Diagnosing Helicobacter pylori In Vivo by Confocal Laser Endoscopy Ralf Kiesslich, Martin Goetz, Juergen Burg, Manfred Stolte, Ekkehard Siegel, Markus J. Maeurer, Steven Thomas, Dennis Strand, Peter R. Galle, Markus F. Neurath  Gastroenterology  Volume 128, Issue 7, Pages 2119-2123 (June 2005) DOI: 10.1053/j.gastro.2004.12.035 Copyright © 2005 American Gastroenterological Association Terms and Conditions

Figure 1 Endoscopy, conventional histology, and in vivo microscopy of a 70-year-old patient with Helicobacter pylori-associated gastritis. (A) Seventy-year-old patient: visible erosion (arrow) of the antrum, as shown by conventional video endoscopy. (B) Seventy-year-old patient: conventional histology showing evidence of gastritis. Gastric glands with an irregular shape (arrow 1) surrounded by inflammatory cells (arrow 2) can be seen. (C) Control patient: in vivo microscopy with confocal laser endoscopy and acriflavine staining during ongoing gastroscopy showing normal distribution of gastric foveolae (arrow 1) and connective tissue (arrow 2) (original magnification, 1000×). (D) Seventy-year-old patient: in vivo microscopy of the antrum in the patient with gastritis during ongoing gastroscopy. Focal white spots were visible after topical application of acriflavine (arrow 1); these are indicative of focal accumulations of H pylori. The gastric foveolae showed an irregular shape (arrow 2), and inflammatory cells were present in the gastric mucosa (arrow 3) (original magnification, 1000×). Gastroenterology 2005 128, 2119-2123DOI: (10.1053/j.gastro.2004.12.035) Copyright © 2005 American Gastroenterological Association Terms and Conditions

Figure 2 Comparison between in vivo histology and conventional histology. (A) Acriflavine-aided in vivo endomicroscopy (1000×) of the antrum during ongoing gastroscopy: focal white spots representing focal accumulations of Helicobacter pylori are visible (arrows). (B) Acriflavine-aided in vivo endomicroscopy at higher magnification (10,000×). A single H pylori with flagella can be identified (upper arrow), as can an accumulation of H pylori (lower arrow). (C) Conventional microscopy of biopsy samples taken during gastroscopy: immunohistology with H pylori-specific antibodies on biopsy samples from the antrum shows the presence of H pylori (arrow). (D) Conventional microscopy of biopsy samples from the antrum. Silver staining according to Warthin-Starry showed the presence of H pylori (arrow). Gastroenterology 2005 128, 2119-2123DOI: (10.1053/j.gastro.2004.12.035) Copyright © 2005 American Gastroenterological Association Terms and Conditions

Figure 3 Ex vivo confocal microscopy of cultured Helicobacter pylori. (A and B) Confocal laser endoscopy ex vivo on agar plates: gastric biopsy samples from the antrum were put in Portacul medium (Becton Dickinson; portagerm, biomerieux). Bacteria were cultured from these biopsy samples for 5 days, followed by analysis of grown bacteria by using the confocal laser endoscope. No distinct structures were seen before the application of acriflavine (A). In analogy to the in vivo situation (Figure 2A), application of the confocal laser endoscope after staining with acriflavine to the agar plate showed the presence of H pylori as white spots (arrows) (B). (C-F) Conventional confocal microscopy: bacteria were taken from the agar plate, put on coverslips, and analyzed by a conventional confocal microscope. The characteristic shape of H pylori can be seen (C and E). Helicobacter pylori emits a characteristic green light after staining with acriflavine (D). A colorized image of H pylori is shown for comparison (F). Gastroenterology 2005 128, 2119-2123DOI: (10.1053/j.gastro.2004.12.035) Copyright © 2005 American Gastroenterological Association Terms and Conditions