Editorial
Les applications pratiques des colorations de muqueuses en endoscopie digestive P. MAINGUET Cliniques Universitaires Saint-Luc, UCL, 1200 Bruxelles
Dye-spraying methods as an aid in digestive endoscopy
Les techniques de colorations des muqueuses en cours d'endoscopie digestive, d6crites et prdconis6es par les auteurs japonais [3, 5, 20, 23] ont tard6 ~ entrer dans la pratique courante des endoscopistes europdens. Avec le souci de promouvoir ces m6thodes, la S.M.I.E.R. (*) a choisi ce th6me lors de son XIV" congr6s ~t Reims en juin 1977, satisfaisant ainsi sa vocation interdisciplinaire, puisqu'en mati6re de colorations vitales, deux gyndcologues, respectivement Schiller [15, 16] (1928) pour le lugol et Richart R.M. [12] (1963) avec le bleu de toluidine, sont unanimement consid6r6s comme les initiateurs. Les <~Acta Endoscopica >>consacrent ce num6ro sp6cial aux communications du congr~s, compl6t6es par les expdriences acquises depuis cette session.
leur rendement diagnostique. En effet, l'amdlioration de la qualit6 des images obtenues reste anecdotique, saul d'un point de vue didactique. Nous allons successivement consid6rer les colorants utilis6s, leurs modes d'application, et leurs indications selon les visc~res examin6s.
LES COLORANTS I1 importe de ne pas confondre les colorants vitaux et les colorants de muqueuses.
Les premi6res applications des colorants fi l'6tude des muqueuses digestives remontent Voegeli R. [26] (1966) et Ida K. [3] (1972). Une revue historique exhaustive n'entre pas dans le cadre de cet 6ditorial, plut6t consacr6 aux prolongements pratiques de ces techniques.
Les colorants vitaux sont n6cessairement fix6s par cellules d'un 6pith61ium, soit absorb6s par certaines cellules 6pith61iales comme le bleu de mdthyl6ne au niveau duod6nal [5, 6, 21], soit captds sdlectivement par des organites ou constituants de la cellule, le lugol au niveau des vacuoles glycog6niques des 6pith6liums malpighiens [11, 24], le bleu de toluidine sur les acides nucl6iques des noyaux cellulaires [14, 25].
Leur utilit6 en endoscopie de routine doit tenir compte de leur facilit6 d'ex6cution et de
Ces colorants vitaux nous renseignent sur les fonctions des 6pith61iums 6tudi6s, absorp-
Tirds fi part : Dr P. MAINGUET. Service de Gastroent6rologie, Cliniques Universitaires Saint-Luc, UCL, avenue Hippocrate 10, 1200 Bruxelles (Belgique).
M o t s - c l d s : colorations de muqueuses, colorations vitales, endoscopie. Key-words : dye spraying methods, endoscopy, vital staining.
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Tome
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- N ~ 3 - I978
135
tion du colorant [5, 6, 21], nombre de cellules en mitoses [12, 17] et la lecture d'une coloration n'est interpr&able qu'apr~s un court d61ai de fixation. En cours d'endoscopie une coloration vitale effective peut ~tre contr616e par un test de ~ washout >>, le colorant absorb6 ou fix6 n'6tant pas 61imin6 apr6s lavage de la muqueuse h l'aide d'une solution physiologique [2]. L e s colorants de m u q u e u s e ont une relation neutre avec l'6pith61ium colorS. Ils se fixent au mucus ou recouvrent les muqueuses en accentuant les reliefs.
L'indigo-carmin utilis6 aux niveaux duod6nal [5, 18] et colique [22] est l'exemple typique d'un colorant de muqueuse. En pratique, cette distinction entre colorants de muqueuse et vitaux est relativement artificielle. Ainsi, en pathologic gastrique, le bleu de m6thyl6ne peut agir comme colorant de muqueuse accentuant les reliefs d'une muqueuse normale, ou 6tre fix6 sur la fibrine des ulc6rations, diffuser de mani6re passive h travers l'6pith61ium alt6r6 des cellules canc6reuses, ou enfin 6tre absorb6 comme colorant vital par les cellules des ilots de m6taplasie intestinale [21].
