Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Magnification endoscopy

Moises Guelrud, MD
Elissa E Kaplan, MD
Section Editor
John R Saltzman, MD, FACP, FACG, FASGE, AGAF
Deputy Editor
Kristen M Robson, MD, MBA, FACG


The ability to magnify endoscopic images in real-time (magnification endoscopy) permits visualization of mucosal details that cannot be seen with standard endoscopy. The images can be further enhanced by the topical application of stains or pigments (enhanced magnification endoscopy or magnification chromoscopy).

Equipment and experience with these approaches is evolving. A growing number of reports suggest that they offer the ability to improve diagnostic accuracy for a variety of gastrointestinal disorders [1]. In addition, newer technologies, such as confocal laser endomicroscopy and endocytoscopy, are now allowing for real-time visualization of the gastrointestinal tract at a microscopic level [2,3].

Magnification endoscopy will be reviewed here. Other methods for enhanced visualization of the gastrointestinal mucosa are discussed elsewhere. (See "Chromoendoscopy" and "Barrett's esophagus: Evaluation with narrow band imaging".)


Magnification endoscopes include an adjustable focusing mechanism that permits standard endoscopic views and the ability to enlarge the image from 1.5X to 150X [4,5]. Several different models are commercially available. The newest magnification endoscopes permit magnification without loss of resolution.

Resolution is related to pixel density. Conventional endoscopes have pixel densities in the range of 100,000 to 200,000. By contrast, the newest magnification endoscopes have pixel densities from 850,000 to more than 1 million, allowing them to discriminate objects that are only 10 to 71 microns in diameter [1,5].

