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Of the Gastrointestinal Tract Color profile: EMBASSY.CCM - Scitex Scitex Composite Default screen 11th INTERNATIONAL COURSE ON THERAPEUTIC ENDOSCOPY 100 100 95 95 75 75 25 25 5 5 0 Tissue staining (chromoscopy) 0 of the gastrointestinal tract M Brian Fennerty MD MB Fennerty. Tissue staining (chromoscopy) of the gastroin- Coloration tissulaire (chromoscopie) des voies testinal tract. Can J Gastroenterol 1999;13(5):423-429. Tissue staining, or chomoscopy, is used as an adjunctive technique dur- digestives ing gastrointestinal endoscopy. Chemical agents are applied to the RÉSUMÉ : La coloration tissulaire, ou chromoscopie, est utilisée comme gastrointestinal mucosal surface to identify specific epithelia or to technique d’appoint durant l’endoscopie gastro-intestinale. Des agents enhance the mucosal surface characteristics of the gastrointestinal chimiques sont appliqués à la muqueuse gastro-intestinale pour identifier epithelium. This aids in the recognition of subtle lesions (ie, pol- les épithélia spécifiques ou pour rehausser les caractéristiques de surface de yps) or allows directed targeting of biopsies (ie, sprue or Barrett’s la muqueuse de l’épithélium gastro-intestinal. Cette technique facilite la esophagus) to increase the yield of endoscopic diagnostic accu- reconnaissance des lésions discrètes (par exemple, polypes) ou permet un racy. The four endoscopic tissue-staining techniques in use are vi- ciblage plus direct des biopsies (par exemple, sprue ou œsophage de tal staining, contrast staining (chromoscopy), reactive staining Barrett) afin d’augmenter la précision diagnostique de l’endoscopie. Les and tattooing. Some of the agents used for endoscopic tissue stain- quatre techniques de coloration tissulaire endoscopique en usage sont la ing and the uses of chromoscopy in identifying pathology of the coloration vitale, la coloration de contraste (chromoscopie), la coloration esophagus, stomach, small bowel and colon during endoscopy are réactive et le tatouage. On présente ici certains des agents utilisés pour la discussed. coloration tissulaire endoscopique et les emplois de la chromoscopie pour l’identification des pathologies de l’œsophage, de l’estomac, du grêle et du Key Words: Chromoscopy; Endoscopy; Tissue staining côlon durant l’endoscopie. issue staining, or chromoscopy, is an adjunctive endo- tion of subtle changes that otherwise may be unrecognized. Tscopic technique using chemical agents applied to the An example of chromoscopy is the use of indigo carmine to gastrointestinal mucosal surface to identify specific epithelia identify flat colonic lesions. The term ‘chromoscopy’ is used or to enhance the mucosal surface characteristics of the gas- interchangeably with ‘tissue staining’ to refer to all forms of trointestinal epithelium. Chromoscopy is performed to aid these tissue staining techniques. Reactive staining is the use in the recognition of subtle lesions (ie, polyps), or to allow - of agents that identify chemical reactions within the gastro- directed targeting of biopsies (ie, sprue or Barrett’s esopha- intestinal tract. For instance, Congo red turns black in the gus) to increase the yield of endoscopic diagnostic accuracy. presence of acid and has been used to identify acid-secreting There are four endoscopic tissue staining techniques: vi- portions of the stomach. Tattooing is a technique that uses tal staining, contrast staining (chromoscopy), reactive stain- either short-acting or permanent agents such as India ink to ing and tattooing (1-4). Vital staining is the use of an agent mark a specific mucosal site for longitudinal study. that is absorbed by the gastrointestinal epithelium, allowing Chromoscopy is not a new technique. Tissue staining was 100 the identification of a characteristic epithelium. An exam- performed by pathologists for many years before the develop- 100 ple of vital staining is the use of methylene blue to identify ment of the endoscope (4). These techniques were adapted 95 95 gastric intestinal metaplasia. Contrast staining, or chromos- to endoscopic practice shortly after the introduction of rigid 75 copy, is the use of an agent to accentuate the surface topogra- and fibreoptic instruments. Tissue stains are usually ‘sprayed’ 75 phy of the gastrointestinal mucosa, allowing the identifica- onto the mucosal surface during endoscopy, but have also Division of Gastroenterology, Oregon Health Sciences University, Portland, Oregon, USA 25 25 Correspondence: Dr Brian Fennerty, Oregon Health Sciences University/PV 310, 3181 SW Sam Jackson Park Road Portland, Oregon 97201-3098, USA. Telephone 503-494-8577, fax 503-494-7556, e-mail [email protected] 5 5 0 0 Can J Gastroenterol Vol 13 No 5 June 1999 423 1 G:\GASTRO\1999\13#5\fennerty.vp Sun Jun 06 10:50:02 1999 Color profile: EMBASSY.CCM - Scitex Scitex Composite Default screen Fennerty 100 100 TABLE 1 95 epithelium, Lugol’s solution results in a characteristic 95 Tissue stains green-brown colour, the intensity of which is in part depend- 75 Class Use ent upon the amount of glycogen present. The absence of 75 Tattooing agents staining with Lugol’s solution can be used to identify abnor- India ink For permanent marking of a mucosal site for mal epithelium such as inflammatory squamous epithelium, 25 relocalization at the time of surgery or neoplastic squamous epithelium or metaplastic epithelium 25 endoscopy. Used in the esophagus, within the esophagus. Lugol’s solution appears to be safe, al- 5 stomach and colon. Safe and without side though in one study a patient later found to be allergic to io- 5 effects. dine developed bronchial spasm following its use in the 0 0 Indocyanine green Shorter-duration tattooing agent than India esophagus (5). Lugol’s solution should, therefore, be used ink. cautiously in patients with reported iodine sensitivity. In the Absorptive stains same study, three of 46 individuals also reported transient Lugol’s iodine Stains normal glycogen-containing squamous heartburn following installation of a 50% solution into the mucosa in the esophagus, allowing recognition of abnormal squamous esophagus (5). epithelium (dysplasia) or metaplastic IG is composed of 1 to 2 µm dimers and polymers of a car- epithelium (Barrett’s esophagus). bon, nitrogen and sulphur compound in solution. IG Methylene blue and Stains the absorptive epithelium (small bowel (5 mg/kg) is usually given as an infusion of 5% albumin 15 to toluidine blue and colon), allowing the identification of 30 mins before visualization of the liver. Following infusion, metaplastic epithelium in the esophagus IG is taken up by normally functioning hepatocytes, allow- (Barrett’s esophagus) and stomach (gastric intestinal metaplasia). Also can identify ing one to differentiate normal from abnormal hepatocellu- gastric metaplasia (negative stain) in the lar function. Thus, IG enhances the identification of duodenal bulb. diseased hepatic tissue for directed biopsy during open or Contrast stains laparoscopic visualization of the liver. IG has also been used Indigo carmine and Accentuates mucosal topography, allowing as a colonic tattooing agent, but is less widely studied than cresyl violet recognition of abnormal small bowel the more commonly used and widely available endoscopic (sprue) and colonic mucosa (inflammatory tattoo, India ink. bowel disease, polyps). Methylene blue (methylthionine chloride) is a nontoxic Reactive stains carbon-based chemical agent that reversibly stains actively Congo red Identifies acid-secreting portions of the absorbing epithelium such as the epithelium of the small in- stomach postoperatively; documents achlorhydria. testine and colon. Methylene blue is not absorbed by the squamous epithelium of the esophagus or the columnar epi- Phenol red Identifies alkaline areas of the stomach. thelium of the stomach. However, metaplastic epithelium with absorptive characteristics such as intestinal metaplasia in the stomach (gastric intestinal metaplasia) or esophagus (Barrett’s esophagus) is capable of absorbing the stain. been given orally and rectally before the procedure. Despite Methylene blue can be used to identify this metaplastic ab- chromoscopy’s many uses and advantages, this endoscopic sorptive epithelium or gastric metaplasia of the duodenal technique is not often used by North American endo- bulb in the absence of uptake when used in the small intes- scopists, and few endoscopists have been formally trained in tine (6,7). chromoscopy (2). Following application of 10 to 50 cm3 of a 5% to 10% so- Some of the agents used for endoscopic tissue staining lution of methylene blue either orally preprocedure or during and the uses of chromoscopy in identifying pathology of the endoscopy by spraying, uptake of the stain occurs within 2 to esophagus, stomach, small bowel and colon during endo- 3 mins, which is then resistant to vigorous washing or lavage scopy are discussed. (Figure 1). The stain fades over the next 15 to 30 mins but persists, in most patients, for up to 12 to 24 h until the stain is TISSUE STAINING lost, secondary to renal excretion or cellular loss. The stain Many different chemical compounds have been used as tis- is preserved in frozen section biopsy specimens but lost dur- 100 sue staining agents (Table 1). Vital or absorptive stains in- ing permanent tissue fixation with formalin and alcohol. 100 clude Lugol’s solution, indocyanine green (IG), methylene Methylene blue results in blue discoloration of the urine and 95 blue and toluidine blue. Lugol’s solution is an inexpensive, stools for the next 24 to 48 h. 95 widely available, nontoxic
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