Clinical Endoscopy

Original Article

Clinicopathological and endoscopic features of Helicobacter pylori infection-negative gastric cancer in Japan: a retrospective study: Kentaro Imamura, Kenshi Yao, Satoshi Nimura, Takao Kanemitsu, Masaki Miyaoka, Yoichiro Ono, Toshiharu Ueki, Hiroshi Tanabe; Clin Endosc 2024;57(4):486-494. Published online March 22, 2024; DOI: https://doi.org/10.5946/ce.2023.258

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Background
/Aims: Helicobacter pylori infection-negative gastric cancer (HPNGC) has not been systematically investigated in consecutive patients. Hence, this study aimed to investigate the clinicopathological and endoscopic features of HPNGC.
Methods
This single-center retrospective study selected participants from patients with gastric cancer who were treated at the Fukuoka University Chikushi Hospital between January 2013 and December 2021. Only patients diagnosed with HPNGC were enrolled, and their clinicopathological and endoscopic features were analyzed in detail.
Results
The prevalence of HPNGC in the present study was 2.6% (54/2112). The types of HPNGC observed in each gastric region were as follows: advanced gastric cancer was observed in the cardia; gastric adenocarcinoma of fundic-gland differentiation, gastric adenocarcinoma of foveolar-type presenting with whitish elevation and raspberry-like foveolar-type gastric adenocarcinoma, gastric adenocarcinoma arising in polyposis, and gastric adenocarcinoma with autoimmune gastritis were observed in the fundic gland region ranging from the gastric fornix to the gastric body; signet-ring cell carcinoma was observed in the gastric-pyloric transition region ranging from the lower gastric body to the gastric angle; and well-differentiated tubular adenocarcinoma with low-grade atypia was observed in the antrum.
Conclusions
This study revealed that tumors from each gastric region exhibited distinct macroscopic and histological types in HPNGC.

Citations

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Is your endoscopist qualified enough to detect Helicobacter pylori-naive status?
Sun-Young Lee
Clinical Endoscopy.2024; 57(4): 466. CrossRef

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Review

E-learning system to improve the endoscopic diagnosis of early gastric cancer: Kenshi Yao, Takashi Yao, Noriya Uedo, Hisashi Doyama, Hideki Ishikawa, Satoshi Nimura, Yuichi Takahashi; Clin Endosc 2024;57(3):283-292. Published online August 3, 2023; DOI: https://doi.org/10.5946/ce.2023.087

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We developed three e-learning systems for endoscopists to acquire the necessary skills to improve the diagnosis of early gastric cancer (EGC) and demonstrated their usefulness using randomized controlled trials. The subjects of the three e-learning systems were “detection”, “characterization”, and “preoperative assessment”. The contents of each e-learning system included “technique”, “knowledge”, and “obtaining experience”. All e-learning systems proved useful for endoscopists to learn how to diagnose EGC. Lecture videos describing “the technique” and “the knowledge” can be beneficial. In addition, repeating 100 self-study cases allows learners to gain “experience” and improve their diagnostic skills further. Web-based e-learning systems have more advantages than other teaching methods because the number of participants is unlimited. Histopathological diagnosis is the gold standard for the diagnosis of gastric cancer. Therefore, we developed a comprehensive diagnostic algorithm to standardize the histopathological diagnosis of gastric cancer. Once we have successfully shown that this algorithm is helpful for the accurate histopathological diagnosis of cancer, we will complete a series of e-learning systems designed to assess EGC accurately.

