Clin Endosc.  2025 Mar;58(2):163-180. 10.5946/ce.2024.159.

Image-enhanced endoscopy in upper gastrointestinal disease: focusing on texture and color enhancement imaging and red dichromatic imaging

• Park JY

• KMID: 2566136
• DOI: http://doi.org/10.5946/ce.2024.159

Abstract

Endoscopic examination plays a crucial role in the diagnosis of upper gastrointestinal (UGI) tract diseases. Despite advancements in endoscopic imaging, the detection of subtle early cancers and premalignant lesions using white-light imaging alone remains challenging. This review discusses two novel image-enhanced endoscopy (IEE) techniques–texture and color enhancement imaging (TXI) and red dichromatic imaging (RDI)–and their potential applications in UGI diseases. TXI enhances texture, brightness, and color tone, which improves the visibility of mucosal irregularities and facilitates earlier detection of neoplastic lesions. Studies have suggested that TXI enhances the color differences between lesions and the surrounding mucosa and improves the visibility of the lesion. TXI aids in the diagnosis of various UGI diseases, including early gastric cancer, esophageal cancer, premalignant conditions such as atrophic gastritis and Barrett’s esophagus, and duodenal tumors. RDI utilizes specific wavelengths to enhance the visualization of deep blood vessels or bleeding points, aiding in the rapid and accurate identification of bleeding sources during endoscopic procedures. Although promising, TXI and RDI require further large-scale studies across diverse populations to establish their clinical utility, diagnostic performance, and cost-effectiveness before integration into the guidelines. Standardized training is also required for effective utilization. Overall, these IEE techniques has the potential to improve the diagnosis and management of UGI.

Keyword

Image-enhanced endoscopy; Red dichromatic imaging; Texture and color enhancement imaging; Upper gastrointestinal tract

Figure

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  Fig. 1. Optimizing the three key elements of images in texture and color enhancement imaging (TXI). TXI emphasizes texture, brightness, and color tone to enhance the visibility of lesions. It seeks to augment the dimensional portrayal of subtle surface irregularities, enhance brightness in dark areas, and accentuate color alterations. WLI, white-light imaging.

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  Fig. 2. A simplified flowchart of image processing algorithm of the texture and color enhancement imaging (TXI). Input image is initially divided into base and detail layers. Brightness correction is applied to dark regions of the base layer, and the dynamic range of the base layer is compressed to maintain local contrast. Texture in the detail layer is enhanced to improve subtle contrast. Compressed base and enhanced detail layers are then merged to generate a TXI image (mode 2). A color enhancement algorithm expands color differences, producing the final TXI mode 1 image. The goal of texture and color tone enhancement is to facilitate the recognition of structural and color tone disparities between lesions and the surrounding mucosa. WLI, white-light imaging.

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  Fig. 3. Cases of upper gastrointestinal tract lesions observed using various modes of endoscopic imaging systems. (A) A case of early gastric cancer located on the posterior wall of the mid body of the stomach. The lesion is evaluated with white-light imaging (WLI), narrow-band imaging (NBI), and texture and color enhancement imaging (TXI) mode 1. (B) A case of atrophic gastritis with intestinal metaplasia evaluated with WLI, NBI, TXI mode 1, and TXI mode 2. The contrast between the lesion and the surrounding mucosa is enhanced in TXI images without darkening due to low illumination. TXI mode 2 shows an image more similar to WLI in color compared to TXI mode 1. (C) A case of esophageal low-grade dysplasia evaluated with WLI, TXI mode 1, and TXI mode 1 after Lugol solution application. TXI mode 1 highlights the redness of the lesion, clarifying its boundary, which aligns with the demarcation seen after Lugol solution application.

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  Fig. 4. The red dichromatic imaging (RDI) illumination system and how it visualizes deep blood vessels. (A) The configuration of the illumination source in the EVIS X1 system (Olympus Marketing) and the wavelength properties in white-light imaging (WLI) and RDI. (B) Thick blood vessels in deep layers can be identified with improved visibility through RDI. Reproduced from Uraoka et al. Therap Adv Gastroenterol 2022;15:17562848221118302, according to the Creative Commons license.68

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  Fig. 5. Identification of bleeding point using red dichromatic imaging (RDI) during gastric endoscopic submucosal dissection. The bleeding point is clearly visualized in RDI mode by enhancing the contrast between the highly concentrated blood and the surrounding diluted blood pool. WLI, white-light imaging.

Reference

1. Hahn KY, Park CH, Lee YK, et al. Comparative study between endoscopic submucosal dissection and surgery in patients with early gastric cancer. Surg Endosc. 2018; 32:73–86.