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Dec 15, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Technology status evaluation report. High resolution and high-magnification endoscopy. Gastrointest Endosc 2000; 52:864.
  2. Inoue H, Kudo SE, Shiokawa A. Technology insight: Laser-scanning confocal microscopy and endocytoscopy for cellular observation of the gastrointestinal tract. Nat Clin Pract Gastroenterol Hepatol 2005; 2:31.
  3. ASGE Technology Committee, Kwon RS, Wong Kee Song LM, et al. Endocytoscopy. Gastrointest Endosc 2009; 70:610.
  4. Kiesslich R, Jung M. Magnification endoscopy: does it improve mucosal surface analysis for the diagnosis of gastrointestinal neoplasias? Endoscopy 2002; 34:819.
  5. Gastrointest Endosc 2014; 80:919.
  6. Indigo Carmine Injection. http://www.ashp.org/menu/DrugShortages/CurrentShortages/Bulletin.aspx?id=861 (Accessed on March 10, 2016).
  7. Guelrud M, Herrera I. Acetic acid improves identification of remnant islands of Barrett's epithelium after endoscopic therapy. Gastrointest Endosc 1998; 47:512.
  8. Acosta MM, Boyce HW Jr. Chromoendoscopy--where is it useful? J Clin Gastroenterol 1998; 27:13.
  9. Canto MI. Staining in gastrointestinal endoscopy: the basics. Endoscopy 1999; 31:479.
  10. Canto MI, Yoshida T, Gossner L. Chromoscopy of intestinal metaplasia in Barrett's esophagus. Endoscopy 2002; 34:330.
  11. Guelrud M, Herrera I, Essenfeld H, Castro J. Enhanced magnification endoscopy: a new technique to identify specialized intestinal metaplasia in Barrett's esophagus. Gastrointest Endosc 2001; 53:559.
  12. Sharma P, Weston AP, Topalovski M, et al. Magnification chromoendoscopy for the detection of intestinal metaplasia and dysplasia in Barrett's oesophagus. Gut 2003; 52:24.
  13. Guelrud M, Herrera I, Essenfeld H, et al. Intestinal metaplasia of the gastric cardia: A prospective study with enhanced magnification endoscopy. Am J Gastroenterol 2002; 97:584.
  14. Curvers W, Baak L, Kiesslich R, et al. Chromoendoscopy and narrow-band imaging compared with high-resolution magnification endoscopy in Barrett's esophagus. Gastroenterology 2008; 134:670.
  15. Hoffman A, Kiesslich R, Bender A, et al. Acetic acid-guided biopsies after magnifying endoscopy compared with random biopsies in the detection of Barrett's esophagus: a prospective randomized trial with crossover design. Gastrointest Endosc 2006; 64:1.
  16. Toyoda H, Rubio C, Befrits R, et al. Detection of intestinal metaplasia in distal esophagus and esophagogastric junction by enhanced-magnification endoscopy. Gastrointest Endosc 2004; 59:15.
  17. Hoffman A, Korczynski O, Tresch A, et al. Acetic acid compared with i-scan imaging for detecting Barrett's esophagus: a randomized, comparative trial. Gastrointest Endosc 2014; 79:46.
  18. Tholoor S, Bhattacharyya R, Tsagkournis O, et al. Acetic acid chromoendoscopy in Barrett's esophagus surveillance is superior to the standardized random biopsy protocol: results from a large cohort study (with video). Gastrointest Endosc 2014; 80:417.
  19. Ferguson DD, DeVault KR, Krishna M, et al. Enhanced magnification-directed biopsies do not increase the detection of intestinal metaplasia in patients with GERD. Am J Gastroenterol 2006; 101:1611.
  20. Singh R, Karageorgiou H, Owen V, et al. Comparison of high-resolution magnification narrow-band imaging and white-light endoscopy in the prediction of histology in Barrett's oesophagus. Scand J Gastroenterol 2009; 44:85.
  21. Lee CT, Chang CY, Lee YC, et al. Narrow-band imaging with magnifying endoscopy for the screening of esophageal cancer in patients with primary head and neck cancers. Endoscopy 2010; 42:613.
  22. Endo T, Awakawa T, Takahashi H, et al. Classification of Barrett's epithelium by magnifying endoscopy. Gastrointest Endosc 2002; 55:641.
  23. Guelrud M, Ehrlich EE. Endoscopic classification of Barrett's esophagus. Gastrointest Endosc 2004; 59:58.
  24. Meining A, Rösch T, Kiesslich R, et al. Inter- and intra-observer variability of magnification chromoendoscopy for detecting specialized intestinal metaplasia at the gastroesophageal junction. Endoscopy 2004; 36:160.
  25. Mayinger B, Oezturk Y, Stolte M, et al. Evaluation of sensitivity and inter- and intra-observer variability in the detection of intestinal metaplasia and dysplasia in Barrett's esophagus with enhanced magnification endoscopy. Scand J Gastroenterol 2006; 41:349.