CONDITIONS
TECHNIQUES
Elles d6pendent des colorants utilis6s, des dimensions des organes examin6s, du comportement fonctionnel de leurs muqueuses et du r61e 6ventuel des s6cr6tions digestives. Ainsi, au niveau de l'estomac, la pr6sence du mucus impose une pr6paration ~t l'aide de prot6inases [4, 20] et certains colorants peuvent virer en fonction des variations du pH [13, 23]. Dans le duod6num, un flux biliaire abondant risque de compromettre une coloration au bleu de m6thyl6ne [8]. Ces divers facteurs interviennent dans le ehoix du moment d'utilisation du colorant, soit extemporairement (m6thodes directes), soit dans un second temps, apr~s pr6paration pr6alable (m&hodes indirectes). 136
Tome VIII - N O 3 - 1978
METHODES
DIRECTES
Les m6thodes directes sont imm6diatement utilisables en endoscopic de routine sans en alourdir exag6r6ment l'ex6cution. Au NIVEAU DE L'(ESOPHAGE, 3 types de colorants sont disponibles : L e lugol en solution "/i2% [26] ou h 5 % [14] facilite la d61imitation exacte de la jonction muqueuse 0eso-gastrique (ligne <) et des h&6rotopies ou m6taplasies de type gastrique ainsi que l'identification des 16sions n6oplasiques [24].
Akasada et al. [l] ont montr6 l'int6r6t de la coloration au lugol dans la surveillance th6rapeutique des cesophagites aigu~s. La technique n6cessite une pr6caution : exclure pr6alablement une pathologic thyroi'dienne ou une intol6rance ~ l'iode. L e bleu de mOthylkne en solution h 0,2 % est peu utilis6, sauf en vue de l'analyse des 16sions de m6taplasie gastrique ou d'endobrachy~esophage. L e bleu de toluidine en solution aqueuse "h 2 % est un colorant nucl6aire d'un grand int6r~t. Fix6 par les acides nucl6iques au niveau des 6pith61iums malpighiens en activit6 mitotique intense [17] il a 6t6 utilis6 efficacement en oto-rhino-laryngologie dans le d6pistage des carcinomes <~in situ >~ ou micro-invasifs [25].
It n'a pas encore 6t6 6valu6 syst6matiquement dans le diagnostic du cancer de l'eesophage thoracique. Au NIVEAU DE L'ESTOMAC, les deux principaux colorants utilis6s par m6thode directe sont le rouge-congo et le bleu de m6thyl~ne. L e rouge-congo en solution bicarbonat6e ~t 0,3 % instill6e au contact de la paroi gastrique a permis ~t Tatsuda et al. [23] de d61imiter, apr~s stimulation s6cr6toire ?~ la pentagastrine, les zones de muqueuse fundique acido-s6cr6tante (rouge-congo vir6 au bleu fonc6) et de type antral (coloration inchang6e). Ce test prolonge l'endoscopie d'environ 30 minutes et a 6t6 propos6 afin de d&erminer les zones acido-s6cr6tantes avant vagotomie super-s61ective Acta Endoscopica
ou comme contr61e d'efficacit6 de l'intervention, mais avec des r6sultats discutables [7, 13]. L e bleu de mdthyldne en solution aqueuse ~t 0,5 % procure selon Suzuki et al. [21] des r6sultats satisfaisants dans le rep6rage des ilots de m6taplasie intestinale au niveau desquels le colorant est rapidement absorb6 (t ( 1 min.).