2. Jung HK, Tae CH, Lee HA, et al. Treatment pattern and overall survival in esophageal cancer during a 13-year period: a nationwide cohort study of 6,354 Korean patients. PLoS One. 2020; 15:e0231456.

3. Lee EH, Lee HY, Choi KS, et al. Trends in cancer screening rates among Korean men and women: results from the Korean National Cancer Screening Survey (KNCSS), 2004-2010. Cancer Res Treat. 2011; 43:141–147.

4. Information Committee of the Korean Gastric Cancer Association. Korean Gastric Cancer Association-led nationwide survey on surgically treated gastric cancers in 2019. J Gastric Cancer. 2021; 21:221–235.

5. Jun JK, Choi KS, Lee HY, et al. Effectiveness of the Korean national cancer screening program in reducing gastric cancer mortality. Gastroenterology. 2017; 152:1319–1328.

6. Pimentel-Nunes P, Libânio D, Marcos-Pinto R, et al. Management of epithelial precancerous conditions and lesions in the stomach (MAPS II): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG), European Society of Pathology (ESP), and Sociedade Portuguesa de Endoscopia Digestiva (SPED) guideline update 2019. Endoscopy. 2019; 51:365–388.

7. Gupta S, Li D, El Serag HB, et al. AGA clinical practice guidelines on management of gastric intestinal metaplasia. Gastroenterology. 2020; 158:693–702.

8. Banks M, Graham D, Jansen M, et al. British Society of Gastroenterology guidelines on the diagnosis and management of patients at risk of gastric adenocarcinoma. Gut. 2019; 68:1545–1575.

9. Lee W. Application of current image-enhanced endoscopy in gastric diseases. Clin Endosc. 2021; 54:477–487.

10. Shahsavari D, Waqar M, Thoguluva Chandrasekar V. Image enhanced colonoscopy: updates and prospects: a review. Transl Gastroenterol Hepatol. 2023; 8:26.

11. Young E, Philpott H, Singh R. Endoscopic diagnosis and treatment of gastric dysplasia and early cancer: current evidence and what the future may hold. World J Gastroenterol. 2021; 27:5126–5151.

12. Park CH, Yang DH, Kim JW, et al. Clinical practice guideline for endoscopic resection of early gastrointestinal cancer. Clin Endosc. 2020; 53:142–166.

13. Na HK, Choi KD, Park YS, et al. Endoscopic scoring system for gastric atrophy and intestinal metaplasia: correlation with OLGA and OLGIM staging: a single-center prospective pilot study in Korea. Scand J Gastroenterol. 2022; 57:1097–1104.

14. Kitagawa Y, Koga K, Ishigaki A, et al. Endoscopic diagnosis of Helicobacter pylori gastritis using white light imaging and texture and color enhancement imaging. Endosc Int Open. 2023; 11:E136–E141.

15. Abe S, Makiguchi ME, Nonaka S, et al. Emerging texture and color enhancement imaging in early gastric cancer. Dig Endosc. 2022; 34:714–720.

16. Tanisaka Y, Mizuide M, Fujita A, et al. Usefulness of texture- and color-enhancement imaging for identifying the bleeding point in a patient with post-endoscopic sphincterotomy bleeding. VideoGIE. 2023; 8:269–271.

17. Meylan L, Süsstrunk S. High dynamic range image rendering with a Retinex-based adaptive filter. IEEE Trans Image Process. 2006; 15:2820–2830.

18. Sato T. TXI: Texture and color enhancement imaging for endoscopic image enhancement. J Healthc Eng. 2021; 2021:5518948.

19. Sugimoto M, Koyama Y, Itoi T, et al. Using texture and colour enhancement imaging to evaluate gastrointestinal diseases in clinical practice: a review. Ann Med. 2022; 54:3315–3332.

20. Kawasaki A, Yoshida N, Nakanishi H, et al. Usefulness of third-generation narrow band imaging and texture and color enhancement imaging in improving visibility of superficial early gastric cancer: a study using color difference. DEN Open. 2022; 3:e186.

21. Jobson DJ, Rahman Z, Woodell GA. Properties and performance of a center/surround retinex. IEEE Trans Image Process. 1997; 6:451–462.

22. Ishikawa T, Matsumura T, Okimoto K, et al. Efficacy of texture and color enhancement imaging in visualizing gastric mucosal atrophy and gastric neoplasms. Sci Rep. 2021; 11:6910.