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Pitfalls in Endoscopic Submucosal Dissection for Early Gastric Cancer with Papillary Adenocarcinoma
Gwang Ha Kim
Gut and Liver.2024; 18(3): 368. CrossRef

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Original Articles

Association between occurrence of multiple white and flat elevated gastric lesions and oral proton pump inhibitor intake: Rino Hasegawa, Kenshi Yao, Takao Kanemitsu, Hisatomi Arima, Takayuki Hirase, Yuuya Hiratsuka, Kazuhiro Takeda, Kentaro Imamura, Kensei Ohtsu, Yoichiro Ono, Masaki Miyaoka, Takashi Hisabe, Toshiharu Ueki, Hiroshi Tanabe, Atsuko Ohta, Satoshi Nimura; Clin Endosc 2024;57(1):65-72. Published online May 9, 2023; DOI: https://doi.org/10.5946/ce.2022.257

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Background
/Aims: Multiple white and flat elevated lesions (MWFL) that develop from the gastric corpus to the fornix may be strongly associated with oral antacid intake. Therefore, this study aimed to determine the association between the occurrence of MWFL and oral proton pump inhibitor (PPI) intake and clarify the endoscopic and clinicopathological characteristics of MWFL.
Methods
The study included 163 patients. The history of oral drug intake was collected, and serum gastrin levels and anti-Helicobacter pylori immunoglobulin G antibody titers were measured. Upper gastrointestinal endoscopy was performed. The primary study endpoint was the association between MWFL and oral PPI intake.
Results
In the univariate analyses, MWFL were observed in 35 (49.3%) of 71 patients who received oral PPIs and 10 (10.9%) of 92 patients who did not receive oral PPIs. The occurrence of MWFL was significantly higher among patients who received PPIs than in those who did not (p<0.001). Moreover, the occurrence of MWFL was significantly higher in patients with hypergastrinemia (p=0.005). In the multivariate analyses, oral PPI intake was the only significant independent factor associated with the presence of MWFL (p=0.001; odds ratio, 5.78; 95% confidence interval, 2.06–16.2).
Conclusions
Our findings suggest that oral PPI intake is associated with the presence of MWFL (UMINCTR 000030144).

Citations

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Endoscopic findings and outcomes of gastric mucosal changes relating to potassium‐competitive acid blocker and proton pump inhibitor therapy
Satoshi Shinozaki, Hiroyuki Osawa, Yoshimasa Miura, Hiroaki Nomoto, Hirotsugu Sakamoto, Yoshikazu Hayashi, Tomonori Yano, Edward J. Despott, Hironori Yamamoto
DEN Open.2025;[Epub] CrossRef
Clinicians should be aware of proton pump inhibitor–related changes in the gastric mucosa
Gwang Ha Kim
Clinical Endoscopy.2024; 57(1): 51. CrossRef
Drug-induced mucosal alterations observed during esophagogastroduodenoscopy
Masaya Iwamuro, Seiji Kawano, Motoyuki Otsuka
World Journal of Gastroenterology.2024; 30(16): 2220. CrossRef

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Efficacy of endoscopy under general anesthesia for the detection of synchronous lesions in oro-hypopharyngeal cancer: Yoichiro Ono, Kenshi Yao, Yasuhiro Takaki, Satoshi Ishikawa, Kentaro Imamura, Akihiro Koga, Kensei Ohtsu, Takao Kanemitsu, Masaki Miyaoka, Takashi Hisabe, Toshiharu Ueki, Atsuko Ota, Hiroshi Tanabe, Seiji Haraoka, Satoshi Nimura, Akinori Iwashita, Susumu Sato, Rumie Wakasaki; Clin Endosc 2023;56(3):315-324. Published online January 5, 2023; DOI: https://doi.org/10.5946/ce.2022.072

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Background
/Aims: Image-enhanced endoscopy can detect superficial oro-hypopharyngeal squamous cell carcinoma; however, reliable endoscopy of the pharyngeal region is challenging. Endoscopy under general anesthesia during transoral surgery occasionally reveals multiple synchronous lesions that remained undetected on preoperative endoscopy. Therefore, we aimed to determine the lesion detection capability of endoscopy under general anesthesia for superficial oro-hypopharyngeal squamous cell carcinoma.
Methods
This retrospective study included 63 patients who underwent transoral surgery for superficial oropharyngeal squamous cell carcinoma between April 2005 and December 2020. The primary endpoint was to compare the lesion detection capabilities of preoperative endoscopy and endoscopy under general anesthesia. Other endpoints included the comparison of clinicopathological findings between lesions detected using preoperative endoscopy and those newly detected using endoscopy under general anesthesia.
Results
Fifty-eight patients (85 lesions) were analyzed. The mean number of lesions per patient detected was 1.17 for preoperative endoscopy and 1.47 for endoscopy under general anesthesia. Endoscopy under general anesthesia helped detect more lesions than preoperative endoscopy did (p<0.001). The lesions that were newly detected on endoscopy under general anesthesia were small and characterized by few changes in color and surface ruggedness.
Conclusions
Endoscopy under general anesthesia for superficial squamous cell carcinoma is helpful for detecting multiple synchronous lesions.