Ces m6mes auteurs n'utilisent par m6thode directe ni dimdthylpolysiloxane, ni prot6inases mais d6conseillent le procdd6 dans l'identification des ldsions canc6reuses gastriques dont le d61ai de coloration est plus long [21]. Au N1VEAUDUODENAL L ' i n d i g o - c a r m i n en solution fi 0,2 % [5] ou 0,4 % [18], apr~s administration per-endoscopique de 20 ml d'une solution h 25 % de dim&hylpolysiloxane, procure instantan6ment un dessin du relief villositaire ou des microl6sions avec selon Kohli et al. [5], une efficacit6 sup6rieure au bleu de m6thyl~ne. N'&ant pas un colorant vital, l'indigo-carmin n'apporte pas d'informations relatives aux d6ficits fonctionnels de muqueuses voisines de 16sions 6volutives (ulc~res, ~rosions). L e bleu de rndthyldne en solution ~t 0,2 % [5], colorant vital le plus employ6 en pathologie duod6nale, n6cessite un temps de latence de 3 g 4 minutes avant lecture des colorations. La comparaison entre zones colordes et non color6es montre au niveau de ces derni~res une proportion moindre de cellules de Paneth et g gobelets ainsi qu'une infiltration inflammatoire accrue, ce qui facilite les contr61es de gu6rison des ulcbres et duod6nites [5, 6].
Au NIVEAU DU C(~LON Les colorants employ~s sont les m~mes qu'au niveau duod6nal, mais ~ des concentrations sup6rieures : indigo-carmin 0,5 % et bleu de m6thyl~ne 1 % [22]. Dans les 16sions inflammatoires du c61on, les deux colorants facilitent le rep6rage des petites 16sions et permettent de d61imiter plus ais6ment les muqueuses saines et alt6r6es [9] mais en outre une absorption correcte du bleu de m6thyl~ne par une muqueuse de colite ulc6rieuse refl~te son degr6 de cicatrisation [22]. Acta Endoscopica
METHODES
1NDIRECTES
Les raisons de la moindre diffusion des mdthodes indirectes sont doubles: i. elles ndcessitent une prdparation plus ou moins longue et contraignante avant l'examen. ii. elles sont rarement applicables au cours d'une endoscopie de premiere intention. Elles concernent l'estomac et utilisent deux colorants : L'indigo-carmin en solution aqueuse 1,5 % administr6 par voie orale (20 ml), apr6s ingestion 15 minutes auparavant d'une solution de dim6thylpolyxylane, bicarbonates et prot6inases [4, 20].
La m6thode convient ~t la d61imitation des aires de distribution des muqueuses de type fundique et pylorique. L e bleu de mdthyldne est administr6 ~t la concentration de 0,7 % (20 ml) [20] ou en capsules de 100 mg [21] apr~s ingestion de la m6me solution prot6olytique que pour l'indigocarmin.
La technique initiale comportait, apr~s rotation du malade, un tubage gastrique pour aspiration de la solution mucolytique [20]. La plupart des auteurs l'ont supprim6 au profit d'une technique simplifi6e [21] et appliquent la m&hode indirecte au d6pistage des 16sions color6es par le bleu de m6thyl~ne (cancers et m6taplasies intestinales). E n conclusion, ~t tousles niveaux du tractus digestif, les m6thodes directes de coloration des muqueuses apportent un compl6ment diagnostique important sans investissement notable de temps ou de moyens, ni servitudes pour le patient.
Lors de la surveillance des 16sions trait6es, les colorants vitaux contribuent ~t 6valuer les processus de cicatrisation et les m6thodes indirectes, bien que plus lourdes pour les malades, trouvent leur justification dans le d6pistage plus efficace des 16sions malignes ou l'&ude prospective des 16sions pr6canc6reuses. Tome VIII - N ~ 3 - 1978
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BI B L I O G R A P H I E 13. ROSCH W. - - Direct application of dyes and drugs in upper gastrointestinal endoscopy. Endoscopy, 1974, 6, 190-192.
1. A K A S A K A Y., K I M O T O K., K A W A I K., T O R I I E S., O K U D A J., K U B A T O K.. IDA K. - - The application of endoscopic lugol's solution spraying method for the diagnosis of the esophagitis (for the follow-up observation of acute severe esophagitis). Endoscopy, 1976, 8, 142-146.
14. SAVARY M., M I L L E R G. - - L'~esophage Manuel et Atlas d'endoscopie. Editions Gassm a n n S.A., 1977, Soleure (Suisse).
2. D E Y H L E P., T S C H E N H. - - Value of the endoscopic dyeing method with methylenblue. Endoscopy, 1975, 7, 24-26.