23. Abe S, Yamazaki T, Hisada IT, et al. Visibility of early gastric cancer in texture and color enhancement imaging. DEN Open. 2021; 2:e46.

24. Koyama Y, Sugimoto M, Kawai T, et al. Visibility of early gastric cancers by texture and color enhancement imaging using a high-definition ultrathin transnasal endoscope. Sci Rep. 2023; 13:1994.

25. Futakuchi T, Dobashi A, Horiuchi H, et al. Texture and color enhancement imaging improves the visibility of gastric neoplasms: clinical trial with image catalogue assessment using conventional and newly developed endoscopes. BMC Gastroenterol. 2023; 23:389.

26. Shijimaya T, Tahara T, Uragami T, et al. Usefulness of texture and color enhancement imaging (TXI) in early gastric cancer found after Helicobacter pylori eradication. Sci Rep. 2023; 13:6899.

27. Wei Y, Jiang C, Han Y, et al. Characteristics and background mucosa status of early gastric cancer after Helicobacter pylori eradication: a narrative review. Medicine (Baltimore). 2022; 101:e31968.

28. Kemmoto Y, Ozawa SI, Sueki R, et al. Higher detectability of gastric cancer after Helicobacter pylori eradication in texture and color enhancement imaging mode 2 in screening endoscopy. DEN Open. 2023; 4:e279.

29. Cho SJ, Choi IJ, Kook MC, et al. Staging of intestinal- and diffuse-type gastric cancers with the OLGA and OLGIM staging systems. Aliment Pharmacol Ther. 2013; 38:1292–1302.

30. Kang SJ, Kim JG, Moon HS, et al. Clinical practice guideline for gastritis in Korea. J Korean Med Sci. 2023; 38:e115.

31. Pimentel-Nunes P, Libânio D, Lage J, et al. 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.

32. Esposito G, Pimentel-Nunes P, Angeletti S, et al. Endoscopic grading of gastric intestinal metaplasia (EGGIM): a multicenter validation study. Endoscopy. 2019; 51:515–521.

33. Sugimoto M, Kawai Y, Morino Y, et al. Efficacy of high-vision transnasal endoscopy using texture and colour enhancement imaging and narrow-band imaging to evaluate gastritis: a randomized controlled trial. Ann Med. 2022; 54:1004–1013.

34. Kato M. Endoscopic findings of H. pylori infection. In : Suzuki H, Warren R, Marshall B, editors. Helicobacter pylori. Springer Japan;2016. p. 157–167.

35. Seo JY, Ahn JY, Kim S, et al. Predicting Helicobacter pylori infection from endoscopic features. Korean J Intern Med. 2024; 39:439–447.

36. Ferlay J, Ervik M, Lam F, et al. Global cancer observatory: cancer today [Internet]. International Agency for Research on Cancer;2024. [cited 2024 May 1]. Available from: https://gco.iarc.who.int/media/globocan/factsheets/cancers/6-oesophagus-fact-sheet.pdf.

37. Sato H, Inoue H, Ikeda H, et al. Utility of intrapapillary capillary loops seen on magnifying narrow-band imaging in estimating invasive depth of esophageal squamous cell carcinoma. Endoscopy. 2015; 47:122–128.

38. Kim SH, Hong SJ. Current status of image-enhanced endoscopy for early identification of esophageal neoplasms. Clin Endosc. 2021; 54:464–476.

39. Inoue H, Kaga M, Ikeda H, et al. Magnification endoscopy in esophageal squamous cell carcinoma: a review of the intrapapillary capillary loop classification. Ann Gastroenterol. 2015; 28:41–48.

40. Endoscopic Classification Review Group. Update on the paris classification of superficial neoplastic lesions in the digestive tract. Endoscopy. 2005; 37:570–578.

41. Gai W, Jin XF, Du R, et al. Efficacy of narrow-band imaging in detecting early esophageal cancer and risk factors for its occurrence. Indian J Gastroenterol. 2018; 37:79–85.

42. Goda K, Dobashi A, Yoshimura N, et al. Narrow-band imaging magnifying endoscopy versus lugol chromoendoscopy with pink-color sign assessment in the diagnosis of superficial esophageal squamous neoplasms: a randomised noninferiority trial. Gastroenterol Res Pract. 2015; 2015:639462.

43. Shin CM. Treatment of superficial esophageal cancer: an update. Korean J Gastroenterol. 2021; 78:313–319.

44. Dobashi A, Ono S, Furuhashi H, et al. Texture and color enhancement imaging increases color changes and improves visibility for squamous cell carcinoma suspicious lesions in the pharynx and esophagus. Diagnostics (Basel). 2021; 11:1971.

