrials.gov, No. NCT03092414; https://clinicaltrials.gov/ct2/show/NCT03092414?id=NCT03092414&rank=1

Diagnostic value of linked color imaging based on endoscopy for gastric intestinal metaplasia: a systematic review and meta-analysis

“…The blue laser endoscopy system that has appeared in recent years has performed well in diagnostic efficiency. Many studies have confirmed that by observing "PLC" (patchy lavender color with a regular mucosal pattern and a clear border) (16,18), "PIM" (Purple in Mist; purple mixed with white on the epithelium with signs of mist detected by the non-magnifying LCI observation) (19), or "LCS" (20) (a lavender color sign), along with other signs through LCI, the detection rate of GIM will significantly increase. In this paper, the sensitivity, specificity, and positive and negative likelihood ratios of LCI for the diagnosis of GIM were integrated through a systematic search of relevant literature, and an SROC curve was drawn to provide visual evidence of the diagnostic efficacy of LCI.…”

“…Compared with NBI, LCI offers greater emphasis of mucous membrane color changes. Furthermore, due to its sufficient brightness, LCI can visualize the purple changes in the gastric cavity which are characteristic of GIM (14,19), which is of considerable value for diagnosing GIM.…”

A prospective randomized tandem gastroscopy pilot study of linked color imaging versus white light imaging for detection of upper gastrointestinal lesions

“…With a long observable distance, LCI facilitates both screening and detailed observation of the GI tract 16 . Min et al 17 . showed that LCI has a high sensitivity and specificity for diagnosis of intestinal metaplasia.…”

The endoscopic predictors of Helicobacter pylori status: a meta-analysis of diagnostic performance

“…Various studies have investigated these appearances and suggested the 'maplike redness' may correlate with atrophy or intestinal metaplasia. 21,54 For the purposes of simplifying the prediction of H pylori status, the distinction may be of lesser importance, but the appearance may also suggest a target region for biopsy, for increasing the yield of further histological assessment. 55 The other finding predictive of an H pylori-eradicated status was found to be atrophic mucosa (DOR 4.0), although the diagnostic performance was inferior to that of map-like redness.…”

“…[12][13][14] In the modern era of high-definition endoscopy, the RAC has been confirmed as an important endoscopic predictor of an H pylori-naïve stomach, which is visible by careful observation without the aid of magnification. 15,16 Further mucosal features, including diffuse erythema, 17,18 linear erythema, 17,19 gastric erosions, 19 mucosal oedema, 20 swollen gastric folds, 20 mosaic appearance of mucosa, 18 fundic gland polyps, 19 mucosal atrophy, intestinal metaplasia 21 and gastric antral nodularity, 22 have been proposed to predict H pylori status. These features, and others, have been investigated to varying degrees, using a variety of endoscopic imaging modalities and study designs, and the Kyoto classification of gastritis divides patients into three groups: H pylori naïve (nongastritis), patients with current infection (active gastritis) and patients with past H pylori infection (inactive gastritis).…”