15. S C H I L L E R W . - - Zur klinischen friihdiagnose des portiokarzinoms. Zbl. Gyniik., 1928, 18861892.
3. J D A K., MISAKI F., KOHLI Y., K A W A I K. -F o n d a m e n t a l studies on the dye scattering method for endoscopy. Gastroint. Endoscop., 1972, 14, 261-266.
16. S C H I L L E R W . - - Early diagnosis of carcinoma of the cervix. Surg. Gynecol. Obst., 1933, 56, 210-222.
4. I D A ,K., H A S H I M O T O Y., K A W A I K. - - In vivo staining of gastric mucosa. Its application to endoscopic diagnosis of intestinal metaplasia. Endoscopy, 1975, 7, 18-24.
17. S H E D D D.P., H U K I L L P.B., BAHN S. - - In vivo staining properties of oral cancer. A m . . t . Surg., 1965, 110, 631-634.
5. KOHLI Y., N A K A J I M A M., I D A K., K A W A I K. - - Minute endoscopical findings of duodenal mucosa using the dye scattering method. Endoscopy, 1974, 6, 1-6. 6. KOHL~ Y., N A K A J I M A M., K A W A I K. Endoscopical and histological studies on vital staining of duodenal mucosa. Endoscopy, 1974, 6, 105-110. 7. K U S A K A R I
L.M., GILLISON A n endoscopic test for completeness of vagotomy. Arch. Surg., 1972, 105, 386-391. E.W.,
K.,
B O M B E C K
NYHUS C.T.
--
8. M A F F I O L I C., L O U V E T H., B R U N E T A U D J.M., H I B O N F., D I E B O L D M.D. - - Endoscopie du bulbe duodenal : apport de la coloration vitale au bleu de m6thyl~ne. Acta Endoscopica, 1978 ~in press). 9. M]rYAOKA T., N A K A J I M A M., MJlSAKI F., M U R A K A M I K., KOHLI Y., T A D A M., KOBAYASHI A., K A W A I K. - - Comparative study of elinicaI and endoscopical observation of ulcerative colitis. Endoscopy, 1974, 6, 169175. 10. N I E B E L H.H., C H O M E T B. - - In vivo staining test for delineation of oral intraepithelial neoplasic change. Preliminary report. ,r Amer. Dent. Assoc., 1964, 68, 801-806. 1I. N O T H M A N N B.J., W R I G H T J.R., S C H U S T E R MM. - - In vivo staining as an aid to identification of esophagogastric mucosal junction in man. Am. ]. Dig,. Dis., 1972, 17, 919-924. 12. R I C H A R T R.M. - - A clinical staining test for the in vivo delineation of dysplasia and carcinoma in situ. Am. ]. Obst. Gynec., 1963, 86, 703-712.
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18. STEVENS F.M., M c C A R T H Y C.F. - - The endoscopic demonstration of coeliac disease. Endoscopy, 1976, 8, 177-180. 19. S T R O N G M.S., V A U G H A M C.W., I N C Z E J.S. - - Tolu~dine blue in the management of carcinoma of the oral cavity. Arch. Otolaryng., 1968, 87, 101-105. 20. S U Z U K I Sh., S U Z U K I H., E N D O M., T A K E MOTO T., K O N D O T., N A K A Y A M A K. Endoscopic dyeing method for diagnosis of early cancer and intestinal metaplasia. Endoscopy, 1973, 5, 124-129. 21. SUZUI~I Sh., G R O I T L H., S U Z U K I H., E N D O M., T A K E M O T O T., K A K A Y A M A K. - - Differential diagnosis of the endoscopically dyed lesions by gastroscopic close-up appearances. Endoscopy, 1974, 6, 99-104. 22. T A D A M., K A T O H S., KOHLI Y., K A W A I K. - - On the dye spraying method in colonofiberscopy. Endoscopy, 1976, 8, 70-74. 23. T A T S U D A M., SAEGUSA T., O K U D A Sh. - Studies on gastritis in the upper portion of stomach by endoscopic Congo Red test. Endoscopy, 1973, 5, 61-69. 24. T O R I I E S., KOHLI Y., A K A S A K A Y., K A W A I K. - - New trial for endoscopic observation of esophagus and its application. Endoscopy, 1975, 7, 75-79. 25. V A U G H A N C.W. - - Supravital staining of early diagnosis of carcinoma. Otolaryngologic Clin. o] North Amer., 1972, 5, 301-302. 26. V O E G E L I R. - - Die schillersche jodprobe im rahmen der Osophagus Diagnostik. Pratt. Otorhino-laryng., 1966, 28, 230-239.