45. Whiteman DC, Appleyard M, Bahin FF, et al. Australian clinical practice guidelines for the diagnosis and management of Barrett’s esophagus and early esophageal adenocarcinoma. J Gastroenterol Hepatol. 2015; 30:804–820.

46. Shaheen NJ, Falk GW, Iyer PG, et al. Diagnosis and management of Barrett’s esophagus: an updated ACG guideline. Am J Gastroenterol. 2022; 117:559–587.

47. Zilberstein N, Godbee M, Mehta NA, et al. Advanced endoscopic imaging for detection of Barrett’s esophagus. Clin Endosc. 2024; 57:1–10.

48. Ikeda A, Takeda T, Ueyama H, et al. Comparison of texture and color enhancement imaging with white light imaging in 52 patients with short-segment Barrett’s esophagus. Med Sci Monit. 2023; 29:e940249.

49. Sugimoto M, Kawai Y, Akimoto Y, et al. Third-generation high-vision ultrathin endoscopy using texture and color enhancement imaging and narrow-band imaging to evaluate Barrett’s esophagus. Diagnostics (Basel). 2022; 12:3149.

50. de Groof AJ, Fockens KN, Struyvenberg MR, et al. Blue-light imaging and linked-color imaging improve visualization of Barrett’s neoplasia by nonexpert endoscopists. Gastrointest Endosc. 2020; 91:1050–1057.

51. Everson MA, Lovat LB, Graham DG, et al. Virtual chromoendoscopy by using optical enhancement improves the detection of Barrett’s esophagus-associated neoplasia. Gastrointest Endosc. 2019; 89:247–256.

52. Coletta M, Sami SS, Nachiappan A, et al. Acetic acid chromoendoscopy for the diagnosis of early neoplasia and specialized intestinal metaplasia in Barrett’s esophagus: a meta-analysis. Gastrointest Endosc. 2016; 83:57–67.

53. Weusten BL, Bisschops R, Dinis-Ribeiro M, et al. Diagnosis and management of Barrett esophagus: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2023; 55:1124–1146.

54. Barsouk A, Rawla P, Barsouk A, et al. Epidemiology of cancers of the small intestine: trends, risk factors, and prevention. Med Sci (Basel). 2019; 7:46.

55. Shenoy S. Genetic risks and familial associations of small bowel carcinoma. World J Gastrointest Oncol. 2016; 8:509–519.

56. Sakaguchi Y, Yamamichi N, Tomida S, et al. Identification of marker genes and pathways specific to precancerous duodenal adenomas and early stage adenocarcinomas. J Gastroenterol. 2019; 54:131–140.

57. Alkhatib AA. Sporadic nonampullary tubular adenoma of the duodenum: prevalence and patients’ characteristics. Turk J Gastroenterol. 2019; 30:112–113.

58. Jepsen JM, Persson M, Jakobsen NO, et al. Prospective study of prevalence and endoscopic and histopathologic characteristics of duodenal polyps in patients submitted to upper endoscopy. Scand J Gastroenterol. 1994; 29:483–487.

59. Batra SK, Schuman BM, Reddy RR. The endoscopic variety of duodenal villous adenoma: an experience with ten cases. Endoscopy. 1983; 15:89–92.

60. Okada K, Fujisaki J, Kasuga A, et al. Sporadic nonampullary duodenal adenoma in the natural history of duodenal cancer: a study of follow-up surveillance. Am J Gastroenterol. 2011; 106:357–364.

61. Vanbiervliet G, Moss A, Arvanitakis M, et al. Endoscopic management of superficial nonampullary duodenal tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2021; 53:522–534.

62. Okimoto K, Matsumura T, Maruoka D, et al. Magnified endoscopy with texture and color enhanced imaging with indigo carmine for superficial nonampullary duodenal tumor: a pilot study. Sci Rep. 2022; 12:10381.

63. Heppt MV, Dykukha I, Graziadio S, et al. Comparative efficacy and safety of tirbanibulin for actinic keratosis of the face and scalp in europe: a systematic review and network meta-analysis of randomized controlled trials. J Clin Med. 2022; 11:1654.

64. Yamashina T, Setoyama T, Sakamoto A, et al. Prospective comparison of diagnostic performance of magnifying endoscopy and biopsy for sessile serrated adenoma/polyp. Ann Gastroenterol. 2022; 35:414–419.

65. Yoshida N, Inoue K, Dohi O, et al. Analysis of texture and color enhancement imaging for improving the visibility of non-polypoid colorectal lesions. Dig Dis Sci. 2022; 67:5657–5665.

