Tonya Kaltenbach, MD, William J. Sandborn, MD

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Endoscopy in inflammatory bowel disease: advances in dysplasia detection and management Tonya Kaltenbach, MD, William J. Sandborn, MD Gastrointestinal Endoscopy Volume 86, Issue 6, Pages 962-971 (December 2017) DOI: 10.1016/j.gie.2017.09.030 Copyright © 2017 Terms and Conditions

Figure 1 Chromoendoscopy uses a dye solution of either indigo carmine or methylene blue onto the colonic mucosa to provide contrast enhancement to augment visualization of epithelial surface detail during colonoscopy. A-C, The innominate grooves of the normal colon in a patient with ulcerative colitis can be easily seen with the use of dye, facilitating efficient examination of the surface during colonoscopy surveillance for dysplasia. Gastrointestinal Endoscopy 2017 86, 962-971DOI: (10.1016/j.gie.2017.09.030) Copyright © 2017 Terms and Conditions

Figure 2 Chromoendoscopy technique. Spraying dye to the antidependent wall. A-C, Dye is sprayed on the dependent wall of the colon along a segment. The resulting effect is pooling of dye along 1 wall and the application of dye to a fraction of the surface area of the colon. D-F, Dye spraying to the antigravity wall is efficient, using less dye and resulting in less volume pooling and more surface area covered in a shorter time. Gastrointestinal Endoscopy 2017 86, 962-971DOI: (10.1016/j.gie.2017.09.030) Copyright © 2017 Terms and Conditions

Figure 3 Endoscopic features of dysplasia. A, Superficially elevated morphology accentuated with chromoendoscopy. B, Nonpolypoid dysplastic lesion with vascular and surface pattern of neoplasia. C, Focal friability. D, Uneven erythema. E, Villous mucosa. F, In contrast, pseudopolyps have an inflammatory appearance often with exudate. Gastrointestinal Endoscopy 2017 86, 962-971DOI: (10.1016/j.gie.2017.09.030) Copyright © 2017 Terms and Conditions

Figure 4 Endoscopically resectable visible nonpolypoid dysplastic lesion removed using endoscopic mucosal resection. A, Nonpolypoid superficial elevated lesion. Methylene blue chromoendoscopy delineates the borders of the lesion in standard (B) and magnified near focus (C) views. D, The lesion is injected using dynamic submucosal injection with a mixture of diluted methylene blue and saline solution. E, The lesion is removed en bloc using a stiff snare and electrocautery. F, Inspection of the defect shows no residual. Pathology showed tubular adenoma (low-grade dysplasia) Gastrointestinal Endoscopy 2017 86, 962-971DOI: (10.1016/j.gie.2017.09.030) Copyright © 2017 Terms and Conditions

Figure 5 Endoscopically resectable visible nonpolypoid dysplastic lesion removed using hybrid endoscopic submucosal dissection. A, Nonpolypoid superficial elevated serrated appearing lesion. B, The periphery of the lesion is marked, and the lesion is injected using dynamic submucosal injection. C, Circumferential incision. D, Some submucosal dissection. E, The lesion is ultimately resected en bloc using a stiff snare. F, The specimen is pinned for orientation and histologic assessment. Pathology showed sessile serrated lesion without cytologic dysplasia. Gastrointestinal Endoscopy 2017 86, 962-971DOI: (10.1016/j.gie.2017.09.030) Copyright © 2017 Terms and Conditions

Figure 6 Small endoscopically resectable visible nonpolypoid dysplastic lesion removed using endoscopic mucosal resection. A, Small nonpolypoid superficial elevated lesion. B, The lesion lifts after dynamic submucosal injection with a mixture of diluted methylene blue and saline solution and the lesion then resection using a stiff snare. C, Inspection of the postresection defect shows erythematous mucosa with ill-defined borders suggestive of inflammation vs residual dypslasa. D, Biopsy sampling of the mucosa a few millimeters outside of the defect is performed. The EMR lesion specimen is diagnosed tubular adenoma (low-grade dysplasia), and the biopsy sampling of the periphery confirmed chronic active inflammation without dysplasia. Gastrointestinal Endoscopy 2017 86, 962-971DOI: (10.1016/j.gie.2017.09.030) Copyright © 2017 Terms and Conditions