  26. Fortun PJ, Anagnostopoulos GK, Kaye P, et al. Acetic acid-enhanced magnification endoscopy in the diagnosis of specialized intestinal metaplasia, dysplasia and early cancer in Barrett's oesophagus. Aliment Pharmacol Ther 2006; 23:735.
  27. Gossner L, Pech O, May A, et al. Inter- and intraobsever variability in high resolution chromoendoscoy with acetic acid for the detection of intestinal metaplasia and early neoplasia in Barrett's esophagus (abstract). Gastrointest Endosc 2005; 61:AB132.
  28. Dinis-Ribeiro M, da Costa-Pereira A, Lopes C, et al. Magnification chromoendoscopy for the diagnosis of gastric intestinal metaplasia and dysplasia. Gastrointest Endosc 2003; 57:498.
  29. Tajiri H, Doi T, Endo H, et al. Routine endoscopy using a magnifying endoscope for gastric cancer diagnosis. Endoscopy 2002; 34:772.
  30. Sumiyama K, Kaise M, Nakayoshi T, et al. Combined use of a magnifying endoscope with a narrow band imaging system and a multibending endoscope for en bloc EMR of early stage gastric cancer. Gastrointest Endosc 2004; 60:79.
  31. Yang HJ, Wang JT, Wang TH, et al. Diagnosis of gastric polypoid lesions by magnifying endoscopy and dye endoscopy. J Formos Med Assoc 1991; 90:371.
  32. Areia M, Amaro P, Dinis-Ribeiro M, et al. External validation of a classification for methylene blue magnification chromoendoscopy in premalignant gastric lesions. Gastrointest Endosc 2008; 67:1011.
  33. Anagnostopoulos GK, Yao K, Kaye P, et al. High-resolution magnification endoscopy can reliably identify normal gastric mucosa, Helicobacter pylori-associated gastritis, and gastric atrophy. Endoscopy 2007; 39:202.
  34. Yoshida T, Kawachi H, Sasajima K, et al. The clinical meaning of a nonstructural pattern in early gastric cancer on magnifying endoscopy. Gastrointest Endosc 2005; 62:48.
  35. Tanaka K, Toyoda H, Kadowaki S, et al. Surface pattern classification by enhanced-magnification endoscopy for identifying early gastric cancers. Gastrointest Endosc 2008; 67:430.
  36. Ohashi A, Niwa Y, Ohmiya N, et al. Quantitative analysis of the microvascular architecture observed on magnification endoscopy in cancerous and benign gastric lesions. Endoscopy 2005; 37:1215.
  37. Ezoe Y, Muto M, Horimatsu T, et al. Magnifying narrow-band imaging versus magnifying white-light imaging for the differential diagnosis of gastric small depressive lesions: a prospective study. Gastrointest Endosc 2010; 71:477.
  38. Kato M, Kaise M, Yonezawa J, et al. Magnifying endoscopy with narrow-band imaging achieves superior accuracy in the differential diagnosis of superficial gastric lesions identified with white-light endoscopy: a prospective study. Gastrointest Endosc 2010; 72:523.
  39. Ezoe Y, Muto M, Uedo N, et al. Magnifying narrowband imaging is more accurate than conventional white-light imaging in diagnosis of gastric mucosal cancer. Gastroenterology 2011; 141:2017.
  40. Yamada S, Doyama H, Yao K, et al. An efficient diagnostic strategy for small, depressed early gastric cancer with magnifying narrow-band imaging: a post-hoc analysis of a prospective randomized controlled trial. Gastrointest Endosc 2014; 79:55.
  41. Siegel LM, Stevens PD, Lightdale CJ, et al. Combined magnification endoscopy with chromoendoscopy in the evaluation of patients with suspected malabsorption. Gastrointest Endosc 1997; 46:226.
  42. Cammarota G, Martino A, Pirozzi GA, et al. Direct visualization of intestinal villi by high-resolution magnifying upper endoscopy: a validation study. Gastrointest Endosc 2004; 60:732.
  43. Cammarota G, Martino A, Di Caro S, et al. High-resolution magnifying upper endoscopy in a patient with patchy celiac disease. Dig Dis Sci 2005; 50:601.
  44. Badreldin R, Barrett P, Wooff DA, et al. How good is zoom endoscopy for assessment of villous atrophy in coeliac disease? Endoscopy 2005; 37:994.
  45. Lo A, Guelrud M, Essenfeld H, Bonis P. Classification of villous atrophy with enhanced magnification endoscopy in patients with celiac disease and tropical sprue. Gastrointest Endosc 2007; 66:377.
  46. Hurlstone DP, Brown S, Cross SS. The role of flat and depressed colorectal lesions in colorectal carcinogenesis: new insights from clinicopathological findings in high-magnification chromoscopic colonoscopy. Histopathology 2003; 43:413.
  47. Hurlstone DP, Cross SS, Adam I, et al. A prospective clinicopathological and endoscopic evaluation of flat and depressed colorectal lesions in the United Kingdom. Am J Gastroenterol 2003; 98:2543.