Citations

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Nasopharyngeal examination during transoral upper gastrointestinal endoscopy
Vui Heng Chong
Clinical Endoscopy.2024; 57(1): 137. CrossRef
Endoscopy under general anesthesia for detecting synchronous lesions of head and neck squamous cell carcinoma
Jin Hee Noh, Do Hoon Kim
Clinical Endoscopy.2023; 56(3): 308. CrossRef

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Non-atrophic gastric mucosa is an independently associated factor for superficial non-ampullary duodenal epithelial tumors: a multicenter, matched, case-control study: Azusa Kawasaki, Kunihiro Tsuji, Noriya Uedo, Takashi Kanesaka, Hideaki Miyamoto, Ryosuke Gushima, Yosuke Minoda, Eikichi Ihara, Ryosuke Amano, Kenshi Yao, Yoshihide Naito, Hiroyuki Aoyagi, Takehiro Iwasaki, Kunihisa Uchita, Hisatomi Arima, Hisashi Doyama; Clin Endosc 2023;56(1):75-82. Published online January 5, 2023; DOI: https://doi.org/10.5946/ce.2022.059

Abstract PDF PubReader ePub: Background
/Aims: The etiology of superficial non-ampullary duodenal epithelial tumors (SNADETs) remains unclear. Recent studies have reported conflicting associations between duodenal tumor development and Helicobacter pylori infection or endoscopic gastric mucosal atrophy. As such, the present study aimed to clarify the relationship between SNADETs and H. pylori infection and/or endoscopic gastric mucosal atrophy.
Methods
This retrospective case-control study reviewed data from 177 consecutive patients with SNADETs who underwent endoscopic or surgical resection at seven institutions in Japan over a three-year period. The prevalence of endoscopic gastric mucosal atrophy and the status of H. pylori infection were compared in 531 sex- and age-matched controls selected from screening endoscopies at two of the seven participating institutions.
Results
For H. pylori infection, 85 of 177 (48.0%) patients exhibited SNADETs and 112 of 531 (21.1%) control patients were non-infected (p<0.001). Non-atrophic mucosa (C0 to C1) was observed in 96 of 177 (54.2%) patients with SNADETs and 112 of 531 (21.1%) control patients (p<0.001). Conditional logistic regression analysis revealed that non-atrophic gastric mucosa was an independent risk factor for SNADETs (odds ratio, 5.10; 95% confidence interval, 2.44–8.40; p<0.001).
Conclusions
Non-atrophic gastric mucosa, regardless of H. pylori infection status, was a factor independently associated with SNADETs.

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White Opaque Substance, a New Optical Marker on Magnifying Endoscopy: Usefulness in Diagnosing Colorectal Epithelial Neoplasms: Kazutomo Yamasaki, Takashi Hisabe, Kenshi Yao, Hiroshi Ishihara, Kentaro Imamura, Tatsuhisa Yasaka, Hiroshi Tanabe, Akinori Iwashita, Toshiharu Ueki; Clin Endosc 2021;54(4):570-577. Published online January 13, 2021; DOI: https://doi.org/10.5946/ce.2020.205

