Advances in image enhancement in colonoscopy for detection of adenomas

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Key Points

  • Adenoma detection rate (ADR) is one of the most important indicators of endoscopy quality, as an increased ADR is related to reduced rates of interval cancer.

  • Although several new technologies have emerged as promising tools to improve ADR, evidence has demonstrated that education in the recognition of colorectal lesions helps to improve ADR

  • Studies evaluating techniques that improve visualization by exposing more mucosa, such as retroflexion, Third Eye Retroscope, add-on devices or wide-angle colonoscopies, report conflicting results regarding ADR improvement

  • Image-enhanced colonoscopes facilitate the detection and characterization of polyps, especially nonpolypoid colorectal neoplasms

  • Image enhancement techniques should be effective and practical to enable routine use in endoscopy units performing colorectal cancer screening.


High-quality colonoscopy is mandatory to prevent adenoma recurrence and colorectal cancer. In the past few years, technical advances have been developed with the purpose of improving adenoma detection rate (ADR), one of the most important validated colonoscopy quality benchmarks. Several techniques or devices are used to optimize visualization: observation techniques; add-on devices; auxiliary imaging devices; colonoscopes with increased field of view; and colonoscopes with an integrated inflatable reusable balloon. Image-enhanced endoscopy (IEE) facilitates the detection and characterization of polyps and especially nonpolypoid colorectal neoplasms. Indigo carmine is the most frequently used dye in colonoscopy as it deposits in depressed areas, improving detection of flat and depressed lesions. Virtual chromoendoscopy has emerged as an effective contrast enhancement technology without the limitation of preparing dyes and applying them through the colonoscope working channel. Narrow-band imaging (NBI) enhances the capillary pattern and surface of the mucosa using optical filters, and second-generation NBI provides a twofold brighter image than the previous system, yielding promising ADR results. Moreover, a second-generation blue laser imaging system, LASEREO, has been reported to improve not only polyp detection rate but also ADR, becoming a promising IEE modality. Herein, we describe technical advances in colonoscopy imaging and their effect on ADR.

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Figure 1: Imaging of a depressed intramucosal carcinoma.
Figure 2: Chromoendoscopy of T1 (submucosal) colorectal cancers.


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The authors acknowledge funding from the National Cancer Center Research and Development Fund, Japan (27-A-5).

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All authors contributed equally to researching data for the article. T.M. and A.O. provided substantial contributions to discussions of the content and wrote the article. All authors contributed equally to reviewing and/or editing of the manuscript before submission.

Correspondence to Takahisa Matsuda.

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Matsuda, T., Ono, A., Sekiguchi, M. et al. Advances in image enhancement in colonoscopy for detection of adenomas. Nat Rev Gastroenterol Hepatol 14, 305–314 (2017) doi:10.1038/nrgastro.2017.18

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