  48. Hurlstone DP, McAlindon ME, Sanders DS, et al. Further validation of high-magnification chromoscopic-colonoscopy for the detection of intraepithelial neoplasia and colon cancer in ulcerative colitis. Gastroenterology 2004; 126:376.
  49. Hurlstone DP, Cross SS, Drew K, et al. An evaluation of colorectal endoscopic mucosal resection using high-magnification chromoscopic colonoscopy: a prospective study of 1000 colonoscopies. Endoscopy 2004; 36:491.
  50. Paggi S, Radaelli F, Amato A, et al. The impact of narrow band imaging in screening colonoscopy: a randomized controlled trial. Clin Gastroenterol Hepatol 2009; 7:1049.
  51. Sada M, Igarashi M, Yoshizawa S, et al. Dye spraying and magnifying endoscopy for dysplasia and cancer surveillance in ulcerative colitis. Dis Colon Rectum 2004; 47:1816.
  52. Kiesslich R, Fritsch J, Holtmann M, et al. Methylene blue-aided chromoendoscopy for the detection of intraepithelial neoplasia and colon cancer in ulcerative colitis. Gastroenterology 2003; 124:880.
  53. Hurlstone DP, Sanders DS, McAlindon ME, et al. High-magnification chromoscopic colonoscopy in ulcerative colitis: a valid tool for in vivo optical biopsy and assessment of disease extent. Endoscopy 2006; 38:1213.
  54. Togashi K, Konishi F, Ishizuka T, et al. Efficacy of magnifying endoscopy in the differential diagnosis of neoplastic and non-neoplastic polyps of the large bowel. Dis Colon Rectum 1999; 42:1602.
  55. Hurlstone DP, Cross SS, Brown S, et al. A prospective evaluation of high-magnification chromoscopic colonoscopy in predicting completeness of EMR. Gastrointest Endosc 2004; 59:642.
  56. Kudo S, Tamura S, Nakajima T, et al. Diagnosis of colorectal tumorous lesions by magnifying endoscopy. Gastrointest Endosc 1996; 44:8.
  57. Huang Q, Fukami N, Kashida H, et al. Interobserver and intra-observer consistency in the endoscopic assessment of colonic pit patterns. Gastrointest Endosc 2004; 60:520.
  58. Hirata M, Tanaka S, Oka S, et al. Magnifying endoscopy with narrow band imaging for diagnosis of colorectal tumors. Gastrointest Endosc 2007; 65:988.
  59. Fu KI, Sano Y, Kato S, et al. Chromoendoscopy using indigo carmine dye spraying with magnifying observation is the most reliable method for differential diagnosis between non-neoplastic and neoplastic colorectal lesions: a prospective study. Endoscopy 2004; 36:1089.
  60. Le Rhun M, Coron E, Parlier D, et al. High resolution colonoscopy with chromoscopy versus standard colonoscopy for the detection of colonic neoplasia: a randomized study. Clin Gastroenterol Hepatol 2006; 4:349.
  61. Kanao H, Tanaka S, Oka S, et al. Narrow-band imaging magnification predicts the histology and invasion depth of colorectal tumors. Gastrointest Endosc 2009; 69:631.
  62. Wada Y, Kudo SE, Kashida H, et al. Diagnosis of colorectal lesions with the magnifying narrow-band imaging system. Gastrointest Endosc 2009; 70:522.
  63. Hurlstone DP, Cross SS, Adam I, et al. Efficacy of high magnification chromoscopic colonoscopy for the diagnosis of neoplasia in flat and depressed lesions of the colorectum: a prospective analysis. Gut 2004; 53:284.
  64. Chiu HM, Chang CY, Chen CC, et al. A prospective comparative study of narrow-band imaging, chromoendoscopy, and conventional colonoscopy in the diagnosis of colorectal neoplasia. Gut 2007; 56:373.
  65. East JE, Suzuki N, Saunders BP. Comparison of magnified pit pattern interpretation with narrow band imaging versus chromoendoscopy for diminutive colonic polyps: a pilot study. Gastrointest Endosc 2007; 66:310.
  66. Kiesslich R, Jung M, DiSario JA, et al. Perspectives of chromo and magnifying endoscopy: how, how much, when, and whom should we stain? J Clin Gastroenterol 2004; 38:7.
  67. Rastogi A, Keighley J, Singh V, et al. High accuracy of narrow band imaging without magnification for the real-time characterization of polyp histology and its comparison with high-definition white light colonoscopy: a prospective study. Am J Gastroenterol 2009; 104:2422.
  68. Nagorni A, Bjelakovic G, Petrovic B. Narrow band imaging versus conventional white light colonoscopy for the detection of colorectal polyps. Cochrane Database Syst Rev 2012; 1:CD008361.
  69. Parikh ND, Chaptini L, Njei B, Laine L. Diagnosis of sessile serrated adenomas/polyps with image-enhanced endoscopy: a systematic review and meta-analysis. Endoscopy 2016; 48:731.