Evaluation of Minimal Change Lesions Using Linked Color Imaging in Patients With Nonerosive Reflux Esophagitis

Abstract

Background and Aims: High prevalence of minimal change lesion (MCL) in nonerosive reflux esophagitis (NERD) patients is commonly recognized by many endoscopists. However, it is difficult to detect MCL with conventional white-light imaging (WLI) endoscopy. Linked color imaging (LCI), a novel image-enhanced endoscopy technology with strong, unique color enhancement, is used for easy recognition of early gastric cancer and detection of Helicobacter pylori infection. The aim of the study was to compare the efficacy of LCI and WLI endoscopy in evaluating MCL in patients with NER. Materials and Methods: Forty-one patients with NERD and 38 subjects with nongastroesophageal reflux disease (non-GERD) were recruited in this study between August 2017 and July 2018. During upper gastrointestinal endoscopy, the distal 5 cm of the esophageal mucosal morphology at the squamocolumnar junction was visualized using WLI followed by LCI. MCL was defined as areas of erythema, blurring of the Z-line, friability, decreased vascularity, white turbid discoloration, and edema or accentuation of the mucosal folds. Three experienced endoscopists evaluated the color patterns for MCL on WLI images and on WLI combined with LCI images in both groups. A biopsy was taken 2 cm above the esophagogastric junction. Histologic slides were scored by a pathologist in a blinded manner. Results: The proportion of MCL was higher in the patients with NERD (70.7%, 29/41) than in patients with non-GERD (39.5%, 15/38) using WLI combined with LCI. In 12 patients with NERD, both WLI and LCI showed normal mucosa. The MCL detection rate was significantly higher when using WLI combined with LCI than when using WLI (70.7% vs. 51.2%, P=0.039) in patients with NERD. The histopathologic score of MCL (+) was significantly higher than that of MCL (−) patients in both the NERD group (4.59±0.32 vs. 2.36±0.34, P<0.01) and the non-GERD group (3.47±0.50 vs. 2.00±0.28, P<0.01). The intraobserver reproducibility levels and interobserver agreement were better with LCI than with WLI alone. Conclusions: Frequency of MCL was higher in patients with NERD than in those with non-GERD. MCL can be identified by using WLI combined with LCI in patients with NERD. By enhancing endoscopic images, LCI is more sensitive in detecting MCL compared with WLI.

Linked color imaging improves the diagnostic accuracy of eosinophilic esophagitis

“…Therefore, we referred to two previous reports investigating the usefulness of LCI for the endoscopic diagnosis of minimal change esophagitis, 28 ,46 in which the addition of LCI on WLI increased the detection rate by 15%–20% compared with WLI alone, increased the inter‐observer agreement from “moderate” to “almost perfect” 28 and “moderate” to “substantial”, 44 and increased the intra‐observer agreement from “fair/moderate” to “moderate/substantial” 28 and “moderate” to “substantial”. 44 Second, we did not objectively evaluate the color difference between WLI and LCI using the CIE Lab color space system. 45 Third, it was impossible to use the images of WLI and LCI taken under the same conditions because LCI is created by pre‐processing and post‐processing technology, although we prepared paired images with as many similar compositions as possible.…”

“…First, the sample size was small, and appropriate sample size to detect statistical significance was not calculated because of the lack of referable reports investigating the efficacy of LCI for the diagnosis of EoE. Therefore, we referred to two previous reports investigating the usefulness of LCI for the endoscopic diagnosis of minimal change esophagitis, 28 ,46 in which the addition of LCI on WLI increased the detection rate by 15%–20% compared with WLI alone, increased the inter‐observer agreement from “moderate” to “almost perfect” 28 and “moderate” to “substantial”, 44 and increased the intra‐observer agreement from “fair/moderate” to “moderate/substantial” 28 and “moderate” to “substantial” 44 . Second, we did not objectively evaluate the color difference between WLI and LCI using the CIE Lab color space system 45 .…”

Endoscopic Diagnosis of Eosinophilic Esophagitis: Basics and Recent Advances

“…LCI is a newly-developed IEE created by short-wavelength narrow-band laser light combined with white laser light, enabling brighter light in a distant area, and enhancing color differences between red and white [ 71 ]. It has been increasingly reported that LCI can improve various esophageal diseases, such as minimal change esophagitis [ 72 , 73 ], erosive esophagitis [ 74 ], Barrett’s esophagus, and esophageal adenocarcinoma [ 75 , 76 , 77 ]. There is a brief report showing that LCI could effectively detect an area of active inflammation, which was observed as yellowish mucosa, compared with cyan or light purple mucosa without active inflammation [ 78 ] ( Figure 5 ).…”

Application of linked color imaging in the diagnosis of early gastrointestinal neoplasms and precancerous lesions: a review

“…Minimal changes are more easily recognizable using LCI, as the white areas appear whiter and the red areas appeared redder. 12,13…”

“…Minimal changes are more easily recognizable using LCI, as the white areas appear whiter and the red areas appeared redder. 12,13 Barrett's esophagus is a risk factor for esophageal adenocarcinoma. As the incidence of GERD has increased, the incidence of Barrett's esophagus and esophageal adenocarcinoma has also increased.…”