Background and Aims: Recently, there have been some reports that image-enhanced endoscopy may improve detection of gastric intestinal metaplasia (GIM). Our aim was to determine the usefulness of linked color imaging (LCI) for detection of GIM. Methods: In prospectively recruited patients, the whole antrum was observed by white light imaging (WLI) followed by LCI. When a whitish flat elevation (WFE) in WLI and a lavender color sign (LCS) in LCI were detected, target biopsies were performed after LCI. Random biopsies were performed in patients who had neither WFE nor LCS. The primary endpoint was the diagnostic accuracy of GIM per patient in WLI and LCI and the secondary endpoints were that of GIM per biopsy and interobserver agreement. Results: Data from 128 patients were analyzed and 58 patients (45.3%) had histological GIM in the antrum. The per-patient yields of WLI and LCI to detect GIM were 19.0% (11/58) and 91.4% (53/58) respectively. Diagnostic accuracies of target biopsies for GIM were 23.7% in WLI and 84.2% in LCI. Kappa values among 3 doctors were 0.60 for WFE and 0.78 for LCS respectively. Conclusion: LCI could be a new diagnostic tool for detecting GIM during routine endoscopy.

Correa P: A human model of gastric carcinogenesis. Cancer Res 1988; 48: 3554–3560.
Uemura N, Okamoto S, Yamamoto S, Matsumura N, Yamaguchi S, Yamakido M, Taniyama K, Sasaki N, Schlemper RJ: Helicobacter pylori infection and the development of gastric cancer. N Engl J Med 2001; 345: 784–789.
de Vries AC, van Grieken NC, Looman CW, Casparie MK, de Vries E, Meijer GA, Kuipers EJ: Gastric cancer risk in patients with premalignant gastric lesions: a nationwide cohort study in the Netherlands. Gastroenterology 2008; 134: 945–952.
Kaminishi M, Yamaguchi H, Nomura S, Oohara T, Sakai S, Fukutomi H, Nakahara A: Endoscopic classification of chronic gastritis based on a pilot study by the Research Society for Gastritis. Dig Endosc 2002; 14: 138–151.
Tatsuta M, Iishi H, Ichii M, Noguchi S, ­Okuda S, Taniguchi H: Chromoendoscopic observations on extension and development of fundal gastritis and intestinal ­metaplasia. Gastroenterology 1985; 88: 70–74.
Fennerty MB, Sampliner RE, McGee DL, Hixson LJ, Garewal HS: Intestinal metaplasia of the stomach: Identification by a selective mucosal staining technique. Gastrointest Endosc 1992; 38: 696–698.
Olliver JR, Wild CP, Sahay P, Dexter S, Hardie LJ: Chromoendoscopy with methylene blue and associated DNA damage in Barrett’s oesophagus. Lancet 2003; 362: 373–374.
Uedo N, Ishihara R, Iishi H, Yamamoto S, Yamamoto S, Yamada T, Imanaka K, Takeuchi Y, Higashino K, Ishiguro S, Tatsuta M: A new method of diagnosing gastric intestinal metaplasia: narrow-band imaging with magnifying endoscopy. Endoscopy 2006; 38: 819–824.
Okubo M, Tahara T, Shibata T, Yonemura J, Yoshioka D, Kamiya Y, Nakamura M, Arisawaz T, Ohmiya N, Hirata I: Light blue crest and ridge/villous patterns in the uninvolved gastric antrum by magnifying NBI endoscopy correlate with serum pepsinogen and gastric cancer occurrence. Hepatogastroenterology 2014; 61: 525–528.
Kanemitsu T, Yao K, Nagahama T, Imamura K, Fujiwara S, Ueki T, Chuman K, Tanabe H, Atsuko O, Iwashita A, Shimokawa T, Uchita K, Kanesaka T: Extending magnifying NBI diagnosis of intestinal metaplasia in the stomach: the white opaque substance marker. Endoscopy 2017; 49: 529–535.
Pimentel-Nunes P, Libânio D, Lage J, Abrantes D, Coimbra M, Esposito G, Hormozdi D, Pepper M, Drasovean S, White JR, Dobru D, Buxbaum J, Ragunath K, Annibale B, Dinis-Ribeiro M: A multicenter prospective study of the real-time use of narrow-band imaging in the diagnosis of premalignant gastric conditions and lesions. Endoscopy 2016; 48: 723–730.
Song J, Zhang J, Wang J, Guo X, Wang J, Liu Y, Dong W: Meta-analysis: narrow band imaging for diagnosis of gastric intestinal metaplasia. PLoS One 2014; 9:e94869.
Okada M, Sakamoto H, Takezawa T, Hayashi Y, Sunada K, Lefor AK, Yamamoto H: Laterally spreading tumor of the rectum delineated with linked color imaging technology. Clin Endosc 2016; 49: 207–208.
Fukuda H, Miura Y, Hayashi Y, Takezawa T, Ino Y, Okada M, Osawa H, Lefor AK, Yamamoto H: Linked color imaging technology facilitates early detection of flat gastric cancers. Clin J Gastroenterol 2015; 8: 385–389.