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Background
/Aims: A white substance that is opaque to endoscopic light is sometimes observed in the epithelium during narrowband imaging with magnifying endoscopy of gastric or colorectal epithelial neoplasms. This prospective observational study aimed to determine whether the morphology of the white opaque substance (WOS) allows differential diagnosis between colorectal adenoma and carcinoma.
Methods
A consecutive series of patients with colorectal adenomas or early carcinomas who underwent endoscopic resection or surgical excision were studied. The morphology of the WOS was determined based on endoscopic images before the histopathological diagnosis was performed. The primary outcome was the diagnostic performance of an irregular WOS as a marker of colorectal carcinoma.
Results
The study analyzed 125 lesions. A total of 33 lesions showed an irregular WOS, and 92 lesions showed a regular WOS. Among the 33 lesions found to show an irregular WOS, 30 were carcinomas. Among the 92 lesions showing a regular WOS, 79 were adenomas. With irregular WOS as a marker of carcinoma, the diagnostic accuracy was 87%, sensitivity was 91%, and specificity was 86%.
Conclusions
This study demonstrated the potential usefulness of the morphology of the WOS as a marker for the differential diagnosis between adenoma and carcinoma in cases of colorectal epithelial neoplasms.

Citations

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Emergence of a New Optical Marker for Colorectal Neoplasms: To What Extent Should We Accept It?
Han Hee Lee
Clinical Endoscopy.2022; 55(2): 315. CrossRef

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Histological Architecture of Gastric Epithelial Neoplasias That Showed Absent Microsurface Patterns, Visualized by Magnifying Endoscopy with Narrow-Band Imaging: Kenta Chuman, Kenshi Yao, Takao Kanemitsu, Takashi Nagahama, Masaki Miyaoka, Haruhiko Takahashi, Kentaro Imamura, Rino Hasegawa, Toshiharu Ueki, Hiroshi Tanabe, Seiji Haraoka, Akinori Iwashita; Clin Endosc 2021;54(2):222-228. Published online November 24, 2020; DOI: https://doi.org/10.5946/ce.2020.090

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Background
/Aims: The objective of this study was to elucidate the histological structure of the absent microsurface patterns (MSPs) that were visualized by magnifying endoscopy with narrow-band imaging (M-NBI).
Methods
The study included consecutive gastric epithelial neoplasias for which M-NBI findings and histological findings could be compared on a one-to-one basis. The lesions were classified as absent MSPs and present MSPs based on the findings obtained using M-NBI. Of the histopathological findings for each lesion that corresponded to M-NBI findings, crypt opening densities, crypt lengths, crypt opening diameters, intercrypt distances, and crypt angles were measured and compared.
Results
Thirty-six lesions were included in the analysis; of these, 17 lesions exhibited absent MSP and 19 lesions exhibited present MSP. Comparing the histological measurements for absent MSPs vs. present MSPs, median crypt opening density was 0.9 crypt openings/mm vs. 4.8 crypt openings/mm (p<0.001), respectively. The median crypt length, median crypt opening diameter, median intercrypt distance, and median crypt angle were 80.0 μm vs. 160 μm (p<0.001), 40.0 μm vs. 44.2 μm (p=0.09), 572.5 μm vs. 166.7 μm (p<0.001), and 21.6 degrees vs. 15.5 degrees (p<0.001), respectively.
Conclusions
Histological findings showed that lesions exhibiting absent MSPs had lower crypt opening density, shorter crypt length, greater intercrypt distance, and larger crypt angle.

Citations

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The staining results of early gastric cancer by indigo carmine chromoendoscopy associated with histological structure: a retrospective study
Xiaosa Jiang, Lingzhi Qin, Yujie Hao, Qian Yang, Yueqin Zheng, Baicang Zou, Lei Dong, Na Liu, Jinhai Wang, Bin Qin
BMC Cancer.2024;[Epub] CrossRef
Magnifying Endoscopy with Narrow-Band Imaging for Duodenal Neuroendocrine Tumors
Gwang Ha Kim, Kiyoun Yi, Dong Chan Joo, Moon Won Lee, Hye Kyung Jeon, Bong Eun Lee
Journal of Clinical Medicine.2023; 12(9): 3106. CrossRef