Acta Endoscopica
The dye spraying methods proposed by japanese authors as an aid for routine endoscopy [3, 5, 20, 23] remains poorly used in Europe. Therefore this topic was chosen by the S.M.I.E.R. for his 14th Congress in Reims on June 1977, so outlining the interest of multidisciplinary sessions. Indeed, we must remember that first pionners of vital staining methods were two gynecologists, respectively Schiller (1928) with lugol's technique [15, 16] and Richart (1963) with toluidine blue [12]. <~Acta Endoscopica ~ proposes nowadays for publication the original records of the communications presented in this congress and results of newly acquired experiences in vital staining's field. Stainers were applied for the first time during upper G.I. endoscopy by Voegeli R. (1966) [26] and Ida K. (1972) [3]. A complete historical review of staining's methods is beyond the scope of this editorial. Usefulness of dye spraying methods depends on their diagnostic ability and their convenience during current endoscopy. Improvement of endoscopical views and photographies is only anecdotic, except for teaching.
lity to absorb the stain [5, 6, 21], correlation. between stain intensity and number of nuclei per unit area [1, 2, 17]. Consequently, vital staining in an active and somewhat time consuming process. False positive results can be excluded by washing the mucosa with a saline solution in order to remove the excess of unfixed stain [2]. D y e s Jor spraying m e t h o d s provides closeup pictures of mucosal relief without functional informations. Indigo-carmine used in duodenal [5, 18] and colonic studies [22] is typicaly such a spreading dye.
In current practice, this differences are somewhat artificial. Methylen blue sprayed on the gastric wall enhance the mucosal relief and moreover can be fixed by fibrin of ulcers or penetrate between the cells of a cancerous damaged epithelium or finaly be absorbed by cells of an intestinal metaplasia [21].
TECHNICS
Procedures depends of the stainer used, size of the organ, relation with the mucosa and possible influence of digestive secretion.
Dyeing digestive mucosae have provided valuable results in experienced hands and we will consider successively different stains, practical procedures, and usefulness at several levels of the digestive tract.
In the stomach a proteolytic enzyme solution (pronase) is used to avoid presence of mucus [4, 20] ans some stain as Congo red can be discolored with variation of acidity [13, 23]. During duodenoscopy a marked bilous reflux may impede the absorption of the dye [8].
STA INER S
This features are taken into account for the moment of staining, either immediately (direct methods) or after a previous preparation (indirect methods).
We must distinguish true vital staining and a spraying with a superficially spreading dye all over a mucosal surface. Vital stainers have an affinity for mucosal epithelium; they are either absorbed by epithelial cells as methylen blue in the duodenum [5, 6, 21] or specifically fixed by some cell's componants as lugol by glycogenic vacuolor content [11, 24] or toluidine blue by nucleic acids of the cells nuclei [14, 25].
This vital stainers provides functional information about the epithelium studied : abiActa Endoscopica
DIRECT
METHODS
They are easily available for routine endoscopy and never tedious for the patients. OESAPHAGUS : three dyes are commonly used : Lugol's solution at 2 % [26] or 5 % [14I Tome VIII . N ~ 3 . 1978
139
facilitate the delineation of the esophago-gastric junction (<~Z>> line), localization of sharply demarcated cancerous lesions or patches of columnar epithelium [24]. Lugol's spraying was proposed with good results by Akasada and al. [1] for endoscopic follow-up of acute severe esophagitis. The procedure will be avoided in patients with iodine intolerance or thyroid's diseases.