Ono S, Abiko S, Kato M: Linked color imaging enhances gastric cancer in gastric intestinal metaplasia. Dig Endosc 2017; 29: 230–231.
Kimura K, Takemoto T: An endoscopic recognition of the atrophic border and its significance in chronic gastritis. Endoscopy 1969; 3: 87–97.
Dixon MF, Genta RM, Yardley JH, Correa P: Classification and grading of gastritis. The updated Sydney System. International Workshop on the Histopathology of Gastritis, Houston 1994. Am J Surg Pathol 1996: 20: 1161–1181.
Fleiss JL: Measuring nominal scale agreement among many raters. Psychol Bull 1971; 76: 378–382.
Landis JR, Koch GG: The measurement of observer agreement for categorical data. Biometrics 1977; 33: 159–174.
Guarner J, Herrera-Goepfert R, Mohar A, Smith C, Schofield A, Halperin D, Sanchez L, Parsonnet J: Diagnostic yield of gastric ­biopsy specimens when screening for preneoplastic lesions. Hum Pathol 2003; 34: 28–31.
Rugge M, Genta RM; OLGA Group: Staging gastritis: an international proposal. Gastroenterology 2005; 129: 1807–1808.
Capelle LG, de Vries AC, Haringsma J, Ter Borg F, de Vries RA, Bruno MJ, van Dekken H, Meijer J, van Grieken NC, Kuipers EJ: The staging of gastritis with the OLGA system by using intestinal metaplasia as an accurate alternative for atrophic gastritis. Gastrointest Endosc 2010; 71: 1150–1158.
den Hoed CM, Holster IL, Capelle LG, de Vries AC, den Hartog B, Ter Borg F, Biermann K, Kuipers EJ: Follow-up of premalignant lesions in patients at risk for progression to gastric cancer. Endoscopy 2013; 45: 249–256.
El-Zimaity HM, Graham DY: Evaluation of gastric mucosal biopsy site and number for identification of Helicobacter pylori or intestinal metaplasia: role of the Sydney System. Hum Pathol 1999; 30: 72–77.
Nagata N, Shimbo T, Akiyama J, Nakashima R, Kim HH, Yoshida T, Hoshimoto K, Uemura N: Predictability of gastric intestinal metaplasia by mottled patchy erythema seen on endoscopy. Gastroenterology Res 2011; 4: 203–209.
Moribata K, Iguchi JK, Nakachi K, Maeda Y, Shingaki N, Niwa T, Deguchi H, Inoue I, Maekita T, Tamai H, Ichinose M: Endoscopic features associated with development of metachronous gastric cancer in patients who underwent endoscopic resection followed by Helicobacter pylori eradication. Dig Endos 2016; 28: 434–442.
Song KH, Hwang JA, Kim SM, Ko HS, Kang MK, Ryu KH, Koo HS, Lee TH, Huh KC, Choi YW, Kang YW: Acetic acid chromoendoscopy for determining the extent of gastric intestinal metaplasia. Gastrointest Endosc 2017; 85: 349–356.
Sha J, Wang P, Zhu B, Zhu M, Li X, Gao F: Acetic acid enhanced narrow band imaging for the diagnosis of gastric intestinal metaplasia. PLoS One 2017; 30:e0170957.
An JK, Song GA, Kim GH, Park DY, Shin NR, Lee BE, Woo HY, Ryu DY, Kim DU, Heo J: Marginal turbid band and light blue crest, signs observed in magnifying narrow-band imaging endoscopy, are indicative of gastric intestinal metaplasia. BMC Gastroenterol 2012; 27: 169.
Mizukami K, Ogawa R, Okamoto K, Shuto M, Fukuda K, Sonoda A, Matsunari O, Hirashita Y, Okimoto T, Kodama M, Murakami K: Objective endoscopic analysis with linked color imaging regarding gastric mucosal atrophy: a pilot study. Gastroenterol Res Pract 2017; 2017: 5054237.
Uchiyama K, Takagi T, Kashiwagi S, Toyokawa Y, Tanaka M, Hotta Y, Dohi O, Okayama T, Yoshida N, Katada K, Kamada K, Ishikawa T, Handa O, Konishi H, Kishimoto M, Yagi N, Naito Y, Itoh Y: Assessment of endoscopic mucosal healing of ulcerative colitis using linked colour imaging, a novel endoscopic enhancement system. J Crohns Colitis 2017; 11: 963–969.
Takeda T, Nagahara A, Ishizuka K, Okubo S, Haga K, Suzuki M, Nakajima A, Komori H, Akazawa Y, Izumi K, Matsumoto K, Ueyama H, Shimada Y, Matsumoto K, Asaoka D, Shibuya T, Sakamoto N, Osada T, Hojo M, Nojiri S, Watanabe S: Improved visibility of Barrett’s esophagus with linked color imaging: Inter- and intra-rater reliability and quantitative analysis. Digestion 2018; 97: 183–194.
Hisamatsu T, Ohno A, Chiba T: Linked color imaging identified ulcerative colitis-associated colorectal cancer: a case report. Dig Endosc 2018; 30: 267.
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