66. Gono K. Narrow band imaging: technology basis and research and development history. Clin Endosc. 2015; 48:476–80.

67. Uedo N, Fujishiro M, Goda K, et al. Role of narrow band imaging for diagnosis of early-stage esophagogastric cancer: current consensus of experienced endoscopists in Asia-Pacific region. Dig Endosc. 2011; 23 Suppl 1:58–71.

68. Uraoka T, Igarashi M. Development and clinical usefulness of a unique red dichromatic imaging technology in gastrointestinal endoscopy: a narrative review. Therap Adv Gastroenterol. 2022; 15:17562848221118302.

69. Al-Sabban AH, Al-Kawas FH. Red dichromatic imaging in acute GI bleeding: does it make a difference? Gastrointest Endosc. 2022; 95:701–702.

70. Taylor-Williams M, Spicer G, Bale G, et al. Noninvasive hemoglobin sensing and imaging: optical tools for disease diagnosis. J Biomed Opt. 2022; 27:080901.

71. Miyazaki K, Kato M, Sasaki M, et al. Red dichromatic imaging reduces bleeding and hematoma during submucosal injection in esophageal endoscopic submucosal dissection. Surg Endosc. 2022; 36:8076–8085.

72. Kubosawa Y, Mori H, Fujimoto A. Utility of dual red imaging for endoscopic hemostasis of gastric ulcer bleeding. Dig Dis. 2020; 38:352–354.

73. Tanaka H, Oka S, Tanaka S. Endoscopic hemostasis for spurting duodenal bleeding using dual red imaging. Dig Endosc. 2017; 29:816–817.

74. Hirai Y, Fujimoto A, Matsutani N, et al. Evaluation of the visibility of bleeding points using red dichromatic imaging in endoscopic hemostasis for acute GI bleeding (with video). Gastrointest Endosc. 2022; 95:692–700.

75. Oka K, Iwai N, Okuda T, et al. Red dichromatic imaging improves visibility of bleeding during gastric endoscopic submucosal dissection. Sci Rep. 2023; 13:8560.

76. Mori Y, Iwatsubo T, Hakoda A, et al. Red Dichromatic imaging improves the recognition of bleeding points during endoscopic submucosal dissection. Dig Dis Sci. 2024; 69:216–227.

77. Miyamoto S, Ohya TR, Nishi K, et al. Effectiveness of red dichromatic imaging for dissection of the submucosal layer when hematoma is encountered. Endoscopy. 2021; 53:E413–E414.

78. Tanaka H, Oka S, Tanaka S, et al. Dual red imaging maintains clear visibility during colorectal endoscopic submucosal dissection. Dig Dis Sci. 2019; 64:224–231.

79. Kita A, Kuribayashi S, Itoi Y, et al. Efficacy of using red dichromatic imaging throughout endoscopic submucosal dissection procedure. Surg Endosc. 2023; 37:503–509.

80. Nabi Z, Chavan R, Ramchandani M, et al. Endoscopic submucosal dissection and tunneling procedures using novel image-enhanced technique. VideoGIE. 2022; 7:158–163.

81. Ishikawa T, Tashima T, Muramatsu T, et al. Endoscopic submucosal dissection for superficial esophageal cancer with ulcer scarring using a combination of pocket creation, gel immersion, and red dichromatic imaging. Endoscopy. 2024; 56(S 01):E87–E88.

82. Ueda T, Kanesaka T, Ishihara R. Endoscopic submucosal dissection for esophageal squamous cell carcinoma with varices using red dichromatic imaging. Clin Gastroenterol Hepatol. 2024; 22:A31–A32.

83. Kikuchi A, Toya Y, Fujino Y, et al. Endoscopic submucosal dissection with red dichromatic imaging for esophageal squamous cell carcinoma after endoscopic variceal sclerotherapy. Endoscopy. 2023; 55(S 01):E120–E121.

84. Minamide T, Kawata N, Ono H. Full-time red dichromatic imaging during esophageal endoscopic submucosal dissection to address intraoperative bleeding. Dig Endosc. 2023; 35:e28–e29.

85. Ikenoyama Y, Iri A, Imai H, et al. Endoscopic submucosal dissection of an early-stage gastric tumor with minimal bleeding using full-time red dichromatic imaging. Endoscopy. 2022; 54(S 02):E1001–E1002.

86. Kv A, Ramchandani M, Inavolu P, et al. Red dichromatic imaging in peroral endoscopic myotomy: a novel image-enhancing technique. VideoGIE. 2021; 6:203–206.