Methylen blue's solution (0,2 %) is somelimes used for study of esophageal gastric metaplasia or ~ endo-brachy-oesophage >>. Toluidine blue 0 in 2 % aqueous solution is a nucleic stainer of great interest.
DUODENUM
Indigo-carmine in 0,2 % [5] or 0,4 % [18] aqueous solution, after perendoscopic administration of a 25 % dimethylpolysiloxane solution (20 ml), provides immediately a sufficient picture of fine villous structures and minute lesions of the duodenal mucosa. Kohli and al. [5] comparing the effet of indigocarmine with that of methylen blue have found more doubtful cases with the latter than the former. Functional deficiences of damaged mucosa or in areas surrounding active lesions (ulcers, erosions) escapes to this unabsorbed dye pigment.
Fixed by nucleic acids of squamous epitheMethylen blue in 0,2 % solution [5] is the lium with mitotic activity [17] toluidine blue more commonly employed stainer in duodenal was effective in the localization and treatment studies. His use needs a delay (3 or 4 minutes) of carcinoma <> or <~micro-invasive >> before observation. of the oral cavity [25]. Comparison between stained and unstained Until now his use for diagnosis of thoramucosa can be correlated with the number of .cic esophageal cancer was not evaluated. goblet and Paneth cells and intramucosal inflammatory cell infiltration [6]. This patterns STOMACH " two dyes are usualy proposed are helpful as survey of healing in duodenal for direct methods : Congo-red and methylen ulcers and duodenitis [5, 6]. blue. With spraying Congo-red in bicarbonate solution (0,3 %) directly on the gastric wall after maximal stimulation of gastric acid output with pentagastrin (6 ~tg/kg), Tatsuda and al. [23] have delineated the boundary between ~undic mucosa with acid secretion pattern (discolored areas) and antral mucosa or extent of gastritis (non discolored areas). The test need watching for 30 min. following administration of pentagastrin and was used with unreliable results to demonstrate still innervated areas during highly selective vagotomy 9or in evaluating the completeness of vagotomy postoperatively [7, 13]. With methylen blue in 0,5 aqueous solution Suzuki and al. [21] have obtained accurate results in diagnosis of stained patches of intestinal metaplasia where the dye is quickly absorbed (t ~ 1 min.). For the direct method neither dimethylpolysiloxane nor proteinase are indispensable but the procedure is unsuitable for localization of gastric cancerous lesions whose dye's uptake is longer [21 ]. 140
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- N ~ 3 - 1978
COLON Indigo-carmine and methylen blue are used as for the duodenum but with higher concentrations, respectively 0,5 % and 1 % [22]. In colonic inflammatory diseases both stainers are helpful in localization of minute findings or delineation of limits between damaged and healed mucosa [9] but only a correct methylen blue absoprtive capacity reflect a complete healed stage [22].
INDIRECT METHODS Reasons of lesser diffusion of indirect methods are : i. the need of a previous time consuming and tedious preparation before endoscopy. it. they are seldom used for a first endoscopy. In gastric pathology, two dyes are proposed : Acta
Endoscopica
Indigo-carmine in 1,5 % aqueous solution given orally (20 ml) after previous oral administration (15 minutes before) of a mixed solution (dimethylpolyxilane, bicarbonates, proteinase) provides an accurate delineation between boundary of fundic and pyloric mucosae [4, 20]. Methylen blue is administrated oraly as a 0,7 % solution (20 ml) [20] or as a capsule containing 100 mg of the dye [21]. The initial procedure needed a vigorous rotation of the patient after swallowing of the dye with proteolytic enzyme solution and further aspiration of the gastric content through a nasogastric tube [20]. A more simple method
Acta Endoscopica
is actualy proposed [26] for identification of stained gastric lesions (cancer and intestinal metaplasia).
Conclusion, at different levels of the digestive tract direct dye spraying methods are easy, not tedious for the patients, takes little time and often provides more diagnostic accuracy. Usefulness of stains for the follow-up of inflammatory lesions and survey of the healing process will probably be emphasized in the future. Indirect methods are rather heavy and must be reserved to repair of malignant or premalignant lesions.
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- N ~ 3 - 1978
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