4,641 View
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2 Web of Science
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Magnified Endoscopic Findings of Multiple White Flat Lesions: A New Subtype of Gastric Hyperplastic Polyps in the Stomach: Rino Hasegawa, Kenshi Yao, Shoutomi Ihara, Masaki Miyaoka, Takao Kanemitsu, Kenta Chuman, Go Ikezono, Akikazu Hirano, Toshiharu Ueki, Hiroshi Tanabe, Atsuko Ota, Seiji Haraoka, Akinori Iwashita; Clin Endosc 2018;51(6):558-562. Published online November 21, 2018; DOI: https://doi.org/10.5946/ce.2018.104

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Background
/Aims: While the occurrence of multiple whitish flat elevated lesions (MWFL) was first reported in 2007, no studies on MWFL have been published to date. The present retrospective observational study aimed to clarify the endoscopic findings and clinicopathological features of MWFL.
Methods
Subjects were consecutive patients who underwent upper gastrointestinal endoscopy as part of routine screening between April 2014 and March 2015. The conventional white-light, non-magnifying and magnifying narrow-band images were reviewed. Clinical features were compared between patients with and without MWFL.
Results
The conventional endoscopic findings of MWFL include multiple whitish, flat, and slightly elevated lesions of various sizes, mainly located in the gastric body and fundus. Narrow-band imaging enhanced the contrast of MWFL and background mucosa, and magnifying narrow-band imaging depicted a uniformly long, narrow, and elliptical marginal crypt epithelium with an unclear microvascular pattern. Histopathological findings revealed hyperplastic changes of the foveolar epithelium, and parietal cell protrusions and oxyntic gland dilatations were observed in the fundic glands, without any intestinal metaplasia. The rate of acid-reducing drug use was significantly higher in patients with MWFL than in those without (100% [13/13] vs. 53.7% [88/164], p<0.001).
Conclusions
The present study indicated a relationship between the presence and endoscopic features of MWFL and history of acidreducing drug use.

Citations

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Endoscopic findings and outcomes of gastric mucosal changes relating to potassium‐competitive acid blocker and proton pump inhibitor therapy
Satoshi Shinozaki, Hiroyuki Osawa, Yoshimasa Miura, Hiroaki Nomoto, Hirotsugu Sakamoto, Yoshikazu Hayashi, Tomonori Yano, Edward J. Despott, Hironori Yamamoto
DEN Open.2025;[Epub] CrossRef
Association between occurrence of multiple white and flat elevated gastric lesions and oral proton pump inhibitor intake
Rino Hasegawa, Kenshi Yao, Takao Kanemitsu, Hisatomi Arima, Takayuki Hirase, Yuuya Hiratsuka, Kazuhiro Takeda, Kentaro Imamura, Kensei Ohtsu, Yoichiro Ono, Masaki Miyaoka, Takashi Hisabe, Toshiharu Ueki, Hiroshi Tanabe, Atsuko Ohta, Satoshi Nimura
Clinical Endoscopy.2024; 57(1): 65. CrossRef
Randomised clinical trial: 3-year interim analysis results of the VISION trial to evaluate the long-term safety of vonoprazan as maintenance treatment in patients with erosive oesophagitis
Ken Haruma, Yoshikazu Kinoshita, Takashi Yao, Ryoji Kushima, Junichi Akiyama, Nobuo Aoyama, Tatsuhiro Kanoo, Kouji Miyata, Naomi Kusumoto, Naomi Uemura
BMC Gastroenterology.2023;[Epub] CrossRef
Helicobacter pylori Eradication-Related Development of Multiple White and Flat Elevated Lesions in the Stomach
Akira Hokama, Mayumi Shiroma, Mami Tomiyama, Yuko Tasato, Maki Setake
Chonnam Medical Journal.2023; 59(3): 203. CrossRef
Differential diagnosis of superficial duodenal epithelial tumor and non-neoplastic lesion in duodenum by magnified endoscopic examination with image-enhanced endoscopy
Atsushi Nakayama, Motohiko Kato, Teppei Masunaga, Yoko Kubosawa, Yukie Hayashi, Mari Mizutani, Yoshiyuki Kiguchi, Motoki Sasaki, Yusaku Takatori, Noriko Matsuura, Makoto Mutaguchi, Kaoru Takabayashi, Naohisa Yahagi
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Gastric Corpus Hypertrophy with a Bleeding Hyperplastic Polyp in a Helicobacter pylori-naive Subject after Long-term Proton Pump Inhibitor Use
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The Korean Journal of Helicobacter and Upper Gastrointestinal Research.2022; 22(1): 63. CrossRef
The effect of proton pump inhibitors and vonoprazan on the development of ‘gastric mucosal redness’
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Changes in gastric morphology during long-term use of vonoprazan compared to proton pump inhibitors
S Shinozaki, H Osawa, Y Hayashi, H Sakamoto, Y Miura, AK Lefor, H Yamamoto
Singapore Medical Journal.2022; 63(5): 283. CrossRef
Image-enhanced endoscopy for real-time differentiation between hyperplastic and fundic gland polyps in the stomach
Amit Kumar Dutta, Noriya Uedo, Deepu David, Jagan Chandramohan, Abhishek Jain, Itish Patnayak, Piyush Gupta, Bharath K. Ayapati, Kaushik Chatterjee, Rajeeb Jaleel, Reuben T. Kurien, Sudipta D. Chowdhury, Ebby G. Simon, Anjilivelil J. Joseph, Anna B. Pulim
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Proton Pump Inhibitor-Related Gastric Mucosal Changes
Gwang Ha Kim
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Gastric Hyperplastic Polyps: A Benign Entity? Analysis of Recurrence and Neoplastic Transformation in a Cohort Study
Mafalda João, Miguel Areia, Susana Alves, Luís Elvas, Filipe Taveira, Daniel Brito, Sandra Saraiva, Ana Teresa Cadime
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British Society of Gastroenterology guidelines on the diagnosis and management of patients at risk of gastric adenocarcinoma
Matthew Banks, David Graham, Marnix Jansen, Takuji Gotoda, Sergio Coda, Massimiliano di Pietro, Noriya Uedo, Pradeep Bhandari, D Mark Pritchard, Ernst J Kuipers, Manuel Rodriguez-Justo, Marco R Novelli, Krish Ragunath, Neil Shepherd, Mario Dinis-Ribeiro
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Multiple White Flat Lesions of the Corpus: Subtype of Hyperplastic Polyps vs. Intestinal Metaplasia
Su Jin Kim, Cheol Woong Choi
Clinical Endoscopy.2018; 51(6): 503. CrossRef

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Focused Review Series: Image Enhanced Endoscopy

Clinical Application of Magnifying Endoscopy with Narrow-Band Imaging in the Stomach: Kenshi Yao; Clin Endosc 2015;48(6):481-490. Published online November 30, 2015; DOI: https://doi.org/10.5946/ce.2015.48.6.481

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Magnifying endoscopy with narrow-band imaging (M-NBI) can visualize superficial microanatomies in the stomach. The normal morphology of the microanatomy visualized by M-NBI differs according to the part of the stomach. The gastric fundic glandular mucosa appears as a regular honeycomb-like subepithelial capillary network (SECN) pattern with a regular collecting venule pattern and regular oval crypt opening with circular marginal crypt epithelium (MCE) pattern. The gastric pyloric glandular mucosa displays a regular coil-shaped SECN pattern and regular polygonal or curved MCE pattern. For a diagnosis of early gastric cancer using M-NBI, the vessel plus surface classification system was developed. This system is clinically useful for the differential diagnosis of focal gastritis and small depressed cancer and for determining the horizontal extent of early gastric cancer for successful endoscopic resection. Advantages of M-NBI over conventional endoscopic imaging techniques with white light include accurate diagnosis and cost effectiveness. This technique is a breakthrough in the endoscopic diagnostic field.

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